frequently-asked
medicare questions

How much in-home care will Medicare cover?

The vast majority of Medicare reimbursement for in-home care is for post-acute care such as physical, occupational or respiratory therapy.

By Meg Fullwood
healthinsurance.org contributor

Each year, an increasing number of Baby Boomers become eligible for Medicare, and with that increase, more and more seniors are deciding to stay in their homes longer – with some planning to forego traditional long-term care facilities entirely.

A 2010 survey by AARP revealed that nearly three-quarters of respondents age 45 and older said they’d like to stay in their homes as long as possible.

This apparent desire is changing the way seniors look at their future care, and it should affect their expectations about the coverage they receive from Medicare. Medicare covers only a fraction of in-home care expenses, but recipients should definitely seek advice about how the program can help with those costs.

Seniors often have unrealistic expectations about Medicare, says Sheri Samotin, president of LifeBridge Solutions, a Florida firm that advises seniors and their families on how to plan for long-term care. “The system was never set up to pay for long-term care,” she cautions. “My clients believe they have a wonderful Medicare card, and they’re surprised when the majority of long-term care expenses aren’t covered.”

Some seniors and their caregivers mistakenly believe that Medicare will cover custodial care – paid services that assist seniors with activities of daily living such a bathing, preparing meals and transportation. “Medicare will never pay for true custodial care – at home or in a long-term care facility,” Samotin says.

In truth, the vast majority of Medicare reimbursement for in-home care is for post-acute care such as physical, occupational or respiratory therapy. And that care is typically ordered by a doctor following inpatient treatment with a minimum stay. “In most situations, Medicare coverage of inpatient rehabilitation only follows inpatient admission or three days or more,” Samotin says.

What in-home care can seniors expect from Medicare?

• In-home physical therapy – In some cases, Medicare covers outpatient physical therapy at home. “If a patient has had a fall, or a doctor detects a change in functional status, the patient may qualify for physical therapy to improve their balance and endurance,” says Nancy Hanley, Team Manager with MyHealthCareManager.com. That physical therapy may continue as long as the patient is progressing. “If the patient plateaus or is no longer benefiting from the service, the service is discontinued” she says.
• Home health aides – Following acute care, a home health aide may also be covered under Medicare for a limited period of time if deemed necessary by the patient’s physician. The services must, however, be related to the illness or injury treated an in conjunction with a skilled service, such as nursing, physical therapy, occupational therapy, respiratory therapy or speech therapy.
• Home safety – Medicare can also help improve the in-home setting for Medicare recipients. The Medicare patient’s physician can prescribe a home risk assessment by a physical or occupational therapist before the patient returns home from inpatient treatment.“They’ll check for clear pathways and make suggestions about rearranging furniture to accommodate wheelchairs and walkers,” says Hanley. “They’ll make recommendations for elevated toilet frames for stability, installing grab bars and even creating a downstairs bedroom in older homes when patients can’t make it up the stairs.”
• Durable medical equipment – Physical and occupational therapists can secure durable medical equipment – hospital beds, bedside commodes, canes, walkers and wheelchairs – for the patient’s use in the home with a doctor’s order. In most cases, Medicare pays 80 percent of the cost of the prescribed equipment, but that equipment can only be prescribed once within a five-year period.But Hanley notes that recipients should be aware that the covered equipment is limited. Medicare typically does not cover grab bars, shower stools and hand-held showerheads.

What about other long-term care expenses?

For the foreseeable future, seniors will have to look outside of Medicare for coverage of most long-term care expenses, Samotin say. “Medicare simply does not cover the vast majority of the help with day-to-day living that seniors often need. There are wonderful options if you can afford to purchase private companionship and care but they won’t be paid for by Medicare.”

Her advice? Think about long-term care insurance for coverage of in-home care. Depending on the policy, long-term care coverage could include skilled nursing care, physical therapy and assistance with activities of daily living (custodial care).

Also, check out the offerings of local social services organizations and – if you’re a veteran – become familiar with VA benefits. But definitely don’t wait.

“It’s so important to people to buy long-term care insurance and to get in early,” Samotin says. “If you buy in your 40s, 50s and 60s, your coverage may cost a few thousand dollars a year. If you wait until you’re older or the point when you need it, the premiums are going to be much higher, or you may be uninsurable.”

Tags: activities of daily living, eligibility, in-home care, inpatient, long-term care, physical therapy, physician reimbursement, rehabilitation, skilled nursing