Paying for Home Health Care: What Do Medicare and Medigap Cover?

Prescribed only by a physician, home health care is skilled nursing care that aids in the recovery from illness, injury, or surgery in the patient's home. And fortunately for many seniors who are now opting for care at home, Medicare insurance covers most costs related to home health care.

The government, however, has set some limitations on payouts - you are only eligible if you need intermittent care (usually defined as seven days a week or less than eight hours a day over 21 days or less) (1), physical/occupational therapy or speech language pathology; you are homebound; and the home health care agency providing care is approved by your Medicare insurance program.

In addition to medication administration, general supervision, and therapy services, the Medicare home health benefit covers a number of other necessities, including medical aids and supplies to aid in recuperation. On the occasion, though, you may be required to cover some of the costs associated with home health care. But what can you expect to pay out-of-pocket that's not covered by Medicare dollars?

Medicare Insurance: Part A and Part B

Hospital Insurance (Medicare Part A) helps cover the costs of your inpatient care at hospitals, skilled nursing facilities, or religious non-medical health care establishments. Part A can also help cover hospice and home health care services. Individuals aged 65 and older are usually automatically enrolled in Medicare Part A and do not have to pay a monthly premium if Medicare taxes were paid while working. If you did not pay taxes, you are still eligible, but you will be required to pay a monthly premium.

Medical Insurance (Medicare Part B) helps cover services such as those offered by your physician and outpatient care. Many seniors maintain their enrollment in Part A, but elect not to use Part B, which requires a monthly premium that is dependent upon income, the requirements of which change yearly. Unfortunately, if you didn't sign up for Part B when you were first eligible for insurance, your premium may be slightly higher (2).

For questions on your Medicare insurance benefits, you should contact 1-800-MEDICARE or read the handbook mailed to you each year entitled "Medicare and You."

What's Covered and What's Not

Medicare insurance pays for physical and occupational therapy and speech language pathology services, counseling, some medical supplies, durable medical equipment (which must meet coverage criteria), as well as general assistance with daily activities which include dressing, bathing, eating, and toileting. For most other medical equipment, Medicare insurance will cover 80% of its cost (3).

However, Medicare will not cover twenty-four hour care at home, meals delivered to your home, and services unrelated to your care such as housekeeping. Of course, as mentioned above, you will be required to pay 20% for medical equipment not fully covered by Medicare insurance such as wheelchairs, walkers, and oxygen tanks (4).

In some cases, your home health care agency may present you with a Home Health Advance Beneficiary Notice (HHABN), which, simply put, means if your agency is ceasing your care services, you will be presented with a written statement outlining the supplies and services the agency believes your Medicare insurance benefits will not cover as well as a detailed explanation of why. Should this situation arise, you do have recourse - the HHABN lists directions on acquiring the final decision on payment issues or filing an appeal if Medicare refuses to cover costs for home health care. In the meantime, you should continue receiving home health care services, but keep in mind that you will be paying for these services out-of-pocket until Medicare accepts your claims and remits past expenses.

Medigap and Other Out-of-Pocket Expenses

Medigap, a supplemental insurance policy, is sold privately and covers the services and supplies not paid for by Medicare insurance. When used in conjunction, Medigap and Medicare can often cover a large majority of the costs of your home health care. Insurance companies offer a variety of different Medigap policies (A through L), but since each one comes with specific benefits, you'll need to compare the highlights closely. Medigap policies vary by cost, and many insurance companies require you to have both Medicare Parts A and B in order to purchase a supplemental plan (5).

For seniors with both Part A and Part B Medicare, your home health care situation is usually covered, save for the 20% out-of-pocket expenses for medical equipment. Just remember to keep track of your Medicare insurance benefits (and Medigap if applicable) by verifying with your physician, home health care agency, and insurance representative. Paying for home health care does not have to cost you an arm and a leg, but do be prepared for the occasional (but necessary) out-of-pocket medical expenses.

Sources

1. Centers for Medicare and Medicaid Services, Medicare and Home Health Care, page 6
2. http://www.medicare.gov/Publications/Pubs/pdf/10116.pdf
3. Ibid.
4. Ibid.
5. http://www.medicare.gov/medigap/Default.asp