Caregiving can be expensive. Lost wages, reduced income, medical equipment costs, and transportation are just a few of the expenses associated with caregiving duties. However, even with Medicare, there is a great deal of confusion about what Medicare covers and what it doesn’t. Many people are surprised to find out that Medicare doesn’t cover the cost of assisted living facilities, for example.
Jump ahead to these sections:
- Medicare Programs
- Will Medicare Pay for an In-Home Caregiver?
- Will Medicare Pay for Other Costs Associated With Caregiving?
Medicare criteria, co-pays, and limits to coverage are always changing. The best way to protect yourself from any surprise costs is to check with your insurance company to verify coverage. If it doesn’t look as if Medicare will help with caregiver costs, there are other possible avenues for support. Eldercare Locator is a good place to start in getting connected to assistance in your community.
Medicare consists of three main types and understanding the types is critical to knowing what is covered. The three types are original Medicare with a supplemental policy, Medicare obtained through a disability benefit, and Medicare Advantage (Part C) plans.
When most people over the age of 65 are asked if they have Medicare, they respond, “yes.” And although they do have Medicare, they may not know whether they have a traditional Medicare with a supplemental plan or a Medicare Advantage Plan. The former option—known as Traditional Medicare—is the federal health insurance plan for people over the age of 65 and some younger people who meet specific criteria. Other people may have primary insurance (through employment), with Medicare as their secondary insurance option.
To know whether your plan pays for in-home caregiving, you may need to know the differences between the three types of Medicare, which are listed below.
1. Traditional (sometimes called original Medicare) Medicare
Traditional Medicare is administered by the government. According to Medicare.gov, this is how Medicare works to cover people’s healthcare costs:
Medicare Part A (hospital insurance): Part A covers inpatient hospital stays, care in a skilled nursing facility, hospice care, and some home health care.
Medicare Part B (medical insurance): Part B covers certain doctors' services, outpatient care, medical supplies, and preventive services.
Medicare Part D (prescription drug coverage): Part D adds prescription drug coverage to the following:
- Original Medicare
- Some Medicare Cost Plans
- Some Medicare Private-Fee-for-Service Plans
- Medicare Medical Savings Account Plans
Most people purchase supplemental plans from private insurance companies to pay for costs that Medicare does not cover. If someone has traditional Medicare with a supplemental plan, they can go to any Medicare provider. This means they can choose any physician, specialist, home health company, or rehabilitation center that accepts Medicare reimbursement.
2. Medicare Disability (obtained through disability benefits)
It is important to note that for people under the age of 65 who have qualified for disability benefits and have been on those benefits for two years, may qualify for traditional Medicare as mentioned above.
The other way to qualify for Medicare under the age of 65 is to have end-stage renal disease or ALS. The coverage will be the same under a disability as if you qualified for Medicare based on age.
3. Medicare Advantage Plans (also known as Part C)
Medicare Advantage plans are a type of Medicare health plan offered by a private company that contracts with Medicare to provide all your Part A and Part B benefits. Most Medicare Advantage plans also offer prescription drug coverage. The premiums for Medicare Advantage plans can be considerably lower than for original Medicare and the plans can offer more flexible benefits.
However, the choice of providers may be limited to a certain network of providers. You may prefer a certain home health company only to find out they are not contracted with your Medicare Advantage Plan. There may also be co-pays associated with a rehabilitation stay or other healthcare services.
Will Medicare Pay for an In-Home Caregiver?
The short answer is yes, but it can be complex and depends on which Medicare plan you have. Let’s take a look at the circumstances under which Medicare will pay for an in-home caregiver.
Under both traditional Medicare and Medicare Advantage plans, in-home caregiving (hands-on care) will be covered if you qualify for home health. To qualify for home health, you have to be under a doctor’s care and need intermittent skilled nursing and/or therapy services like physical and occupational therapy. A physician’s order is required. If in doubt, ask your doctor if he or she thinks you would qualify for home health.
In-home caregivers, or aides, are part of the home health team and are covered under the benefit. However, the aides can only help with bathing and dressing and cannot provide “custodial” tasks like transportation, shopping, companionship, cooking, and cleaning. In-home caregivers through home health provide a valuable service by helping people safely navigate recovery. The therapy and caregiver services can get you back on the road to health more quickly.
If your loved one needs custodial tasks, like those mentioned above, you would have to pay privately for these in-home caregiver services and many people do choose to do this once the home health benefit has expired. Long-term care insurance will also help pay for in-home caregivers, but there is often a 90-day waiting period and other criteria that must be met.
Keep in mind, that home health services are time-limited and the person receiving this Medicare benefit must be “homebound.” You will also want to ask about any time limits to home health coverage so that you can plan for any additional care needs beyond what Medicare pays for.
If your loved one is on hospice, this means they are receiving end-of-life care. This benefit is covered under both the traditional Medicare and Medicare Advantage plans. Hospice care includes in-home caregivers that can help with activities of daily living such as bathing, dressing, and transfers.
Just as with home health, hospice does not provide 24-hour care, but the period of time you can receive hospice is longer than for home health. Caregivers may usually come in from one to three times a week. If you need help more often than that, you would need to pay privately for these in-home caregivers.
Rehabilitation communities are specifically designed for intensive short-term nursing and rehabilitation services after a hospitalization. Original Medicare and Medicare Advantage plans both cover rehabilitation services although for differing numbers of days. With Medicare Advantage plans there may be a copay after a certain number of days.
Caregiving aides are part of the treatment team and are included in covered costs of care. The length of rehabilitation is determined by your insurance company. Some people can qualify for home health once they leave rehabilitation and go home. Home health can be a good bridge from intensive inpatient rehab to home therapy services.
In-home services covered by Medicare Advantage plans
In 2019, Medicare Advantage plans were allowed to cover a range of in-home services. According to Home Health Care News, “Other types of newly allowed supplemental benefits will be offered on a larger scale. For instance, about 13 percent of plans will cover family caregiver support services such as respite care or counseling.”
Companion services such as basic housekeeping, running errands, and shopping are other added benefits for Medicare Advantage plans. The criteria for qualifying for these caregiver services are stringent with the goal of keeping seniors healthy and out of the hospital.
The best thing to do is contact your insurance company to see if they are already covering in-home caregiving services and what you need to do to qualify. Although the Centers for Medicare and Medicaid Services have issued guidelines, each insurance company will determine eligibility. As this benefit grows, it could mean big savings for families who would otherwise have to pay for caregivers. Time will tell how many families can take advantage of this new benefit.
Will Medicare Pay for Other Costs Associated With Caregiving?
As you may know, caregiving involves more than just paying for a caregiver. Durable Medical Equipment, also abbreviated as DME, can be very expensive. Durable medical equipment includes a wide range of equipment including wheelchairs, hospital beds, commodes, oxygen, canes, test strips, and much more.
Fortunately, Medicare can help with many of these costs. If you need DME in your home, your doctor or treating practitioner (like a nurse practitioner, physician assistant, or clinical nurse specialist) must prescribe the type of equipment you need by filling out an order. It’s a good idea to ask if you are unsure about whether something can be covered because it just might be. There may be co-pays or other costs associated with covered equipment. However in most cases, you will have a choice of renting or buying the equipment.
Medicare does not cover home modification costs. Medicare will, however, pay for an occupational therapist (through the home health benefit) to do a home modification assessment and make recommendations based on that assessment. Major home accessibility modifications are costs you would have to cover yourself or through some other community resource.
Medicare and Caregiver Costs
Although Medicare has its limitations, it is possible to maximize the benefits it does offer. Covering caregiver costs has yet to be incorporated as part of a larger plan that includes not only Medicare but other state and federal programs as well. However, with some research and diligence, you can start to learn how to cover caregiving costs for you and your family.
- “What’s Medicare?” Medicare.gov, www.medicare.gov/what-medicare-covers/your-medicare-coverage-choices/whats-medicare.
- Mullaney, Tim. “Few Medicare Advantage Plans Will Offer New Home Care Benefits in 2019.” Home Health Care News, 4 November 2018, homehealthcarenews.com/2018/11/few-medicare-advantage-plans-will-offer-new-home-care-benefits-in-2019/
- “Durable Medical Equipment (DME) Coverage.” Medicare.gov. www.medicare.gov/coverage/durable-medical-equipment-dme-coverage
- Holly, Robert. “CMS Loosens Medicare Homebound Requirements, Suspends Review Choice Demo.” Home Health Care News, 30 March 2020, homehealthcarenews.com/2020/03/cms-loosens-medicare-homebound-requirements-approves-use-of-telehealth-in-home-health-care/