Do I have Medicare’s “in-home” coverage?

There are two distinct types of “In-Home” care for seniors in Medicare. They are Home Health and Home Care. They sound very similar, but they very different services — especially when it comes to what Medicare covers.

Home health (Medical care at home)

Home Health is medical care provided in the home and is usually ordered by a doctor after an illness, surgery, hospitalization, or worsening condition. A nurse or therapist visits periodically — not full-time. Home Health is generally short-term and medically necessary.

Typical services include: Skilled nursing care; Physical therapy; Occupational therapy; Speech therapy; Wound care; Medication management; Monitoring chronic conditions

Under Original Medicare (Part A and/or Part B), Medicare generally pays 100% for covered Home Health services if the person qualifies. To qualify, in general, the patient usually must: be under a doctor’s care, need intermittent skilled care, be considered “homebound” (leaving home is difficult), and use a Medicare-certified home health agency.

If these qualifications are met, you can expect Medicare to pay for: Skilled nursing visits; therapy visits; medical social services; some home health aide care only if tied to skilled care, and certain medical supplies. On some plans, you can expect to have some out-of-pocket expenses like 20% coinsurance for durable medical equipment (walker, wheelchair, etc), and any non-covered expenses.

It is important to understand the limitations, however, such as what Medicare does not pay for: 24-hour care; Meal preparation; Housekeeping; Long-term bathing/dressing help by itself.

Home care (Custodial or personalcCare)

In contrast, Home Care focuses on daily living assistance, not medical treatment. It is provided by a caregiver or aide and does not require a doctors order.

Examples of typical services include: bathing, dressing, toileting, meal preparation, light housekeeping, companionship, transportation and medication reminders (not administration).

Original Medicare generally does NOT pay for Home Care if it is only personal assistance. That means most families pay either out of pocket, through long-term care insurance, through Medicaid (if financially eligible), or through VA benefits (for qualifying veterans).

Costs vary by location and agency, but many areas average: $25–$40 per hour, or more for overnight or 24-hour care.

In Bluffton and nearby parts of South Carolina, rates are often somewhat lower than large metro areas, but still substantial for ongoing care.

Simple way to remember the difference:
Home health: Medical, nurse or therapist, short-term recovery/support, usually Medicare-covered if qualified, requires doctor order

Home care: Non-medical, caregiver or aide, long-term daily help, usually private pay, no doctor-order usually needed

Occasionally there is confusion because many people assume Medicare covers bathing help, cooking, supervision for dementia, or full-time in-home caregiving. However, in most cases, it does not, unless those services are part of a short-term skilled Home Health episode.

For example:
• After a hip replacement, Medicare may cover a nurse and physical therapist visiting the home.
• But Medicare usually will not pay someone to stay all day helping with meals and bathing long term.

Some Medicare Advantage plans offer limited supplemental in-home support benefits, such as: a few hours of caregiver help, meal delivery, transportation, or post-hospital support. These benefits vary widely by plan and county.

Makrauer is an independent insurance broker and Certified Medicare Advisor living in Bluffton. nanette@health-wealth-insurance.com www.health-wealth-insurance.com