As Medicare open enrollment approaches on October 15, it’s important to understand the coverage options available for home care and home health services. With many choices and variables in play, it can be overwhelming to decipher what’s covered by Medicare versus Medicaid and how it all works. Let’s break it down to ensure you or your loved ones get the care you need.
What Does Medicare Cover?
Medicare, the federal health insurance program for people 65 and older or those with certain disabilities, provides coverage for medically necessary home health services. But, Medicare does not cover non-medical services such as personal care or housekeeping. Here’s what Medicare typically covers under home health care:
- Skilled nursing care. If prescribed by a doctor, skilled nursing services, such as wound care, injections, or monitoring of a serious illness, are generally covered.
- Physical therapy. Medically necessary physical therapy to restore or improve function after an illness or injury is covered by Medicare. In addition to physical therapy, Medicare covers occupational and speech therapy services when prescribed.
- Medical supplies. Medicare may also cover medical supplies such as catheters and wound dressings as part of home health care services.
Non-medical home care, which may include personal care (bathing, dressing), homemaker services (cleaning, meal prep), and companionship, are not generally covered by Medicare.
For example, if an older adult is recovering from a hip replacement, Medicare will cover skilled nursing care and physical therapy to aid in recovery at home. It would not cover a caregiver to assist with bathing or household chores.
What does Medicaid cover?
Medicaid is a joint federal and state program that provides health coverage for individuals with low income. Unlike Medicare, Medicaid often covers non-medical home care. However, Medicaid coverage varies from state to state, making it important to understand what your own state’s program offers.
In general, Medicaid covers:
- Home health services. Like Medicare, Medicaid often covers medically necessary services such as skilled nursing, physical and occupational therapy.
- Non-medical home care. In many states, Medicaid extends to personal care services, homemaker services, and adult day care programs. This support can be crucial for older adults who require help with daily tasks but do not need skilled medical care.
- Personal care services. Assistance with activities of daily living (ADLs) such as bathing, dressing, and eating may be covered under Medicaid.
So, for the hip replacement example above, Medicaid might cover a home aide’s daily help, such as bathing, dressing, and meal preparation. Again, coverage depends on the state’s program parameters.
Eligibility and costs
Eligibility for Medicare home health services is usually based on medical necessity while Medicaid eligibility depends on income, age, and state-specific guidelines. It’s crucial to understand these differences when planning for care.
- Medicare eligibility typically requires a doctor’s certification that home health care is medically necessary, and the patient must be homebound.
- Medicaid eligibility varies by state, but generally requires individuals to meet income and asset limits. States often provide non-medical home care through Medicaid waivers.
The costs associated with home health services can also vary. While Medicare covers 100% of medical care costs, there may be out-of-pocket expenses for non-medical services that are not covered. Medicaid, in contrast, may cover both medical and non-medical care, but eligibility can be much stricter.
Where to get help
Deciding what governmental healthcare coverage to get can be confusing. There are free resources available to help you navigate the options. Medicare.gov has resources for finding health and drug plans, providers, and can connect you directly with assistance. Help from Medicare is also available 24 hours a day, 7 days a week, except some federal holidays, at 1-800-MEDICARE (1-800-633-4227), where you can get information about coverage, eligibility, and costs – including answers to home health and home care questions. To find out how to contact your state’s Medicaid office, visit Medicaid’s Get Help page.
Understanding the differences between Medicare and Medicaid is essential to ensuring you or your loved ones receive the right type of care. As Medicare open enrollment begins on October 15, take the time to explore the options available. Whether it’s medical or non-medical care, having a clear understanding of coverage and eligibility can make a world of difference in managing healthcare needs.
