Original Medicare covers certain types of caregivers. Rules apply depending on the kind of care a person receives and the services a caregiver provides.
Original Medicare consists of Part A, which covers inpatient services and Part B, which covers outpatient services, including some at-home care.
A person must meet certain eligibility rules to get home care services, and sometimes, extra costs may apply that Medicare does not cover.
In this article, we discuss the different types of caregivers, what Medicare pays for, and help with out-of-pocket costs.
We may use a few terms in this piece that can be helpful to understand when selecting the best insurance plan:
- Deductible: This is an annual amount that a person must spend out of pocket within a certain time period before an insurer starts to fund their treatments.
- Coinsurance: This is a percentage of a treatment cost that a person will need to self-fund. For Medicare Part B, this comes to 20%.
- Copayment: This is a fixed dollar amount that an insured person pays when receiving certain treatments. For Medicare, this usually applies to prescription drugs.
There are different types of in-home caregivers. Some help with nonmedical personal care, while others offer medical services.
Common types of caregivers include:
- companion services: offering fun activities, supervision, or company
- personal care services: assisting with personal care, including exercise, eating, dressing, and more
- homemaker services: helping with housekeeping, meals, shopping, and transport
- skilled care: often licensed healthcare professionals who help with wound care, physical therapy, or medicine
Services provided by caregivers could be covered by Medicare if:
- a person is under the care of a doctor
- a doctor has certified a person as homebound
- the care delivered is through a written plan that is regularly reviewed by the doctor
A person must usually have Medicare parts A and B to be eligible for home care. Some of the services covered by Medicare include:
- part-time skilled nursing care
- physical therapy
- occupational therapy
- speech and language therapy
- part-time home health aide services
Private insurance companies administer Medicare Advantage (Part C) plans. Sometimes these plans will cover extra services, such as transportation to medical appointments and adult daycare.
Some Medicare Advantage plans also tailor plan benefits to groups of people who have a specific chronic illness.
Although Medicare stipulates that a person must be homebound, they may leave home for short periods to attend doctor visits, or for nonmedical reasons, including religious services.
Medicare does not pay for:
- 24-hour care at home
- meal delivery
- homemaker services when this is the only service needed
- supervision, or personal care, when this is the only service required
Medicare Part B covers durable medical equipment (DME), but it does not include items such as bandages and medical tape.
Medicare covers medically necessary DME when supported by a doctor’s letter. Equipment may include:
- blood sugar monitor and test strips
- canes, crutches, scooters, walkers, and wheelchairs
- commode chairs
- Continuous Positive Airway Pressure (CPAP) devices
- hospital beds
- nebulizers and medications
- oxygen equipment
- suction pumps
- traction equipment
To qualify as DME, an item must:
- be able to withstand steady use
- be needed for a medical reason
- only be used by someone who is sick or injured
- be used in a person’s home
- be expected to last at least 3 years
A person may need to rent or buy the DME they need. Medicare only pays for DME supplied by companies enrolled with Medicare.
Suppliers not enrolled with Medicare can charge more for DME. A person is responsible for paying all costs over the Medicare-approved amount.
Medicare has provided a helpful search tool for individuals to locate DME in their area.
There are options available that can help individuals cover costs they may have to pay out of pocket.
Medicare supplement insurance (Medigap) plans help to pay Medicare parts A and B copayments, coinsurance, and deductibles. Private insurance companies administer the plans.
Medigap plans K and L have an out-of-pocket limit.
Once a person’s costs reach this limit, the plan pays 100% of Part B services. This could lower the amount paid for caregivers.
People who qualify for Medicaid may be eligible for help paying costs not covered by Medicare.
Individuals qualify for Medicaid if they have limited resources and income, or if they have a disability.
Rules around Medicaid can differ depending on the state in which a person lives. A local Medicaid office may be able to offer advice on eligibility and answer questions about enrollment.
The Medicaid Self-Directed Care Program allows individuals to hire family members to provide their care. Family members of veterans or people with disabilities may qualify.
Medicare Savings programs (MSP)
Medicare Savings programs are plans for those with limited resources.
How the plans work can be different from state-to-state, but all assist with paying monthly premiums.
There are 4 different types of MSP:
|Qualified Medicare Beneficiary (QMB) program||helps pay for Medicare Part A and Part B premiums, deductibles, coinsurance, and copayments|
|Qualifying Individual (QI) program||covers Part B premiums only|
|Specified Low-Income Medicare Beneficiary (SLMB) program||covers Part B premiums only|
|Qualified Disabled and Working Individuals program||covers Part A premiums only|
Supplemental Security Income (SSI)
People who qualify for Supplemental Security Income (SSI) receive a cash benefit each month. This is not the same as a Social Security retirement benefit.
A person may be eligible for SSI if they have limited income and resources, or if they have a disability.
Extra Help is available to those who qualify. This program helps to pay for the cost of prescription medication under Medicare Part D, including monthly premiums, coinsurance, and deductibles.
The level of coverage is based on a person’s income and resources.
Those who qualify for Medicaid, SSI, or one of the Medicare Savings programs automatically qualify for Extra Help.
Medicare Part B benefits help pay for home healthcare services, including caregivers.
The coverage is not available for 24-hour care, meal delivery, and personal care when personal care is all that is needed.
If a person expects to use an item, such as a walker, for at least 3 years, it may be covered as durable medical equipment (DME). Medicare Part B pays for DME that has been prescribed by a doctor. Part B does not pay for medical supplies, such as bandages, used at home.
People may get help with out-of-pocket costs through Medicare Advantage plans or Medigap, and there is additional support available for those with limited income and resources.