Original Medicare only covers treatment by certain types of caregivers. Rules apply depending on the kind of care a person receives and the services a caregiver provides.
A person must meet specific eligibility rules to get home care services, and sometimes, extra costs may apply that Medicare does not cover.
This article discusses 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
Medicare pays for caregivers when:
- 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 the doctor regularly reviews
Although Medicare stipulates that a person must be homebound to receive coverage, they may leave home for short periods to attend doctor visits or for non-medical reasons, such as religious services.
A person must usually qualify under Medicare parts A and B to get home care coverage. Some of the services Medicare covers include:
- part-time skilled nursing care
- physical therapy
- occupational therapy
- speech and language therapy
- part-time home health aide services
Some Medicare Advantage plans tailor their benefits to groups of people who have a specific chronic illness. These Special Needs Plans (SNPs) help those with certain conditions, such as diabetes, chronic heart failure, or dementia.
Medicare does not pay for caregivers that provide the following:
- 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 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.
Paying for care can be expensive. However, there are options available to help individuals cover costs they would otherwise have to pay out-of-pocket, including:
- Medigap: Private insurance companies administer Medicare supplement insurance, or Medigap plans, to help to pay Medicare parts A and B copayments, coinsurance, and deductibles. Medigap plans K and L have an out-of-pocket limit. Once someone’s costs reach this limit, the plan pays 100% of Part B services, which could lower the amount paid for caregivers.
- Medicaid: Individuals qualify for Medicaid if they have limited resources and income or a disability. The rules can differ by state. Medicaid may help with costs that Medicare does not cover. The Medicaid Self-Directed Care Program allows people to hire family members to care for them. Family members of veterans or people with disabilities may qualify. A local Medicaid office can offer advice on eligibility and answer questions about enrollment.
- Medicare Savings Programs (MSP): Medicare Savings Programs are plans for those with limited resources. How the plans work can differ by state, but all assist with paying Medicare out-of-pocket costs.
- Supplemental Security Income (SSI): People qualify for Supplemental Security Income (SSI) because they have limited income and resources or a disability. It provides a cash benefit each month, which is different from the Social Security retirement benefit.
- Extra Help: Those who qualify for Medicaid, SSI, or an MSP automatically qualify for Extra Help. The program helps pay for the cost of prescription medication under Medicare Part D, including monthly premiums, coinsurance, and deductibles. The coverage levels depend on someone’s income and resources.
Medicare Part B benefits help pay for home healthcare services, including caregivers. It does not cover 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, Medicare may cover it as DME. Medicare Part B pays for DME that a doctor has prescribed but does not cover medical supplies, such as bandages, used at home.
People may get help with out-of-pocket costs through Medicare Advantage plans or Medigap. People with limited income and resources can find additional support through Medicaid and other programs.