Until a few weeks ago, I had no idea that Medicare covers long-term home care services. I was under the impression that, at most, Medicare covered a few hours of homecare for a few days after someone comes home from a hospital stay. I was wrong about that and I’m not alone. I’ve read dozens of articles saying that Medicare doesn’t pay for homecare.
What tipped me off was a piece I stumbled upon from Kaiser Health News this month, explaining that federal law actually requires Medicare to pay for up to 35 hours a week of homecare and in-home skilled care combined for patients who qualify, with no copayments or deductibles.
This is potentially a hugely important benefit for millions of people with disabilities or chronic health conditions who do not qualify for Medicaid and who want to live at home. Yet it is not only a well-kept secret; patients who are entitled to the benefit need to be prepared to fight to get it – something that’s hard to do when you are in a vulnerable condition.
Why the Confusion?
It seems to me that a primary source of confusion is that Medicare will not pay for homecare if someone only needs what they call “custodial care.” What is custodial care? It’s another term for “activities of daily living,” that is, help with bathing, dressing, eating, toileting, keeping a medication schedule and similar needs. In order to get homecare for help with activities of daily living, you must also need some kind of intermittent skilled care at home, such as a service you might receive from a visiting nurse or physical therapist once or twice a week.
If you are confused and think this is complicated, you would be right. Perhaps the rules are designed to discourage people from using the benefit; perhaps they are not. I suppose it makes a perverse kind of sense that the federal Centers for Medicare and Medicaid (CMS), which runs the Medicare program, doesn’t advertise the homecare benefit, given the cost of long-term care. But the bottom line is that anyone who is qualified should be able to get homecare through Medicare. That said, it will likely take quite a bit of work on the part of patients, their doctors, and family members.
One example from the Kaiser Health article illustrates how people are often unable to surmount the barriers to using Medicare’s homecare benefit. Colin Campbell has Lou Gehrig’s disease, has a feeding tube because he is unable to swallow, and needs help dressing, bathing and moving between his bed and his wheelchair.
While the writer points out that he meets Medicare’s requirements, Mr. Campbell hit a wall trying to services. Why? Because the 14 agencies he contacted all told him that Medicare would not pay for homecare; despite the fact that this is just not the case it is widely believed to be true. Today, Mr. Campbell spends $4,000 a month of his own money for homecare.
Obviously, millions of Americans do not have the option of paying for homecare themselves. For the rest of us, securing Medicare coverage for homecare will require persistence. John Gillespie is another example from the Kaiser article. Mr. Gillespie’s mother’s mother has ALS and he successfully appealed Medicare’s decision denying her homecare.
“You have to have a good doctor and people who will help fight for you,” he told Kaiser. “Do not take no for an answer.”
How Do I Qualify for Medicare’s Homecare Benefit?
Here are the specific qualifications:
- You must be enrolled in Medicare.
- You will need a prescription from your doctor for homecare for the purpose of helping you to maintain your health.
- You must be unable to leave home without difficulty.
- Most importantly, you must also need and be receiving intermittent skilled care prescribed by your doctor from a trained professional, such as a visiting nurse, or a physical, occupational or speech therapist.
If you meet these qualifications, Medicare is required to pay for up to 35 hours per week of skilled intermittent care and home care combined. So, for example, if someone receives two hours of physical therapy a week, their homecare benefit cannot exceed 33 hours a week. If they receive an hour of visiting nurse services each week, Medicare would only be required to cover up to 34 hours a week of homecare. All of these rules and requirements are spelled out in this Medicare publication.
As things stand, this is a highly unsettled picture that will require ongoing advocacy and education. For years, Medicare routinely refused to pay for skilled services provided in the home – such as nursing care or therapies – unless the patient could document that these services were improving their condition. In fact, under the law, people with Medicare are entitled to have these services paid for in order to maintain their condition or slow deterioration of their health – improvement is not a requirement but many people still believe that it is because of the way the Medicare program treated people for decades.
As part of the 2013 settlement of a class action lawsuit, Medicare was required to take steps to educate consumers, claims processers, medical providers and the judges who hear appeals of service denials about what the law requires Medicare to cover for in-home services. Still, consumers and their family members are faced with an entrenched culture where the first response is often a denial of services that Medicare beneficiaries are in fact entitled to under the law.
As the Center for Medicare Advocacy points out, if you are denied services under Medicare, your doctor is your most important ally. Not only does a doctor need to prescribe homecare services, but a doctor’s order is required to reduce or end them.
Patients or family members who plan to advocate for services from Medicare can review self-help materials available from the Center for Medicare Advocacy here. It is probably the best free resource available to assist anyone pursuing such a claim.