Which Type of Care is Not Covered by Medicare?

This blog is part of a series in our comprehensive guide to home care. To access our guide to home care, click here.

To say the world of Medicare is complicated might be the understatement of the century. Not only is general Medicare divided into four different parts – supplemental insurance plans sold by private companies have added additional layers of complexity to the program. When it comes to the kinds of care not covered by Medicare, the main focus of this blog will be to clarify that question with regard to home care specifically; as it’s important to know if, when and how Medicare covers home care expenses. This is especially relevant if you’re dealing with a home bound senior loved one after hospitalization, or a senior who has one or more conditions that require ongoing care.

To understand the types of care Medicare does not cover, it’s important to know two things:

1) Medicare is divided into four general parts; Parts A, B, C and D. Parts A, B and C contain some level of coverage for home care, but since part C involves additional costs to the consumer for coverage beyond the original government program – this blog will primarily discuss parts A and B.

2) There are two types of home care – home health or medical home care, and non-medical home care.

Does Medicare Pay for an In-Home Caregiver?

In a limited capacity, Medicare can cover an in-home caregiver, but coverage depends largely on a senior’s care needs as defined by the government. These care needs are generally outlined in the senior’s care plan – a document written by a physician or nurse that the senior will receive after they are discharged from a hospital or Skilled Nursing Facility (SNF). Often, a senior’s true care needs go beyond what Medicare is willing to provide coverage for.

When Medicare pays for a non-medical, in-home caregiver, it only does so if that caregiver is part-time and working alongside someone who is in the home providing another form of skilled care; like skilled nursing, physical therapy, speech therapy, or occupational therapy. Medicare does not pay for 24-hour home care, home meal delivery, or caregiver services like house cleaning (services not specifically related to a senior’s care plan).

It generally does not pay for Activities of Daily Living (ADLs), which are services critical for many seniors – unless, again, that kind of care is occurring alongside skilled care. ADLs include things like bathing, dressing, feeding, and toileting. For more detailed information on ADLs and what they entail, click here.

The Difference Between Medicare Part A and Part B

Medicare Part A primarily covers inpatient hospital care, skilled nursing facility care, hospice care, and limited home health care. It focuses on services that require hospitalization or facility-based care.

Medicare Part B covers outpatient care, including doctor visits, preventive services, outpatient procedures, medical supplies, and some home health care. It focuses on medically necessary services and preventive measures that do not require inpatient admission.

Does Medicare Part B Cover Caregivers?

Even though many people think the “outpatient services” covered by Medicare part B include caregivers, the reality is that Medicare’s coverage of in-home care is extremely limited. In most cases, the highest number of hours a caregiver covered by Medicare can work is 8 hours per day or 28 hours per week. It’s important to remember that Medicare-covered home care only kicks in when there is some other form of skilled care being offered – therefore, a caregiver (like a CNA or HHA) covered by Medicare is almost always working alongside or in conjunction with another skilled care provider.

Does Medicare Pay for Home Health Care After Hospitalization?

It depends. If the post-hospitalization care plan involves other skilled services (like skilled nursing or certain types of therapy), Medicare may provide intermittent home care through Medicare Part A. However, if the care plan doesn’t involve skilled service aside from home care, the cost of a caregiver (or home assistant) is not covered.

Any post-hospitalization care within 14 days of a hospital discharge, if covered by Medicare, is covered under Part A. Any care provided 100 days after a hospital or SNF discharge will, if covered, be covered by Medicare Part B.

Regardless of whether a senior is covered through Part A or B, hours are virtually always limited to 28 hours per week at most.

Is In-Home Nursing Care Covered by Medicare?

Interestingly enough, Medicare Part A does cover some home health care (nursing care), in addition to hospice care, inpatient hospital stays, and care in a skilled nursing facility (SNF). However, it only covers this kind of care after a hospitalization or stay in a SNF, and the amount provided is very limited. More specifically, if you spend at least three consecutive days in either a hospital or Medicare-covered SNF, Medicare part A covers your first 100 days of home health care. That said, you still have to meet the eligibility requirements mentioned above (i.e. with regard to skilled care) and a few additional eligibility requirements. You also must receive home health care services within 14 days of your SNF or hospital discharge in order to be covered by Medicare Part A. Any care provided past the 100-day mark is covered by Medicare part B.

Which Type of Care is NOT Covered by Medicare?

A significant area where Medicare coverage falls short is in-home care and support for ADLs. Many seniors and individuals with chronic illnesses or disabilities require assistance with ADLs to live independently at home. This type of care is often provided by home health aides or personal care aides and includes:

Bathing and Grooming: Assistance with personal hygiene tasks, including bathing, shaving, and hair care.

Dressing: Help with putting on clothes and getting ready for the day.

Eating: Assistance with feeding oneself or preparing meals.

Using the Bathroom: Help with toileting, including transferring on and off the toilet, and maintaining continence.

Mobility: Assistance with moving around the home, including transferring from a bed to a chair or wheelchair.

Medication Management: Ensuring that medications are taken correctly and on time.

Since these services are considered non-medical, Medicare does not cover them under Parts A or B. Beneficiaries who need this type of care must look for alternative options, such as:

Long-term Care Insurance: Purchasing long-term care insurance can help cover the costs of in-home care and support for ADLs.

Veteran’s Benefits: If you are a veteran or the surviving spouse of a veteran, you may be eligible for certain benefits like the Aid and Attendance benefit or the Homemaker benefit.

Private Pay or Personal Savings: Wealthy seniors often pay for caregivers out-of-pocket, or through personal savings.

Community Programs: Exploring local and community-based programs that offer support services for seniors and disabled individuals.

Understanding what Medicare does not cover, particularly in the realm of non-medical in-home care and ADLs, is essential for people to make informed decisions about their healthcare and financial planning. By recognizing these gaps and exploring additional insurance options or savings strategies, seniors in need can better prepare for their healthcare future and ensure they receive the necessary support to maintain their quality of life.

by Jeremy Brooker
Amada blog contributor
May 28th, 2024