Does Medicare Pay for Home Health Care for Dementia Patients?

Nowadays, it seems like everybody’s living a lot longer. Medicine has greatly progressed in areas like surgeries, medicine, and even in-home health care. These medical advancements help combat physical and mental conditions, such as dementia.

Currently, most Medicare plans will provide coverage for skilled in-home health care. This care is provided to patients with qualifying conditions per the discretion of your doctor.

For senior citizens, conditions like Dementia are becoming an increasingly prevalent topic in health care. In 2015, there were an estimated 50 million people affected by dementia worldwide. (Alzheimer’s Disease International, 2018)

With such conditions, in-home health care is often an effective treatment option. Having constant treatment and supervision can help patients return to normal and happy life as soon as possible.

For those who are new to the Medicare system, it is important to know what your healthcare options are, especially before you are injured or diagnosed. This will help you get the services you need and retain the quality of life that you deserve.

Below is a breakdown of everything you need to know about receiving the in-home care you need. Topics include:

• Requirements for getting in-home care
• What is Medicare?
• Services provided
• Getting the most out of your benefits
• How to claim in-home care benefits
• Payments and coverage
• In-home services not covered by Medicare
• Alternatives within Medicare: PACE Program

What is Medicare?

Medicare is an insurance company run by the government. It provides health and medical insurance for people age 65 and over. You can also be on Medicare if you are under 65, but have a qualifying disability or disease such as Lou Gehrig’s disease.

There are two main parts of Medicare insurance: Part A and Part B. Hospital insurance is covered in Part A, and medical insurance is covered in Part B. Everyone who signs up for Medicare receives Part A, but Part B is optional.

There is another type of Medicare plan called Medicare Advantage or Part C. Medicare Advantage encompasses both Parts A and B into one insurance plan. Medicare Advantage may also cover some prescription drug costs, depending on your plan.

What home care is covered by Medicare?

If your doctor determines you are eligible, you will receive benefits for temporary skilled in-home care. According to the Alzheimer’s Association, Medicare will cover up to 100 days of in-home health care. (Alz.org, 2018)

One of the key parameters of getting Medicare coverage on in-home care is that health care needs to be skilled care. Skilled care can include nursing care, physical therapy, and speech-language pathology. (Medicare.gov, 2018)

While it is called home health care coverage, actual services may not be limited to in-home services. This coverage can also apply to treatments at facilities like Physical Therapy centers.

If you have a condition like dementia or Alzheimer’s, there are some additional health care options for you. As of 2017, Medicare now covers cognitive assessments and professional care planning. (Alz.org, 2018)

Having options like cognitive assessments means that you will be able to find out if you have a mental condition faster. With the care planning with a professional, choosing your care no longer becomes guessing.

Requirements for receiving home care coverage

While in-home health care services are available for all patients who are enrolled in Original Medicare and Medicare Advantage, there are several parameters that must be met. You will need to be under the care of a physician, and he or she will determine if you meet those parameters.

Your physician will determine whether you need skilled in-home services for your condition based on several factors. The first factor is the severity of your condition, and whether it will require skilled in-home care.

One key criterion for determining the severity of your condition is whether you need to be certified as homebound. You actually have to be certified as homebound by your physician to receive in-home health care.

What being homebound means is that you have difficulty leaving your house without the use of a cane, wheelchair, etc. Or your condition makes going out a major effort and/or potentially risky. (Medicare.gov, 2018)

While it may not be recommended, being certified as home-bound does not mean you are under house arrest. You are still able to leave your home for short non-medical reasons like going to a church service or something similar.

Another factor that will affect your eligibility is whether your condition is expected to improve, and how quickly. For example, if you are recovering from a hip replacement surgery, you would most likely qualify for in-home services.

This example brings up another factor. This factor is the complexity of the condition. Your doctor will determine if your needs are complex enough to require the care of a professional, like a physical or occupational therapist in the case of hip replacement.

Claiming your home health care benefits

So, you’ve been under the care of a doctor, he has certified you as homebound, and he has determined that your condition requires in-home care. What next? Well, now comes the part of actually setting up the in-home health service.

Your doctor is the one that will set up your claim for in-home care benefits, the next step is to find a suitable in-home service. Medicare has a network of approved home care agencies that are covered by your care plan.

When choosing your in-home care provider, sometimes it can be difficult to find the best service. There are numerous providers out there, especially in large cities. Fortunately, Medicare has a comparison tool on its website to help find the perfect option for you.

Getting the most out of your benefits

Everybody wants to get the best healthcare possible. However, sometimes trying to figure out how your benefits work and how to get the care you need can be confusing. Fortunately, there are several resources and tools that can help you.

One such tool is, of course, the official Medicare website. This website has a ton of information about Medicare plans and policies. To visit the Medicare site, click here.

Another useful tool for finding the best care is the State Health Insurance Assistance Program (SHIP). This program is a consulting service that helps you get the most out of your Medicare benefits. For more information, visit their website here.

If you aren’t under a Medicare plan yet, don’t worry. Medicare is easy to apply for, and often not necessary if you are on Social Security benefits. If you need to apply for Medicare, you can do so at your local Social Security office.

If you need to find the necessary forms, or if you want to enroll in Medicare before you retire, the Social Security website has printable forms and an online application process for the early enrollment.

Special plan options for patients with dementia

If you have a mental condition like Alzheimer’s or another form of dementia, you may qualify for a plan that is specific to your condition. (Medicare.gov, 2018) These plans are called Medicare Special Needs Plans (SNPs).

Having an SNP provides an advantage for getting the right in-home care. This is because everything in your plan is tailored to your condition, which streamlines the process of finding a specific caregiver.

Premiums and payment information

Fortunately, for patients with Medicare policies, there are no additional costs for in-home care on top of your regular Medicare premiums and copayments. These are covered under your Original or Advantage plan.

While the services are fully covered by Medicare, there is a caveat if you require certain medical equipment. According to Medicare’s official website, you will be required to pay 20% of the Medicare-approved amount for the equipment. (Medicare.gov, 2018)

If you have more than one type of medical insurance, you will need to talk to representatives of both companies. Your in-home care coverage may be more comprehensive with one company, or it may be less expensive.

Also, if you receive medical benefits from the Veterans Administration (VA) you may want to talk to your local VA representative. You can have both VA and Medicare at the same time, however, there will most likely be differences on what each will cover.

While you can have both VA and Medicare at the same time, the benefits will not overlap. For example, Medicare will not cover a visit to the VA hospital and vice versa.

Although Medicare is designed to be as affordable as possible, there are financial aid options if you are in need. One such option is Medicaid. Medicaid is a government program that helps make Medicare more affordable.

Another set of programs that help reduce Medicare costs are the Medicare Savings Programs (SMP). These are state-level programs that provide financial assistance for individuals/families within certain monthly income brackets.

NOTE: You would only qualify for Medicare Savings Programs if you are still working. This program does not apply to individuals who are retired.

If you live in certain areas, there is another program that is extremely beneficial. This program is the PACE Program. The PACE is a Medicare and Medicaid service that stands for Programs of All-Inclusive Care of the Elderly.

With the PACE program, you are connected to a community of healthcare professionals. This increases the effectiveness of the care and their coverage is much more comprehensive.

Unlike regular Medicare coverage, coverage from the PACE program covers many more services. Some of the services that PACE covers include meal deliveries, transportation to medical facilities, and long-term home care.

What services are not covered?

While there are several services that Medicare covers, there are a few that they do not. Normally, Medicare’s coverage is sufficient for a patient’s needs. However, here is what Medicare does not cover in case you need more care than what is originally provided.

Medicare does cover skilled in-home care. However, they do not cover general in-home care if this is all that you need. This would be services like bathing, dressing, and so on. Medicare also doesn’t cover 24/7 care.

Depending on where you live, this may not actually be the case. Some State Medicaid Programs do offer coverage help on custodial (unskilled) care for older adults. (Medicare Matters, 2018)

For lower-income families, there may also be some Medicaid vouchers available for custodial care. There is a tool called BenefitsCheckUp that will help you find these programs to see if you qualify.

Another thing that Medicare does not cover is long-term care. As previously stated, Medicare only covers up to 100 days of skilled in-home care. Anything that goes beyond that will be your responsibility.

Now, your doctor may recommend that you receive care for longer than this. However, Medicare will not be able to cover the additional care. Be sure to explore all of your options before beginning any care program.

One such option for receiving long-term or additional care is the PACE program. While Original Medicare and Medicare Advantage don’t cover long-term care, the PACE program is an exception.

Since PACE is a community-based program, sometimes long-term custodial care is an option for qualifying patients. If you are unsure if your state has PACE programs, the official Medicare site has a PACE plan finder tool.

Further guidance and recommendations

No matter what you go through, keeping your quality of life is always important. When something changes, whether it’s a knee replacement, or you are diagnosed with Alzheimer’s, all of these affect your quality of life. Fortunately, Medicare can help.

Whether you are close to turning 65 or already have, it is important to know what kind of medical coverage you have in case something happens. Hopefully, this article has given you some insight into what kind of Medicare coverage you have or might need.

With all of the options that Medicare provides for covering in-home health care, you can return to your life stronger than ever. Just because you have a condition doesn’t mean you can’t live life to the fullest.