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Medicare/Medicaid

Medicare is a set of benefits you paid for through Social Security taxes and are entitled to at age 65 or if disabled. Medicaid is a federal and state program for low-income individuals, and provides specific coverage under special waivers for some services that Medicare does not cover such as long term personal care.

Many people believe that Medicare will cover all services required by the patient. That is not the case. For the home care benefit, very strict rules, called qualifying criteria, must be met before Medicare will pay for these services. While all the qualifying rules are important, there are two rules that are the most problematic for beneficiaries. These are the homebound status criteria and the skilled intermittent status rule.

Homebound Status generally means leaving the home causes a taxing effort or to leave home requires the assistance of another person for support or the use of an assistive device. These are broad and ambiguous statements that require a professional registered nurse to evaluate.

Skilled Intermittent Care generally means care that requires a licensed professional to perform and this care must be part time, generally meaning a visit of two hours or less.

Many people believe that Medicare should cover the services of a personal care aide needed for several hours a day. This level of care does not meet the criteria of skilled intermittent care and therefore is not a covered service of Medicare. This service can be covered by long term care insurance when such coverage has been purchased by the policy holder. Without this assistance, this coverage may be covered by a Medicaid Waiver when the eligibility criteria have been met or by private pay from the patient or a family member.

Medicare

Medicaid

Medicaid Waiver

Qualifying Criteria:

  • Must be homebound
  • Under the care of a physician
  • In need of skilled, intermittent care
  • Face to face requirement for physician intervention
Depends on state; however, many rules of Medicare will also apply to Medicaid. Depends on state and the specific waiver program the client has applied for and must fit the eligibility criteria for the program designated.

The following table identifies what is paid by each part of the Medicare benefit:

Medicare Part A Medicare Part B Medicare Part C Medicare Part D
Hospitals (acute care) Physicians Medicare Managed Care programs Drugs and biological agents
Home Health and Hospice benefits Durable Medical Equipment and supplies

We would be happy to discuss home care coverage criteria under any of these programs. Please contact us if you have any questions about Medicare and how it relates to the cost of home care services.