Does Medicare Pay for Home Care?What Georgia Families Should Know

Medicare pays for some home care, but only part-time skilled care for people who are homebound. It does not pay for ongoing help with bathing, dressing or meals when that is the only help someone needs. In Georgia, that kind of long-term help at home is usually paid for by Medicaid, through the Elderly and Disabled Waiver Program (EDWP).

The confusion comes from the words. Medicare uses "home health care" for nursing and therapy ordered by a provider. Families often mean "home care" as an aide who helps every day. This guide explains what Medicare covers, how long it lasts, what to do when it ends, and where Georgia families can turn next.

Medicare home care at a glance

• What Medicare covers: part-time or intermittent skilled nursing and therapy at home, plus some aide help while skilled care is going on
• Who qualifies: people who are homebound, under a provider's care and need skilled care
• Who provides it: a Medicare-certified home health agency
• What you pay: Medicare.gov says you pay nothing for covered home health services; medical equipment has a cost share
• What Medicare does not cover: round-the-clock care, meal delivery, housekeeping, and personal care when it is the only care needed
• Georgia option for long-term help: Medicaid's EDWP, if your loved one qualifies

What does "homebound" mean, and who qualifies for Medicare home health?

Medicare has a short list of conditions. Your loved one must meet all of them. According to Medicare.gov, they must:

• Be under the care of a doctor or other allowed provider, such as a nurse practitioner
• Have a provider order home health care and set up a plan of care
• Have an in-person visit with the provider about the reason for care, before services begin
• Need part-time or intermittent skilled nursing or therapy
• Be homebound, as Medicare defines it
• Get care from a Medicare-certified home health agency

"Homebound" has two parts. First, leaving home is not advised because of an illness or injury, or the person needs help, a device or another person to leave. Second, the person normally cannot leave home, and leaving takes a lot of effort.

What home care does Medicare cover, and what does it leave out?

The table sorts common needs into what Medicare home health covers and what it does not. It is based on Medicare's own home health services page.

Medicare also says plainly that it does not pay for most long-term care. This includes non-medical help with daily tasks, whether at home or in a facility. Medicare.gov points people to Medicaid, if they qualify, as one way to cover it.

How long will Medicare pay for home health care?

There is no set number of visits. Medicare.gov says people who qualify can get unlimited home health visits. But each visit must still meet the rules above. Care must stay part-time or intermittent, and Medicare caps how many hours a day and week count as part-time. You can see the current hour rules on Medicare's home health page.

Care continues as long as your loved one still qualifies and the provider keeps the orders current. The Medicare and Home Health Care booklet explains that Medicare pays in periods of care, and a person can have more than one. The plan of care is reviewed on a regular schedule. Once your loved one no longer needs skilled care, or is no longer homebound, Medicare home health ends.

How do you start Medicare home health after a hospital stay?

Many families first hear about home health from a hospital discharge planner. A provider must order the care, and a Medicare-certified agency must provide it. Your provider should give you a list of agencies that serve your area. They must tell you if they have a financial interest in any agency on that list.

You can compare agencies with Medicare's Care Compare tool, linked from the home health plan page. If your loved one has a Medicare Advantage plan, check with the plan. It may require you to use agencies in its network.

Before care starts, the agency should tell you, out loud and in writing, what Medicare will pay. It should also tell you what you would owe for anything Medicare does not cover. For services Medicare probably will not cover, the agency should give you an Advance Beneficiary Notice first.

What happens when Medicare home health care ends?

Home health agencies should give you written notice before they cut back or stop care. The booklet describes two main notices. A Home Health Change of Care Notice comes when services are reduced or the plan changes. A Notice of Medicare Non-Coverage comes at least two days before all covered services end.

If you think care is ending too soon, you can ask for a fast appeal. The reviewer is an independent group called the Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO). Medicare.gov says to ask no later than noon on the day before the end date on the notice.

1. 1

   Read the notice

   Check the date covered services will end and the BFCC-QIO phone number.

2. 2

   Call before the deadline

   Ask the BFCC-QIO for a fast appeal by noon on the day before services end.

3. 3

   Share your reasons

   Explain why your loved one still needs skilled care. Ask the doctor to support you.

4. 4

   Wait for the decision

   If the reviewer agrees, Medicare may keep covering care. If not, care after the end date may be your cost.

Does Medicare pay for hospice care at home?

Yes, for people who choose comfort care instead of treatment to cure a terminal illness. Medicare.gov says a hospice doctor, and the person's regular doctor if they have one, must certify the illness as terminal. The person must sign a statement choosing hospice. Hospice care is usually given at home.

Hospice can also arrange short respite stays so family caregivers can rest. Medicare does not pay for room and board at home, though.

What can Georgia families use when Medicare is not enough?

For long-term help at home, Georgia's main option is EDWP. It covers services Medicare leaves out, such as personal support with bathing and dressing, adult day health, home-delivered meals, respite and Structured Family Caregiving. The DCH EDWP fact sheet lists one of its conditions as needs that Medicare home health or hospice cannot meet.

EDWP is a Medicaid program, so your loved one must have Medicaid or be likely to qualify. They must also need a nursing home level of care. Read our full guide to what EDWP is and how it works. If a relative lives with your loved one, also read about Structured Family Caregiving in Georgia.

For free, unbiased help with Medicare itself, contact Georgia SHIP, the State Health Insurance Assistance Program. Counselors can review notices and help with claims and appeals. Call 866-552-4464 and choose option 4.

How A1-GA Healthcare Agency helps

A1-GA Healthcare Agency is a Georgia DCH-approved Medicaid home care provider in Norcross. We have provided in-home care since 2008. We serve metro Atlanta families through EDWP in-home services and Structured Family Caregiving. These cover the kind of ongoing daily help that Medicare does not.

If Medicare home health is ending, or never fit your loved one's needs, we can explain the EDWP steps and what to expect. Call 678-446-1832, Monday to Friday, 8am to 6pm. You can also check your eligibility online.