Does Medicare pay for home health aides?

Many families picture Medicare sending a helper several hours a day to bathe, dress and keep an eye on Mom. Medicare does pay for home health aides, but in a narrower way than most people expect. Knowing the rules up front helps you plan for the gaps.

When Medicare pays for an aide

Under Original Medicare, a home health aide is covered only when all of these are true:

• There is also a skilled need. Your loved one must be getting skilled nursing, physical therapy, speech-language therapy or occupational therapy at the same time. Aide visits ride along with skilled care; they cannot stand alone.
• They are homebound. Leaving home is not recommended or is very hard without help, and leaving takes a lot of effort.
• A doctor ordered it after seeing them. A doctor or allowed provider must see your loved one in person and confirm the need for home health before care begins.
• The agency is Medicare-certified, and the care is part-time or intermittent.

How many hours will Medicare pay for?

Part-time or intermittent generally means skilled nursing and aide services combined for up to 8 hours a day, and no more than 28 hours a week. For a short time, if the provider finds it necessary, Medicare may allow up to 35 hours a week, still under 8 hours a day. In practice, aide visits are often shorter and less frequent than those limits.

When the skilled need ends, for example when therapy goals are met, the aide visits end too.

What Medicare does not cover at home

• Care around the clock, 24 hours a day.
• Meals delivered to the home.
• Homemaker services like shopping, cleaning and laundry that are not part of the care plan.
• Personal care such as bathing and dressing when that is the only help needed.

Medicare home health aide vs. private home care

Signs Medicare home health will not be enough

Medicare home health is excellent at what it is built for: getting someone through a recovery or a flare-up at home. It struggles when the real need is constant. Watch for these:

• Your loved one cannot be left alone safely for more than an hour or two.
• Nights are the hardest part, with wandering, falls or calling out.
• The family caregiver is exhausted, sick or missing work.
• The skilled need has ended, but the need for daily help has not.

Any of those means it is time to plan for paid help, a different setting, or both.

Other ways to pay for help at home

• VA. Enrolled veterans may qualify for the VA’s Homemaker and Home Health Aide program, with aides from VA-contracted agencies, or for Veteran-Directed Care. See VA long-term care benefits.
• Long-term care insurance, which commonly pays for home care once someone needs help with a set number of daily activities.
• Medicaid, which in many states offers in-home services for people who qualify financially and medically. Utah’s local Area Agencies on Aging can explain the in-home programs available where your loved one lives.
• Hospice, if your loved one is terminally ill. Hospice includes aide visits as part of the benefit, without the skilled therapy requirement. Compare the two in hospice vs. home health.

If Medicare home health is ending too soon

Before covered home health services end, the agency should give you a Notice of Medicare Non-Coverage at least two days ahead. If you disagree, you can ask for a fast appeal by an independent reviewer, the BFCC-QIO, no later than noon the day before the end date on the notice. The reviewer usually decides by the end of the day after it gets what it needs.

What to do next

1. Ask the doctor whether your loved one has a skilled need that qualifies for home health.
2. Choose a Medicare-certified agency that serves your address, and ask how often an aide will come.
3. Map out the hours no one is covering, and price private help for just those hours.
4. If needs keep growing, compare home health with assisted living before a crisis forces the choice.

Common questions

How do I get Medicare to pay for a home health aide?

Your loved one needs a doctor’s order after an in-person visit, must be homebound, and must also need skilled nursing or therapy. A Medicare-certified agency then adds aide visits to the plan.

Does Medicare pay for in-home care for dementia?

Not for ongoing supervision or personal care alone. If a person with dementia is homebound and has a skilled need, such as therapy after a fall, Medicare home health and an aide may be covered for a time.

Does Medicare pay for a live-in caregiver?

No. Medicare does not cover 24-hour care at home.

Does Medicare pay family members to provide care?

No. Medicare pays Medicare-certified agencies, not relatives. Some veterans can pay family caregivers through VA programs.