Do Medicare Advantage Plans Cover Home Health Care?

Medicare Advantage plans (Part C) offer an alternative way to receive Medicare benefits. Provided by private insurance companies, these plans must cover all services Original Medicare (Part A and Part B) covers. Many of these plans also include additional benefits not covered by Original Medicare, such as vision, hearing, or dental care.

Home health care involves medical services delivered in a person’s home to help them recover from an illness, injury, or surgery, or to manage a chronic health condition. This type of care allows individuals to receive necessary medical attention while remaining in the comfort and familiarity of their own residence. Home health care can be an important option for those who prefer to age in place or who need skilled care following a hospital stay.

Defining Covered Home Health Care Services

Home health care services covered by Medicare and Medicare Advantage plans generally focus on skilled medical care deemed medically necessary. This includes intermittent skilled nursing care, such as wound care, injections, medication management, and vital sign monitoring performed by a licensed nurse. Physical therapy, occupational therapy, and speech-language pathology services are also covered when provided by licensed therapists to help a patient regain function or improve communication.

Beyond direct therapeutic services, coverage can extend to medical social services that help patients and their families understand and manage the social and emotional aspects of an illness. Certain medical supplies, such as dressings for wounds, and durable medical equipment, like wheelchairs or oxygen equipment, may also be included.

Non-covered services include general homemaker duties, such as cleaning or cooking, if these are the only services needed. Personal care (custodial care), which involves help with daily activities like bathing or dressing, is also not covered if it is the sole care required. Round-the-clock care is not covered under the standard home health benefit.

Medicare Advantage Plan Coverage Requirements

For home health care to be covered, certain foundational requirements must be met, which Medicare Advantage plans must match. A physician’s order is necessary, indicating that the care is medically necessary for treating an illness or injury. The patient must also require intermittent skilled nursing care or therapy services, meaning care is needed on an occasional or part-time basis.

Another requirement is that the individual must be considered “homebound,” meaning it is difficult to leave their home without assistance and significant effort. Absences from home must be infrequent and for short durations, such as for medical appointments or religious services. The care must also be provided by a Medicare-certified home health agency.

Medicare Advantage plans, while required to cover the same home health benefits as Original Medicare, may have specific rules regarding how these benefits are accessed. Many plans utilize network providers, meaning care may need to be received from an in-network home health agency. Using an out-of-network agency could result in higher out-of-pocket costs or no coverage, depending on the plan type.

Prior authorization is a common feature of Medicare Advantage plans for home health services. This means the plan must approve the services before they are rendered for coverage to apply. Failure to obtain prior authorization can lead to the plan denying payment for the services. Out-of-pocket costs, such as copayments or deductibles, may also apply, varying based on the specific plan’s structure.

Accessing Home Health Care Through Your Plan

Initiating home health care through a Medicare Advantage plan begins with a consultation with your doctor. Your physician will assess your medical condition and determine if home health care is medically appropriate for your needs. If deemed necessary, your doctor will provide an order for the specific services required, outlining the type and frequency of care.

After obtaining a doctor’s order, it is important to understand the specifics of your Medicare Advantage plan’s coverage. You can review your plan’s Evidence of Coverage document, which details covered services, network requirements, and any necessary procedures like prior authorization. Calling your plan’s member services department is also a direct way to confirm coverage details for home health care and understand any financial responsibilities or specific steps.

Finding a home health agency that is both Medicare-certified and within your plan’s network is the next step. Your plan’s member services or website often provide a directory of in-network providers. If your plan is a Health Maintenance Organization (HMO) or Preferred Provider Organization (PPO), staying within the network typically helps manage your costs and ensures coverage.

If your plan requires prior authorization for home health services, the home health agency, often in coordination with your doctor, will submit the necessary paperwork to your Medicare Advantage plan. This submission includes the doctor’s order and a proposed plan of care. The plan will then review the request to determine if the services meet their medical necessity criteria and will approve or deny the authorization.

Once prior authorization is approved, the home health agency can proceed with an initial assessment at your home, which further refines your care plan. Services will then begin according to the authorized plan. Throughout the care period, the agency and your doctor will monitor your progress and may adjust the care plan as needed, potentially requiring further authorization for changes or extensions of services. You should also be mindful of any copayments or deductibles outlined in your plan for home health services, as these costs will be your responsibility.