Medicare rules for in-home care

Ron – Texas: My spouse is 76 and has been disabled for years due to congestive heart failure and other problems. He was recently in the hospital with pneumonia. He is unable to walk and has problems with expressive speech, has been diagnosed with short-term dementia, has had triple bypass surgery and has multiple other problems. He is currently in inpatient rehab for physical, speech and occupational therapy. We are both receiving Social Security and cannot afford extensive inpatient rehab treatment. He is covered by a Medicare Advantage plan. We will be discussing alternatives with his primary physician concerning qualification for being homebound and receiving home-health services. Any thoughts you have would be extremely helpful.

Phil Moeller: I’m so sorry to hear of your spouse’s health problems. I wish you both the best.

In terms of insurance, basic Medicare does not cover so-called custodial care in the home, but does provide up to 35 hours a week for nursing and home-health aides in addition to rehabilitation therapy. This short-term home care must be considered medically necessary by his doctor, and he must be homebound. However, the doctor can prescribe care for multiple 60-day coverage periods.

Medicare requires that such care be provided by a certified home-health agency, and it has online tools to help you find one. The issue, however, is not so much qualifying for Medicare’s home-health benefit as finding an agency to provide the care. Your Medicare Advantage insurer might be able to help here, but there no requirement that agencies must take on patients such as your spouse, and finding a care provider can be difficult.

Because your spouse has serious multiple health problems, it’s likely his insurer has a special program to coordinate his health needs. This program may have some additional benefits for home-based care, which generally is less expensive than care in a hospital or skilled nursing facility.

Lastly, if your spouse’s health is failing, you might wish to discuss with his doctor whether he thinks at-home hospice care is appropriate. Medicare provides in-home hospice care and pays for nearly all of its expenses. To qualify for hospice, his doctor has to certify that he expects your spouse to have no more than six months left to live. Many hospice patients live for longer periods, but that’s the approval standard. Of course, I hope your husband’s health has not reached this point, but from your description, it seemed to me that it should be included in the discussion.