Medicare is a federally funded insurance plan that provides health insurance to people 65 years and older, as well as to younger people with certain disabilities and conditions (including ALS). Because of your ALS diagnosis, you are automatically enrolled in the Medicare program as soon as you begin to receive disability benefits from Social Security (or, if you were a railroad worker, the Railroad Retirement Board).
A brief overview of Medicare
There are two main ways to get Medicare coverage— through original Medicare (Medicare Parts A and B), or through a Medicare Advantage plan (Medicare Part C). You can also elect to add prescription drug coverage (Medicare Part D) to either original Medicare or a Medicare Advantage plan.
- Medicare Part A is hospital insurance. It helps pay for inpatient care in hospitals and skilled nursing facilities, hospice care, and home health care after a hospital stay. There is no monthly premium for Medicare Part A for people who paid Medicare taxes while they worked.
- Medicare Part B helps pay for services from doctors and other health care providers, outpatient care, home health care, and durable medical equipment. Beneficiaries must pay a monthly premium for Medicare Part B.
- Medicare Part C (Medicare Advantage) is run by private insurance companies and includes all of the benefits covered under Parts A and B. In addition, most plans cover benefits not covered by Medicare, such as vision, dental, and hearing services, as well as prescription drugs. Beneficiaries pay the Part B premium and, in some cases, an additional premium to the managed care plan.
Under original Medicare, you can use any provider who accepts Medicare. You pay premiums, deductibles, and coinsurance or co-payments for most services, and annual out-‐of-‐pocket costs are not capped. If you want drug coverage, you must purchase a plan separately. Under Medicare Advantage, you must choose a provider from the plan’s network, and specialist referrals may be required. Medicare Advantage programs may also have premiums, deductibles, and co-payments or coinsurance, but annual out-of-pocket costs are capped.
Home health care services under Medicare
In order to receive home health benefits under Medicare, you must meet all of the following criteria:
- You must be under the care of a doctor, and the services you receive must be according to a care plan established and reviewed regularly by a doctor.
- A doctor must certify that you are homebound (i.e., unable to leave your home without considerable effort and assistance).
- A doctor must certify that you need intermittent skilled nursing care, physical therapy, speech-‐language pathology services, or continued occupational therapy. “Intermittent” skilled nursing care is care that is needed or given on fewer than 7 days each week or less than 8 hours each day over a period of 21 days or less.
- The care must be provided through a Medicare-‐certified home health agency (i.e., a home health agency that has been approved by Medicare).
Medicare covers the following home health services for eligible beneficiaries:
- Skilled nursing services (such as assistance with a feeding tube or ventilator) are covered when they are needed on an intermittent or part-‐time basis. Skilled nursing services are provided by a registered nurse (RN) or a licensed practical/vocational nurse (LPN/LVN).
- Assistive (personal) care services (such as assistance with bathing or dressing) are covered, but only when they are needed to support skilled nursing care, and only on an intermittent or part-‐time basis. Assistive care services are not covered by Medicare when they are the only care that you need. Assistive care services are provided by a home health aide (HHA) or certified nursing assistant (CNA).
- Therapy services. Medicare may cover physical therapy, occupational therapy, and speech-‐ language pathology services when these services are necessary to help you maintain or regain the ability to move, perform everyday tasks for self-care, speak, or swallow safely. In order to be covered, the services must require the skill or supervision of a licensed therapist.
- Medical social services (such as counseling) are covered by Medicare when they are ordered by your doctor.
- Medical supplies and durable medical equipment. Disposable medical supplies are covered by Medicare when they are used as part of your care. Medicare also pays 80% of the cost for durable medical equipment (such as a hospital bed, walker, or wheelchair) when the doctor has ordered the equipment for use in the home.
Medicare will pay for covered home health services as long as you are eligible and your doctor certifies that the services are needed.
Choosing a Medicare-certified home health agency
A Medicare-certified home health agency is one that is eligible to receive payments under Medicare because it adheres to standards of care established by the Centers for Medicare and Medicaid Services (CMS). In order to maintain its Medicare-certified status, the home health agency must undergo regular inspections (surveys) to ensure that it is in compliance with federal standards and regulations. Medicare will not pay for services received from a home health care agency that is not Medicare-certified. You can use Home Health Compare, a tool on medicare.gov, to find and evaluate Medicare-certified home health agencies in your area. The tool gives you information about the types of services the agencies offer, as well as about the quality of care they provide.
“A Primer on Medicare: Key Facts about the Medicare Program and the People It Covers.” The Henry J. Kaiser Family Foundation. March, 2015.
“Enrolling in Medicare if you have ALS.” Medicare Interactive, 2016.
“Medicare and Home Health Care.” Centers for Medicare & Medicaid Services. May, 2010.
“Medicare Basics: A Guide for Families and Friends of People with Medicare.” Centers for Medicare & Medicaid Services. November, 2014.
“Types of home health care that Medicare will pay for.” Medicare Interactive, 2016.