home health aides in personal activities such as going to the bathroom, bathing, dressing, or preparing a light meal if these are necessary in relation to your illness or injury. (But if this personal care is the only kind of care you need, you don’t qualify for home health coverage.)
❯❯ Medical supplies such as catheters and wound dressings.
❯❯ Medical social services such as counseling for social or emotional concerns related to your illness or injury and help finding community resources if you need it.
Medicare covers all these services in full by paying a home health agency a single payment to provide them for 60 days at a time. Home health care is a valuable benefit, but the rules for qualifying are pretty strict. To get Medicare coverage, you must meet all these conditions:
❯❯ You must be homebound – that is, unable to leave home without considerable effort, unaided, or at all.
❯❯ A doctor must certify that you need one or more of the professional services in the preceding list (skilled nursing, physical or occupational therapy, or speech pathology).
❯❯ You must be under a plan of care established and regularly reviewed by a doctor.
❯❯ The home health agency caring for you must be approved by Medicare.
If you qualify, the agency must provide all the services specified in the doctor’s plan of care for you. But if you need (or ask for) an item or service that Medicare doesn’t cover, the agency must tell you so in advance and explain what it would cost you. If you need medical equipment, such as a wheelchair or a walker, while receiving home health care, you may get it through the agency, but you pay the normal 20-percent co-pay (as explained later in this chapter) unless you have Medigap insurance that covers that cost.
Hospice care
There may come a time when a treatment intended to cure a serious illness stops working effectively or is more than the patient can bear. Hospice care offers an alternative in the last days or months of life. It focuses not on trying to cure the disease but on providing as much comfort as possible – medical, social, emotional, and spiritual – during the time left.
Medicare began covering hospice care in 1983, and it’s one of the most generous benefits that the program provides – at little cost to terminally ill patients or their caregivers. Patients who choose hospice care are offered a full range of medical and support services, most often in their own homes. It also allows them to be cared for temporarily in an inpatient facility, such as a hospital or nursing home, if their regular caregivers need a break.
To qualify for the hospice benefit, you must meet all these conditions:
❯❯ You must choose to receive hospice care and give up treatments intended to cure your terminal illness.
❯❯ Your doctor and the medical director of a hospice program must certify that you probably have less than six months to live.
❯❯ You must enroll in a hospice program that Medicare has approved.
❯❯ You must have Medicare Part A hospital insurance.
If you qualify, Medicare pays in full – 100 percent – for a wide range of services, including
❯❯ Medical and nursing care, plus round-the-clock on-call support
❯❯ Medical equipment and supplies
❯❯ Homemaker and home health care services
❯❯ Physical therapy
❯❯ Social worker services and dietary counseling
❯❯ Support for your caregiver
❯❯ Grief and loss counseling for you and your family
Your share of the cost is limited to a maximum of $5 per prescription for drugs used to control the symptoms and pain of your terminal illness; and 5 percent of the cost of respite care if you’re taken into a nursing home to give your caregiver a break. However, if you have Medigap supplemental insurance, both these costs are fully covered, as Chapter 4 explains. (Costs related to any medical conditions other than your terminal illness are covered by Medicare Part B or Part D in the usual way.)
Pregnancy and childbirth
Medicare does indeed cover pregnancy and childbirth. Are you astonished? That’s probably because you see Medicare as a program only for people way past childbearing age. But of course Medicare is also for much younger people who qualify through disability, and some of them become pregnant.
The relevant regulation in the Medicare Benefit Policy Manual explains the scope of coverage: “Skilled medical management is appropriate throughout the events of pregnancy, beginning with the diagnosis of the condition, continuing through delivery, and ending after the necessary postnatal care.” Medicare also helps cover the cost of treatment for miscarriages, and for abortions in circumstances where pregnancy is the result of incest or rape or would threaten your life if you went to term. It doesn’t cover elective abortion if you choose to terminate your pregnancy.
To receive hospital services, you need Part A hospital insurance. For doctors’ services and outpatient procedures (such as lab tests), you need Part B coverage. If you’re enrolled in Medicaid because your income is low, that program may pay some or all of your out-of-pocket Medicare costs, depending on your state’s eligibility rules. Medicaid may also pay for your infant’s medical care. But after the birth, Medicare doesn’t cover services for your baby at all.
Medical supplies and equipment
What if you need a wheelchair, an artificial limb, an oxygen tank, or other items that help you function but really qualify as things rather than services or treatments? Medicare has a suitably bureaucratic name for these things – durable medical equipment – and its meaning is precise. Durable means long-lasting, and Medicare covers only items that will stick around a while. With only a few exceptions, it doesn’t cover disposable items that you use once or twice and then throw away.
To get Medicare coverage for durable medical equipment, it must be
❯❯
