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Who Qualifies as a Caregiver Under Medicare Rules?

who qualifies as a caregiver under medicare rules

Plus Home Health Services Covered by Medicare

If your loved one requires care, you are probably wondering what is covered under their insurance plan and how much of their social security check will be needed to pay for medical care or homemaker services. If your parent needs specialized services such as medical supplies, physical therapy or occupational therapy; or if you need to pay for a caregiver that comes in when you can’t be there because you work part time, it can be even more important to know if original Medicare pays for some of those services or if your parent needs to sign up for Medicare Advantage plans.

As your parent ages, they will need additional prescription drugs or more than just intermittent skilled nurses from a home health agency, which can be stressful to think about how much it will cost. Look at what Medicare beneficiaries can expect in coverage, who qualifies as a caregiver (Part A caregiver under Medicare rules), what the Medicaid Self-Directed Care Program is, and how your local area Agency on Aging can assist you.

See more: Does Medicare cover home health care in PA?

Original Medicare

Medicare not only offers coverage for various services, but also many different support programs to help alleviate the burden on family caregivers.

First, it’s essential to understand who qualifies as a caregiver under Medicare rules to ensure your loved one receives the necessary assistance.

Definition of a Caregiver

Under the context of Medicare, a caregiver is an individual who provides substantial support and assistance to a person with a chronic illness, frailty, or disability. A caregiver can be a family member, friend or a professional hired to offer essential care and to support eligible Medicare beneficiaries.

Part A Caregiver Under Medicare Rules: Who Qualifies as a Caregiver?

To be recognized as a caregiver under Medicare, you must meet certain requirements. These qualifications may vary depending on the specific Medicare programs or services available, but generally the following criteria apply:

  • The caregiver should have a personal relationship with the Medicare beneficiary (through familial ties or close friendship).
  • The caregiver must provide essential assistance (daily activities, medical tasks, or emotional support).
  • The caregiver’s services should be crucial for the Medicare beneficiary’s wellbeing and overall health.

Medicare Programs for Caregivers

Medicare not only offers coverage for Medicare beneficiaries, but also offers several programs and services that provide support to the beneficiary’s caregiver. These programs are to help improve the quality of care for the patient and to alleviate the financial burden associated with caregiving. Some programs of note include:

  • Medicare Advantage Plans (MA): Also known as Medicare Part C, these plans offer additional benefits such as respite care, caregiver support services or adult daycare programs.
  • Home Health Services: Medicare may cover intermittent skilled nurses from a home health agency, therapy services and personal care assistance that can ease the burden on a family caregiver.
  • Hospice Care: Medicare provides coverage for hospice services, including respite care, emotional support and counseling to individuals who are terminally ill and their caregivers.

Caregiver Support Through Your Local Area Agency on Aging

Your local Area Agency on Aging the Caregiver Support Program. It offers support to caregivers that aims to reduce stress and financial burden for primary caregivers. To learn about your eligibility and the services offered, visit the program website.

Services Covered by Medicare

Let’s look more broadly at the coverage of services for Medicare beneficiaries to help you understand what you may need to pay for out-of-pocket.

Services covered by Medicare include:

  • Part Time or Intermittent Skilled Nursing Care: Part A covers intermittent skilled nurses (i.e. less than eight hours per day) up to 21 days (35 days in certain cases). Medicare covers this care from a registered nurse (RN) or licensed practical nurse (LPN).
  • Part Time Home Health Aide Services: Home health aides assist with monitoring vital signs and ensure the patient is eating well. They help with bathing and dressing and can also check the home for safety issues.
  • Physical Therapy: Medicare will pay for in-home physical therapy services, wound care and gait training.
  • Speech Language Pathology: A speech therapist works with individuals in their homes to help them remember words, and to eat and drink as normally as possible. They may also assist with learning new ways to communicate for speech or hearing loss cases.
  • Occupational Therapy: This service helps people set up daily routines to follow their doctor’s orders, take care of personal needs and reduce stress.
  • Medical Social Services: This involves counseling or assistance from a social worker to address emotional issues that may impact health and wellbeing.
  • Prescription Drugs: This coverage depends on the type of coverage the beneficiary has.
  • Injectable Osteoporosis Drugs: for women and provided in-home by a licensed care professional
  • Durable Medical Equipment: This is equipment and supplies ordered by a health care provider for everyday or extended use, such as oxygen equipment, wheelchairs, or blood testing strips for diabetics.
  • Medical Supplies: These are supplies that may or may not be prescribed by a physician.

Services Not Covered by Medicare

These are the services that Medicare does not pay for:

  • 24-hour care in the home
  • Meals delivered to the patient’s home
  • Homemaker services (e.g. shopping, house cleaning) that are not related to the patient’s care plan
  • Custodial or personal care that helps with daily living activities (bathing, groom, toileting) when this is the only care you need (in other words, if you do not need medical care)

Your Costs with Original Medicare

Under original Medicare, your cost for home health care services is $0. After you meet the Part B deductible, 20% of the Medicare-covered medical equipment is covered. If you need additional coverage through your insurance plan, you should look into Medicare Advantage Plans.

Additional Information: Medicaid Self-Directed Care Program

Some Medicare beneficiaries also qualify for Medicaid assistance. Medicaid Self-Directed Care programs allow for the participant or their representative to have decision-making authority over certain services, taking direct responsibility of managing their services with the assistance of a system of available support. In Pennsylvania, this program is known as Consumer-Directed Services, which includes:

  • Service coordination
  • Individualized planning
  • Quality management
  • Flexible supports
  • Person-centered approach
  • Consumer direction
  • Health and safety
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