Does Medicare Cover Home Care in New York? What Families Need to Know Before Open Enrollment

Questions regarding care for parents begin to appear every Fall in many of Brooklyn’s kitchens. In addition to the family member returning home from the hospital, the mail box becomes filled with all of the Medicare plans that are available. Eventually, one person will ask: how are we going to pay for my mom’s in-home support?

The above is an honest question. The response is not as simply a “yes” or “no.” It is a great opportunity to clarify exactly what Medicare covers and what it does NOT cover when choosing your Medicare Plan for next year. This can be accomplished now since Medicare Open Enrollment begins on October 15th and runs through December 7th.

The Short Answer

Medicare will pay for some home care, but by no means all of it. Generally, Medicare will cover medical care in your home (as opposed to hospital) on an intermittent, part-time basis if that care is “skilled” in nature (e.g., nursing visits and/or physical therapy), ordered by your physician, and provided under certain conditions. In contrast, Medicare has little to do with providing long-term assistance for daily living activities such as bathing, dressing, preparing meals, etc. or round-the-clock supervision when that is the primary type of care needed.

“Home Care” Means Two Different Things

The phrase gets used loosely, but insurers draw a hard line between two types of care.

Skilled care is medical. It’s provided or supervised by licensed professionals like registered nurses and therapists. Think wound care, injections, monitoring after surgery, or physical therapy to get someone walking again. You can read more about this on our Skilled Services page.

Care that is defined as “custodial” or “personal” includes assistance with all aspects of one’s daily routine including bathing, dressing, toileting, food preparation, light housekeeping and social interaction/companionship. This is the type of care that most individuals would envision when they hear the term “home health aide.” Additionally, this is also the focus of our Homecare Services.

Medicare was developed based upon the idea of skilled care. Therefore, Medicare does not cover the vast majority of the care that most senior citizens require for weeks/months/year(s).

What Medicare Does Cover

Original Medicare (Parts A and B) will cover Home Health Care if all four requirements below are met:1. You have been certified by your Doctor or Practitioner as needing Home Health Care. The certification process should also include developing a Plan of Treatment for you with regular reviews to ensure that you are receiving the appropriate treatment.2. You require Skilled Services in an intermittent or part time manner. This includes; Skilled Nursing, Physical Therapy, Speech-Language Pathology, Occupational Therapy and/or Medical Social Work. 3. You are Home Bound. Your ability to leave home requires significant difficulty and usually assistance from another individual such as a walker, wheelchair, transportation etc.4. The Agency providing the Home Health Care is certified by Medicare

You don’t need a hospital stay first, either. A doctor’s order and a documented need are what count.

When you qualify, Medicare can cover:

• Part-time skilled nursing
• Physical, occupational, and speech therapy
• Medical social services
• Part-time home health aide services, but only while you’re also receiving skilled care
• Medical supplies

For these services, you typically pay nothing. Durable medical equipment like walkers or hospital beds usually comes with 20% coinsurance.

What Medicare Does Not Cover

This is what families need to know first before making decisions about long-term care:

• Care provided in your own home around-the-clock
• Care where you just need assistance with daily living skills (bathing, dressing, toileting)
• Homemaking services; grocery shopping, housekeeping etc.
• Meals delivered to your home

Aides are also an important option. While Medicare covers a Home Health Aide while you receive Skilled Care, the moment the Skilled Care stops so does the Aide coverage. For people who have long term needs due to chronic illness such as Arthritis, Memory Loss or Recovery which takes longer than expected, this can be a large gap.

What This Looks Like in Real Life

Picture a woman in Flatbush who breaks her hip and spends a week in the hospital. When she comes home, Medicare-covered home health can send a nurse and a physical therapist to help her recover. That’s exactly what the benefit is for.

A few weeks later, she’s stronger but still can’t bathe safely on her own or manage meals. Her therapy goals have been met, so the skilled visits wind down. Now she needs someone a few hours a day, or more, and Medicare no longer pays for it.

That’s the moment many families start looking at other options. Knowing about it before it happens makes those decisions a lot less stressful.

Original Medicare vs. Medicare Advantage

Before you weigh your options during this Open Enrollment period, consider these important aspects of home care when comparing Medicare Advantage Plans:

All Medicare Advantage (MA) plans will cover all of the services that are included with Original Medicare, which includes home health. The way in which you access services may be different from one MA Plan to another. For example, some MA Plans may only allow in-network providers to provide home health services while others may require prior authorization before home health care begins. In addition, a limited number of MA Plans have “extra” benefits such as a brief amount of short term assistance at home post-hospitalization. However, these “extra” benefits are typically not the same as ongoing long-term care benefits.

You can make changes during Open Enrollment through Dec. 15th; your new benefits will go into place on Jan. 1st, 2027.

Questions to Ask Before You Choose a Plan

• Are the home health agencies we’d want to use in the plan’s network?
• Does the plan require prior authorization for home health visits?
• What are the out-of-pocket limits if care runs long?
• Does the plan offer any in-home support benefits, and what are the exact limits? (Check the plan’s Evidence of Coverage document, not just the marketing summary.)

Free, unbiased Medicare counseling is available in New York through HIICAP. You can also call 1-800-MEDICARE or visit Medicare.gov.

How New York Families Pay for Long-Term Home Care

There are ways to get the ongoing support your family member needs if Medicare does not provide coverage. Many families choose to take advantage of multiple resources together:

• Medicaid. People may be able to qualify for New York Medicaid (which includes long-term home care) if they qualify financially/asset wise; many of these plans also include a managed long term care plan. The city has agencies like NYC Aging and HRA that can assist in finding what next steps you should take.
• NHTD waiver. The Nursing Home Transition and Diversion program allows eligible older adults & individuals with physical disabilities to access services in their homes as opposed to a nursing facility. Please view information about this program on our NHTD page.
• Long-term care insurance. If your family member purchased an LTC policy years ago, it is likely to be time to pull up that policy & assess both the benefits and waiting period.
• Veteran Benefits. Eligible Veterans and surviving spouses can apply for various programs from the VA such as Aid & Attendance which could benefit them.
• Private Pay. Families sometimes will privately fund all or part of their schedules or use private funds to supplement gaps.

Frequently Asked Questions

1. Are home health aides paid by medicare?Only under very specific circumstances. In order to receive coverage by medicare for a part-time home health aide, you must be getting skilled nursing care or skilled therapy.
2. Will medicare pay for full time (24 hour) care at home?No. Medicare will only pay for part time/intermittent care at home. They do not pay for full time care at home.
3. For how long will medicare cover home health care?There is no set time limit to medicare covering home health care. Your coverage can continue as long as you are meeting all of the required criteria and your physician is continuing to certify your plan of care which is done every so often. Also, the care provided cannot exceed what is medically necessary and it must be part time.
4. Will medicare pay for home health services for someone with dementia?No. However if there was some medical necessity associated with their dementia, such as requiring skilled care from a nurse after they were discharged from the hospital, then the skilled portion of that care may be paid for by medicare. Most ongoing supervision of a person with dementia along with most ongoing personal care would not qualify.
5. Are Medicare Advantage plans better than traditional medicare when it comes to home health care?Neither. The best option for you and your family will depend upon many factors including your medical condition(s), who your physicians and home health agencies are, and your financial situation.

Not Sure What Kind of Care Fits?

Figuring out coverage is stressful enough without also trying to decode which type of care your loved one needs. If you’d like to talk it through, the team at Angel Care in Brooklyn is happy to help you understand the options and what a care plan could look like for your family.

This article is for general information only and isn’t medical, legal, or insurance advice. Medicare rules and plan details change, so confirm current coverage at Medicare.gov or by calling 1-800-MEDICARE.