Insurance and benefit programs are confusing by design — and understanding them can save thousands of dollars and unlock services your person is entitled to. You do not need to become an insurance expert, but you do need to know the basics of what is covered and how to access it.

Section 01

Medicare Parts A, B, C, and D

A

Part A — Hospital Insurance

Covers inpatient hospital care, skilled nursing facility care (after a qualifying hospital stay), some home health care, and hospice. Most people do not pay a premium for Part A if they paid Medicare taxes for at least 10 years.

B

Part B — Medical Insurance

Covers physician services, outpatient care, preventive services, durable medical equipment (wheelchairs, hospital beds, oxygen), and home health care. Has a monthly premium and an annual deductible.

C

Part C — Medicare Advantage

Private insurance plans that cover Parts A and B and often Part D, sometimes with additional benefits (dental, vision, hearing). Different rules than original Medicare — verify coverage carefully when making decisions.

D

Part D — Prescription Drug Coverage

Covers prescription medications. Separate plan with its own premium and formulary (covered drug list). Check whether your person's medications are covered before choosing a plan.

Section 02

What Medicare Home Health Covers

💡 Medicare home health requirements
Medicare covers home health care when:

  • The person is homebound (leaving home requires considerable effort)
  • A physician certifies the need for skilled care
  • Care is provided by a Medicare-certified agency
  • The skilled need exists (nursing, physical therapy, occupational therapy, speech therapy, or medical social services)
Medicare covers: skilled nursing visits, therapy services, home health aide services (when skilled care is also occurring), and medical social services. Medicare does NOT cover: custodial care only (bathing, dressing, meals without skilled need), 24-hour care, or most personal care aide services without an associated skilled need.
Section 03

What Medicare Does Not Cover

⚠ The gaps in Medicare
  • Long-term custodial care: The help with bathing, dressing, and daily activities that most people think of as "home care" — without a skilled nursing or therapy need, Medicare does not cover this
  • Dental, vision, and hearing: Original Medicare has minimal coverage in these areas
  • Prescription drugs: Covered by Part D, not original Part A or B
  • Most nursing home care: Medicare covers skilled nursing facility care for up to 100 days after a qualifying hospital stay — not long-term custodial nursing home care
Section 04

Other Programs Worth Knowing

  • Medicaid: For people who qualify financially, Medicaid covers many services Medicare does not — including long-term custodial care. Eligibility varies by state. Many people are unaware they may qualify.
  • VA Benefits: Veterans may have significant home care and caregiver support benefits through the VA — including the Program of Comprehensive Assistance for Family Caregivers (PCAFC), which provides stipends and support to eligible caregivers.
  • Long-term care insurance: If your person has a long-term care insurance policy, review it now — these policies have specific requirements for triggering benefits and waiting periods.
  • Area Agency on Aging: Every community has an Area Agency on Aging that coordinates local services for older adults and their caregivers — often including no-cost or low-cost services that are not well publicized.
Section 05

When Insurance Denies a Claim

✓ Appeals work — pursue them
Insurance denials are not final. Most denials can be appealed — and a significant percentage of appeals are successful. When a claim is denied:

  1. Get the denial in writing and understand the specific reason
  2. Ask the treating physician to write a letter of medical necessity
  3. File a formal appeal within the deadline specified in the denial letter
  4. Request a peer-to-peer review (physician to physician) if available
  5. Escalate to the state insurance commissioner if the internal appeal fails
Many families accept denials as final and lose coverage they were entitled to. Appeals are worth pursuing.
Knowledge Check

Lesson 4 Quiz

5 questions · Passing score: 80%
Question 1
Medicare Part A covers home health care when:
Question 2
Medicare does NOT cover which of the following home care services?
Question 3
The Program of Comprehensive Assistance for Family Caregivers (PCAFC) is a benefit available through:
Question 4
Insurance claim denials should be:
Question 5
An Area Agency on Aging in your community provides: