Why Doesn’t Medicare Cover CDPAP?

When it comes to CDPAP, some of the many questions we are asked almost daily are “What if I have Medicare?” or “Why won’t Medicare cover CDPAP services?” and often the answers can sound a bit confusing.


After all, Medicaid and Medicare are government-funded health plans, so they are the same, right? Not quite.


First, Medicare is a federally run program and subject to federal laws and regulations when it comes to what it covers and who is eligible. Any benefit that Medicare covers is always subject to what the lawmakers in Washington say.


While private plans under Medicare Advantage (Part C) often offer a little more than the bare minimum of what straight Medicare offers (like vision and hearing in some cases), none offer the long-term care feature needed to access most home health services. This is primarily true for non-medical based home care.


Medicaid, however, is a primarily state-funded health benefit, and most of the regulations that govern Medicaid are handled at the state level via the state legislature. Medicaid does provide more inclusive benefits for those who qualify for the coverage and typically has an income requirement that you are required to meet to obtain free coverage.


Since CDPAP is a Medicaid-based program, Medicaid enrollment is required and Medicare is not enough to qualify for access to the services.


If you are still curious about why Medicare isn’t enough to obtain CDPAP services, we’ve provided a list of reasons below:

Medicare does not offer long-term care benefits


Regardless of what anyone tells you, Medicare is not in the long-term care business. All too often, seniors think that because they are enrolled in Medicare, any future long-term care or nursing home stay will be covered. This is not the case.


Per the Department of Health and Human Services:


Medicare covers medically necessary care for acute care, such as doctor visits, drugs, and hospital stays.


Medicare does not pay for most long-term care services or personal care— such as help with bathing or for supervision (often referred to as custodial care).


There are exceptions, like durable medical equipment deliveries to your home or physical therapy, where Medicare will pay; however, at no point will Medicare cover “custodial care” or home health services performed by an aide to assist in day to day activities.

Medicare only offers medical-related benefits


As stated above, Medicare Part A and Part B (or Part C, if you have Medicare Advantage) only cover acute care or “immediate” care. Because of this, all care covered by Medicare is that of a medical or therapeutic nature in conjunction with a treatment plan by your doctor.


If your doctor feels as though you would benefit from having someone come into your home for treatment and Medicare approves it, it will be done mainly through home nurses on a part-time or intermittent basis.

Medicare only offers short-term care (after a qualifying inpatient stay)


In most cases, if Medicare approves any home health services, it will be for the short term and follow what is called a “qualifying inpatient stay”.


In the event you are in the hospital and the doctor feels you are safe to go home, but still would like a nurse to handle helping you take medications or thinks a physical therapist should work with you, Medicare will often cover these services as long as they are approved by Medicare and are reordered by the doctor every 60 days.


Even with this option, non-medical personal care for supervision and routine daily assistance is not covered.

Medicare offers coverage for an SNF (skilled nursing facility), but not a long-term nursing home

This is one area that confuses many people. A skilled nursing facility is not the same as the idea of a nursing home as we know it. After an inpatient stay, you can be transferred to a skilled nursing facility for additional recovery and Medicare will cover it for 100 days (covered at 100% for the first 20 days, after which a modest daily copay is charged). After 100 days, Medicare stops covering.


A great example would be if you were to break your leg and had other health risks, the doctor may opt for you to go to a skilled nursing facility after a hospital stay for additional recovery.


As stated before, Medicare isn’t in the long-term care business and reviews medical necessity regularly.

Hospice is different than home health


Sometimes people confuse hospice care with home health care when they are very different concepts. While Medicare will cover hospice care in a home or nursing home setting, this is usually a short-term arrangement as the patient is not expected to live longer than six months.


Medicare will provide limited respite care to relieve the person providing care and provide home services to keep the patient comfortable; however, this situation is not long-term and has additional oversight from Medicare.

How can I get home health services with Medicare?


Just because you have Medicare doesn’t mean you can’t get the at-home care you need. There are a few solutions you can consider:


  • Apply for MedicaidYou can enroll in both Medicare and Medicaid as well. In many cases, there isn’t even a cost involved as long as your income level is within Medicaid’s qualifying income level.

    In the event that you do make too much to qualify for the no-cost coverage, there are a few options you can consider:

  • Spend DownA Medicaid spend down is basically paying the difference between what you bring in as income and what the qualifying income limit is. For example, if the income limit is $850 and your income is $1000, then you would pay Medicaid the $150 difference in exchange for access to Medicaid coverage and programs.
  • Pooled Income TrustThis is a more popular option. Instead of sending the difference between Medicaid income limits and your income to Medicaid, you can enroll in a Pooled Income Trust. Managed by non-profits, these trusts act like a managed bank account where you send your surplus income and in turn, they pay your bills and reimburse you for approved expenses out of the money sent.

    For those who are on Social Security or a pension plan, this option is often more popular because you can still have you expenses taken care of without causing major financial issues to your current way of life.

  • Pay out of pocket

Not everyone likes the idea of having someone else managing their money or having others digging into your finances. Because of this, many people often pay out of pocket for services. The great thing about this option is that it gives you the same type of choices that CDPAP offers when it comes to choosing your own caregiver.

  • Talk to your life insurance companyIf you have a private life insurance policy, you may be able to use that to help cover part or all your long-term care costs. Numerous life insurance policies offer “accelerated benefits” which give you access to part of the death benefit to cover long-term care costs for those with terminal or chronic conditions. Older policies may even have a rider that you purchased (and probably forgot about) that gives you long-term care coverage as an extra benefit.

    If you have a cash value policy, you could potentially take loans against the cash value to cover home health costs. These loans are typically easy to get and if not paid back, are simply deducted from your death benefit.

    Depending on your health issues, you may also qualify for a viatical settlement. A viatical settlement is when someone else (usually a company) will pay you to take over ownership of your life insurance policy and make that company the beneficiary of the face amount upon your death. This often works well for those in the end stages of a terminal health issue and would like to have access to money to cover health care costs so as not to leave a large debt upon death.

    There are numerous ways you can finance home health with life insurance and speaking to your insurance agent as well as the company that wrote the policy can point you in the right direction.

In conclusion


Until lawmakers in Washington change what Medicare covers and begins covering long-term home health services, access to CDPAP with Medicare alone will not be possible. Those with Medicare who want long-term types of services often find great success in also enrolling in Medicaid and enjoying the benefits that CDPAP and other services offer them as they age.


Even if your income level is too high to qualify for the no-cost option of Medicaid, solutions like spend downs and pooled income trusts are great options for aging seniors to consider to help ensure their health and safety in the home as they age in place.