Does Medicare cover doctor house calls?

If you are arranging care for a parent who has stopped going to appointments, the first question is usually about money: will Medicare pay for a doctor to come to the house, or is this a private-pay luxury? The short answer is that Medicare Part B covers medically necessary house calls from a physician or nurse practitioner. The longer answer involves one confusing rule about the word "homebound" that trips up nearly every family.

Does Medicare Part B actually pay for a doctor to come to my house?

Yes. Under Original Medicare, a visit from a doctor or nurse practitioner at home is covered when it is medically necessary. It is billed as an evaluation and management visit, the same category as a clinic appointment, with a code noting it happened at the patient's residence: a house, an apartment, an assisted living apartment or a family member's home.

One practical note: a practice that accepts Medicare assignment agrees to take Medicare's approved amount as payment in full, so there is generally no separate travel fee or mileage charge on top of the visit. If a practice asks for a monthly retainer before anyone comes to the door, that is a business model choice, not a Medicare requirement.

Does my parent have to be homebound to get a house call?

No, and this is one of the most misunderstood rules in home based care.

The homebound requirement belongs to a different Medicare benefit. The home health benefit covers skilled nursing, physical and occupational therapy and home health aide time from a Medicare-certified agency. To qualify, a patient generally must be certified as homebound, meaning leaving home takes a considerable and taxing effort and normally requires help or a device.

A physician house call under Part B is separate, with a separate rule: there is no homebound requirement. Medicare asks that the visit be medically necessary and that the home be a reasonable place for the care to happen.

In practice that standard is met easily. Advanced arthritis that makes the trip to the car exhausting, dementia that turns a waiting room into a crisis, oxygen, recovery from surgery, a caregiver who cannot keep taking days off work: these are ordinary, appropriate reasons for care to happen at home.

So if someone told you your mother "doesn't qualify because she isn't homebound," they were describing the home health benefit. The two can run side by side: a patient can have a visiting nurse from an agency and a primary care provider who makes house calls.

What will we actually pay out of pocket?

A house call is billed like an office visit, so cost sharing works the same way:

• You first meet the annual Part B deductible, which resets each calendar year.
• After that, Medicare generally pays 80 percent of the approved amount and you owe the remaining 20 percent coinsurance.
• A Medigap (supplement) policy often covers some or all of the coinsurance and sometimes the deductible, depending on the plan letter. Medicaid or other secondary coverage may pick up the remainder.

Some preventive services carry no coinsurance at all when the provider accepts assignment. The Medicare Annual Wellness Visit is the main one: covered once every 12 months with no copay and no deductible. It is a planning visit rather than a head-to-toe physical, covering a health risk review, a medication and provider list, cognitive and depression screening, a fall risk assessment and a schedule of the screenings your parent is due for. Done at home, the fall risk portion is more useful, because it is assessed on the actual stairs.

One fair warning: if a new problem is treated during that same appointment, that part may be billed separately with normal cost sharing. A good practice tells you first.

What if my parent has a Medicare Advantage plan?

Medicare Advantage (Part C) plans must cover everything Original Medicare covers, but they set their own networks, copays and prior authorization rules. Some actively promote in-home visits; others have narrow networks. Coverage varies by plan and by county, so check two things: whether the practice is in your plan's network, and the copay for a primary care visit. Any practice worth using will verify benefits on the phone before booking.

What is covered during the home visit itself?

Essentially everything a primary care office does that does not need fixed hospital equipment:

• A full physical exam and vital signs
• Ongoing management of chronic conditions: diabetes, hypertension, heart failure, COPD, kidney disease
• A medication review, checking every bottle in the house against every prescriber
• Blood draws and point-of-care testing, with results called back
• EKG when indicated
• Prescriptions, refills, specialist referrals, and orders for imaging or home health

Anything that truly needs a hospital gets referred, exactly as it would from a clinic.

What should I ask when I call a house call practice?

• Do you accept Medicare assignment, and are you in network for my parent's Medicare Advantage plan?
• Is there any travel fee, membership fee or retainer beyond the visit itself?
• Will you verify benefits and tell us the expected cost before the first visit?
• Do you cover our town? (Life Primary Care visits patients in Somerset, Morris, Union, Essex, Passaic and Bergen counties.)
• Who comes to the house, and is it the same person each time?
• How quickly can an established patient be seen for an urgent problem?
• Can you do the Annual Wellness Visit at home, and coordinate with a home health agency if we need one?

Where to verify all of this

Medicare rules, deductibles and coinsurance amounts change from year to year, and Medicare Advantage benefits change every January. Confirm current details with Medicare at 1-800-MEDICARE or medicare.gov, or with your plan's member services line.

If you want help sorting out what your parent's coverage will do, call us at 973-607-4911. We check benefits on the phone, tell you what to expect before anyone books a visit, and then we come to the house.