Are you or a loved one among the 12.5 million people receiving primary health insurance coverage through Medicare? It’s crucial to know the top Medicare changes that directly impact seniors receiving in-home care. Older adults on Medicare and their family caregivers should stay updated on the latest changes to ensure the senior still qualifies for the coverage they need.
Some of the top Medicare changes include the expansion of mental health and dementia programs, more convenient payment options and different criteria for in-home care. Explore this guide from Village Caregiving to learn more.
How Will the 2025 Medicare Changes Affect In-Home Care Coverage for Seniors?
Medicare’s 2025 changes will modify who qualifies for in-home care coverage and how much they’ll pay. The criteria for eligible people have seen significant changes. If the services are considered necessary and reasonable for the patient’s injury or illness, they qualify for Medicare coverage.
In-home care is crucial for reducing stress on family members and assisting with certain illnesses, like late-stage dementia. Many older adults feel more comfortable in their homes, and families want to respect their wishes.
One survey from 2024 found that 75% of adults in the U.S. over the age of 50 would prefer to live in their current residence for as long as possible. In-home care is an excellent option to keep the patient content and comfortable.
In-home health care is more convenient and typically less expensive than receiving the same care at a hospital. It can help injured patients regain function and confidence. Individuals with dementia also benefit from in-home care’s ability to help improve and maintain their independence and self-sufficiency. In some cases with severe mobility challenges and cognitive decline, 24/7 care is needed to prevent serious injuries and enhance safety.
Meet the Criteria for Home Health Eligibility
Medicare does cover part-time or intermittent home health services, but you need to be considered “homebound”. Here’s how to qualify for home health care under Medicare:
- You have an illness or injury that makes it challenging to leave your home without crutches, a wheelchair, a cane, specialized transportation or another person’s help.
- You are typically homebound because leaving your home is a serious effort.
- You have a condition for which leaving your home is not recommended by health care professionals.
Fulfill the Patient Acceptance-To-Service Policy
Medicare has an acceptance-to-service policy that patients must satisfy to qualify for in-home care. Here’s the criteria to qualify for in-home care under Medicare:
- Your medical practitioner certifies that you require physical therapy, continued occupational therapy, speech-language pathology or intermittent skilled nursing (doesn’t apply to only drawing blood).
- Your medical practitioner certifies that you’re homebound and they don’t recommend leaving due to your condition.
- Your doctor identifies that you need in-home skilled nursing care for less than seven days a week and less than 8 hours daily for up to 21 days.
- Your doctor has met with you face-to-face within the specified time frame regarding your need for in-home care.
Medicare will cover skilled home care if the patient is considered homebound, but you should also ensure that the in-home care agency you get these services from is Medicare-certified. Check that the agency accepts Medicare payments to reduce your out-of-pocket costs.
What In-Home Care Benefits Does Medicare Cover?
Medicare covers temporary home care to help patients get access to professional assistance, where they receive treatment and help with daily activities. It’s also important to note that Medicare provides skilled in-home health care, which includes skilled nursing techniques. It does not cover custodial in-home care, which includes things like assistance with getting dressed, unless it forms part of the skilled care plan. Here are some of the home care benefits that Medicare covers:
- Managing and observing an injury or illness and evaluating the prognosis
- Teaching family caregivers about medication prescription
- Giving injections, IV drugs or tube feedings
- Changing dressings
What Are the Top 2025 Medicare Changes?
Medicare changes for 2025 include the expansion of mental health support and waving goodbye to the infamous donut hole coverage. Here’s a detailed breakdown of the top changes that will affect seniors:
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A $2,000 Out-Of-Pocket Cap
One of the most notable Medicare changes is the $2,000 out-of-pocket cap, which has replaced the notorious donut hole coverage. This change applies specifically to prescription drug costs under Medicare Part D. Once your out-of-pocket prescription drug costs hit $2,000, you don’t pay for further covered medications for the duration of the year. With the updated plan, you enter the catastrophic phase at a much slower rate, and once you’re there, the burden of your covered medications is no longer yours to bear.
If your plan has a deductible, once you reach the full amount, you’ll pay 25% of the total as coinsurance for generic and brand-name medications. Once your out-of-pocket spend on covered drugs hits $2,000 in that year, you automatically enter the catastrophic phase.
The new Medicare changes are of notable contrast with the previous “donut hole” plan. In the old plan, you would enter the catastrophic phase when you and your plan paid for drugs that reached the threshold. You would need to pay a certain amount for your drug costs, and then your plan would cover some of the amount. There would be a significant gap where you would pay full cost before getting coverage from your plan again, hence the nickname “donut hole.”
More Convenient Payment Options
If you have a Medicare drug plan, you qualify for the Medicare Prescription Payment Plan (M3P). It provides a way to better manage out-of-pocket drug costs by splitting the total amount of your filled prescription across a calendar year. You don’t have to choose this option, but it is available to those who need and qualify for it. To be eligible, you need to be enrolled in a standard Medicare drug plan or a Medicare Advantage plan and currently paying for prescription drugs.
There’s no cost to participate in the Medicare Prescription Payment Plan, and it can be a superior choice for some. Here are the top benefits of the M3P option:
- Improves financial planning: With the costs spread out, you can better plan how to cover the drug bills in line with your monthly income.
- Increases financial flexibility: While taking the M3P option won’t save you money since you still pay the same amount, it does offer you better flexibility with your payments. You can spread out your money further and account for bad months or months where you may have more expenditure, but still require medications.
- Enhances affordability: If you can’t afford to pay the once-off out-of-pocket fee for your medications, this option can make it more affordable by dividing the costs so you can pay them off in smaller amounts.
Paying More for Medicare Parts A and B Premiums, Deductibles and Coinsurance
Every year, the Medicare Part B premium is adjusted according to economic factors and in alignment with the Social Security Act. In 2025, the standard monthly premium for Medicare Part B will increase by $10.30, going up from $174.70 in 2024 to $185.00 in 2025. The Medicare Part A increases include the inpatient hospital deductible, which went up by $44 in 2025, taking it from $1,632 in 2024 to $1,676 in 2025.
You’ll also be required to pay a coinsurance amount of $419 per day for the 61st through 90th day of a hospitalization, which went up from $408 in 2024. Part A premiums have increased to $285 per month, but very few beneficiaries need to pay them. The Part B premiums went up from $10.30 to $185 per month.
Expanded Mental Health and Well-Being Coverage
One of the top Medicare changes for 2025 is the increased emphasis on mental health and well-being coverage. This new focus will benefit seniors, where affordability is a barrier to accessing mental health services like counseling. With the new changes, more than 400,000 licensed counselors and therapists, addiction counselors and mental health counselors can enroll as Medicare providers. This change enables them to bill Medicare, thus opening up access to mental wellness specialists for seniors.
The goal of expanding the coverage to mental health providers is to provide more comprehensive mental health scanning. This facilitates early identification and treatment for seniors at risk of depression, anxiety and other mental health conditions. It also offers reimbursement for mental health providers who perform safety planning, which is shown to reduce rates of suicide, making it a vital behavioral health service.
The other goal of the changes is to expand on mental health services available to seniors. With these changes, patients can also gain access to types of providers they would not have had access to in the past, such as marriage counselors and family therapists.
Cut Benefits on Some Plans
Some Medicare Advantage plans have cut benefits like coverage for over-the-counter medications and transportation services. Here are some of the top areas where Medicare Advantage plan benefits for 2025 have been cut:
- Only 65% offer meal benefits as compared to 72% in 2024.
- Only 73% offer over-the-counter drug benefits as compared to 85% in 2024.
- Only 30% offer transportation benefits as compared to 36% in 2024.
Although some benefits are cut, most Medicare Advantage plans still offer benefits such as hearing, vision and dental. From 2024 to 2025, around the same percentage of plans have no premium, so they don’t have a direct impact on affordability.
Reduced Medicare Telehealth Coverage
Telehealth services that were once popular during the COVID-19 pandemic are slowly declining in coverage. With the 2025 Medicare changes, you’ll need to live in a rural area to access some telehealth services. The good news is that there are still some crucial telehealth services you can access, including:
- Monthly kidney dialysis check-ins.
- Substance abuse or mental health treatments.
- Stroke care.
- Behavioral health services.
- Self-management training for diabetes.
- Nutrition therapy.
It’s best to pair telehealth services with face-to-face health care and other technological health gadgets. Seniors can also access other essential tech to monitor and maintain their health, such as fitness trackers and medical alert systems.
Training to Support Caregivers
Without access to adequate resources and support, family caregivers can experience burnout, which may affect their mental health and level of care. With the updated Medicare changes, caregivers can receive training to learn essential skills. It can help them offer better quality of care, reducing some of the stress associated with caregiving.
The new Medicare training option covers caregiver training for crucial skills like giving medications. The patient will be responsible for 20% of the Medicare cost for this training. The caregiver will need a doctor’s recommendation to attend these sessions. The training will be tailored to the type of medical condition, and the patient won’t need to be present.
New family caregivers should build their knowledge about medical conditions and learn more about safety-proofing the home. These Medicare training options help them develop these crucial skills.
Enhanced Dementia Support
Approximately one-third of all people over 85 years old have some form of dementia. Medicare offers the Guiding an Improved Dementia Experience (GUIDE) Model pilot program, which includes new features like a support line and community-based assistance. This program gives eligible patients and their families the support they need to navigate the symptoms of this disease.
One of the most crucial aspects of dementia support is in-home care. It provides the one-on-one attention the person needs and relieves families from the complexities of care. In-home care delivers the professional intervention necessary, especially as the disease progresses and the patient experiences more severe symptoms that affect mobility and cognitive function.
The new GUIDE Model provides $2,500 annually as part of the program’s funding to support enhanced care coordination and services. Some of these benefits may include adult day care, at-home care and overnight care services.
Key Medicare Takeaways for In-Home Care
Medicare coverage for 2025 includes many changes, such as a $2,000 out-of-pocket cap and more convenient payment options. These modifications can significantly affect the treatment options older adults qualify for. They can help cut some out-of-pocket costs if you know what you or your loved one is eligible for.
Eligible patients can receive temporary or intermittent in-home care, which can improve their lives substantially. In-home care provides personal attention and evaluation. Patients with injuries and illnesses that require in-home care can benefit from qualified caregivers for symptom management evaluation, proper medication hygiene, and maintaining and encouraging independence.
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