When Does Medicare Cover Home Health Care?

Under Original Medicare (Part A and/or Part B), home health care is covered when specific conditions are met.

You must:

• Need part-time or intermittent skilled care

• Be considered “homebound”

• Have an in person eval by a doctor certifying that you need home health services

• Receive care from a Medicare-certified home health agency

What Does “Homebound” Mean?

Being homebound means that leaving home requires a major effort or assistance because of illness or injury.  For example, you may need:

• A walker, cane, crutches, or wheelchair

• Special transportation

• Help from another person

You are still allowed to leave home for medical appointments, adult day care, religious services, or short, infrequent outings. Doing so does not automatically disqualify you.

Your doctor must create and order a plan of care. The home health agency will coordinate services and keep your doctor informed about your progress.

What Services Are Covered?

Medicare covers medically necessary, part-time or intermittent skilled services, including:

• Skilled nursing care

  • IV therapy or injections

  • Wound care for pressure sores or surgical wounds

  • Monitoring serious or unstable health conditions

• Therapy services

  • Physical therapy

  • Occupational therapy

  • Speech-language pathology

• Medical social services

• Education for patients and caregivers

Home health aide services (such as help with bathing or dressing) are covered only if you are also receiving skilled nursing or therapy services as part of your care plan.

What Is Not Covered?

It’s important to understand what Medicare does not pay for:

• 24-hour-a-day care at home

• Meal delivery

• Homemaker services like shopping or cleaning (unless part of a covered care plan)

• Help with activities of daily living (walking, bathing, dressing, grooming, toileting) if that is the only care you need

If someone only needs custodial or personal care, Medicare alone will not cover those services.

How Much Care Can You Receive?

“Part-time or intermittent” generally means:

• Up to 8 hours per day (combined skilled nursing and aide services)

• A maximum of 28 hours per week

In certain situations, this may increase temporarily (up to 35 hours per week) if medically necessary.  If you require full-time skilled nursing care, you would not qualify under the Medicare home health benefit.

What Are the Costs?

Under Original Medicare:

• $0 for covered home health care services

• After meeting your Part B deductible, you pay 20% of the Medicare-approved amount for durable medical equipment (like a walker or wheelchair)

Before services begin, the home health agency must explain what Medicare will pay. If they believe Medicare may not cover something, they must give you an Advance Beneficiary Notice (ABN) explaining your potential financial responsibility before providing that service.

What If You Have Other Coverage?

If you have a:

• Medicare Advantage (Part C) plan – The plan must cover at least what Original Medicare covers, but network rules or prior authorization may apply. It’s important to check directly with your plan.

• Medicare Supplement (Medigap) policy – This can help cover your share of certain costs under Original Medicare.

• Other health insurance – Always let your providers know so billing is handled correctly.

  

  Medicare and Home Health Care