Medicare Home Health Care: Eligibility and Benefits You Need to Know

Medicare Home Health Care: Eligibility and Benefits You Need to Know

Many healthcare treatments once used to offer only in a hospital or a doctor’s office can now be done at your home. Home health care is usually cheaper, more convenient, and can be just as effective as what you’d find in a skilled hospital or nursing facility. In general, the purpose of home health care is to provide treatment for illness or injury.

Where possible, home health care helps you recover fast and at your convenience. Medicare pays for health services in your home if you meet specific eligibility criteria and if the services are considered appropriate and necessary to treat your illness or injury. This article describes the home health care services covered by Medicare.

Home health care Eligibility

If you’ve Medicare, you can use your home health care benefits. If:

  1. You are under a doctor’s care, and you receive services under a care plan established and regularly reviewed by a physician.
  2. You need one or more of these with a doctor’s declaration/certification:
    • Speech-language pathology services
    • Intermittent skilled nursing care (except drawing blood) 
    • Continued occupational therapy 
    • Physical therapy
  1. The home health agency that is caring for you is Medicare-approved (Medicare-certified).
  2. You’re homebound, and the doctor certifies that you are homebound. Being homebound states:
    • You’ve difficulty leaving your home without help or support due to illness or injury (such as using a walker, wheelchair, or crutches; special transportation; or assistance from another person), or leaving your home is not recommended.
    • You usually can’t leave your house, or doing so takes a lot of effort.

You will not be eligible for home health care if you can leave home for a short time, for medical treatment, or frequent non-medical reasons. Non-medical reasons include a visit to the barbershop, a walk around the block or drive, or attending a family reunion, funeral, graduation, or other rare or unique events. However, you will get home health care if you attend adult daycare.

  1. As part of your eligibility, a doctor or specific health care professionals who work with the doctor (such as a nurse practitioner) must state that they had a one-on-one meeting with you concerning why you need home health care.

You don’t qualify for home health care services if you need more than intermittent skilled nursing care. To identify your eligibility for home health care, consider Medicare’s definition of intermittent nursing care. 

    • Less than seven days each week.
    • Less than 8 hours per day for 21 days. In some cases, Medicare may increase the limit to three weeks if your doctor can predict the end of your need for daily skilled nursing care.

If you are expected to have full-time skilled nursing care for an extended period, you will not usually be eligible for home health benefits.

Home Health Benefits rANGE

The elements of Original Medicare — Part A (hospital insurance) and Part B (doctor visits and outpatient treatment) — may cover home care. Services include:

  • Skilled nursing care, such as changing wound dressings, tube feeding, and injection medication, is provided part-time or intermittently. In addition, your combined home and personal care cannot exceed eight hours a day or 28 hours a week. If you need long-term nursing care, you probably won’t qualify for home health benefits.
  • Home health support helps with personal activities such as bathing, dressing, or going to the bathroom if your illness or injury requires such assistance. Medicare only covers these services if you also receive skilled nursing or Medicare.
  • Medical social services such as social or emotional counseling related to your illness or injury if you’re receiving skilled care and help find community resources when required.
  • Occupational, physical, and speech therapy with occupational therapists to restore or improve your ability to perform everyday tasks, mobility after illness or injury, or help prevent your condition from getting worse.
  • Your home health agency provides medical supplies related to your condition, such as catheters and wound dressings. It may also include durable medical equipment from a home health agency, such as walkways or wheelchairs, but Medicare does not cover its total cost. You are typically responsible for 20 percent of the amount approved by Medicare.

Medicare does not cover:

  • 24-hour care at home
  • Custodial care – when this is the only home care you need.
  • Meal delivery to your home.
  • Household services such as shopping, laundry, and cleaning are not related to your care plan.

How Medicare Pays for Home Health Care 

Medicare pays your Medicare-certified home health agency a single payment for the services you receive during the 30-day care. You can take advantage of more than one 30-day period of care. Payment for each 30 days-care is based on your condition and care needs. Getting treatment from a Medicare-certified home health agency can cut your expenses. A Medicare-certified home health agency agrees:

  • To be paid by Medicare
  • To accept only the amount Medicare approves

Medicare home health benefits only pay for services offered by the home health agency. Other medical services, such as doctor visits or the need for equipment, are generally still covered by your other Medicare benefits.

The Medicare website has a search and comparison tool that help you find certified home health agencies in your area. If you have Original Medicare (Part A & B), choosing any approved agency will work.

Before you start receiving care, the agency must tell you, both verbally and in writing, whether some of the services they provide are covered by Medicare and what you will pay for them.

You can consult our licensed insurance agents specializing in Medicare to find the Medicare plan that matches your needs.

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