Medicare home health care may cover certain skilled services provided in the home to help treat an illness or injury when eligibility requirements are met.
These services allow some types of medical care to be delivered at home instead of in a hospital or outpatient setting, depending on the individual’s condition and care plan.
Home health care can be an option for receiving medically necessary services in a familiar environment. The type of care provided, how it is delivered, and any associated costs will depend on your specific situation and Medicare’s coverage rules.
Types of Services Covered Under Medicare Home Health Benefits
Medicare home health benefits may include a range of covered services, depending on your eligibility and care needs. Understanding what may be available can help you better evaluate how your coverage works and what services you may receive.
Intermittent Skilled Nursing Care:
This may involve a nurse visiting your home on a part-time basis to provide medically necessary care when eligibility requirements are met. The term “intermittent” generally means care is provided fewer than seven days per week or less than eight hours per day over a limited period of time.
Therapy Services:
Medicare may cover certain therapy services as part of home health care, including physical therapy, occupational therapy, and speech-language pathology services, when they are medically necessary and eligibility requirements are met.
Home Health Aide Services:
Home health aide services may include personal care, such as bathing, dressing, and grooming. Medicare may cover these services only when you are also receiving covered skilled nursing care or therapy services. Personal care alone is not covered.
Additional Covered Services:
Medicare home health care may include medical social services to help address social or emotional concerns related to your condition, as well as limited medical supplies and durable medical equipment for use in the home. Coverage depends on the specific services provided and Medicare’s requirements.
Determining Your Eligibility for Medicare Home Health Benefits
Qualifying for home health care services requires meeting specific criteria established by Medicare. Understanding these requirements helps you know whether you’re eligible and what documentation you’ll need.
1. The “Homebound” Requirement
To receive Medicare home health benefits, you must be considered “homebound”. This doesn’t mean you can never leave your home; rather, leaving must require considerable effort.
You’re considered “homebound” if:
- Leaving home requires supportive assistance from another person
- Special transportation arrangements are required
- Your doctor believes that leaving home is medically detrimental
You can still leave home for medical appointments, religious services, or occasional trips, such as a family gathering, and remain eligible. The key is that leaving home requires significant effort and doesn’t happen on a regular basis.
2. Need for Skilled Care
Medicare home health benefit eligibility requires intermittent skilled nursing care, physical therapy, speech-language pathology services, or occupational therapy. Needing only personal care or custodial services doesn’t qualify you for Medicare home health coverage.
In summary, the care must be medically necessary and require the skills of a licensed healthcare professional.
3. Doctor’s Certification
Before becoming eligible for home health benefits, your doctor must certify that you need these services. This requires a detailed plan of care outlining the specific services you require.
Additionally, the plan must be reviewed and updated regularly to maintain Medicare coverage. This means that you must see your doctor face-to-face within a specified timeframe related to the primary reason you need home healthcare.
4. Medicare Enrollment Requirements
To receive Medicare-covered home health services, you must be enrolled in Medicare (either Original Medicare or a Medicare Advantage plan) and meet specific eligibility and medical necessity requirements.
The coverage works similarly under both options, though Medicare Advantage plans may have stipulations on which agencies you can use, so it is always best to check.
Home Health Benefit Costs and What Medicare Covers
One of the most attractive aspects of Medicare home healthcare is its cost structure. Understanding what you’ll pay helps you budget effectively and avoid unexpected expenses.
Costs for Covered Home Health Services
If you qualify for Medicare home health services, Medicare may cover eligible skilled nursing care, therapy services, and certain home health aide services provided in the home. For the covered home health visit itself, you may have no out-of-pocket cost when Medicare’s eligibility and coverage requirements are met. However, coverage depends on your specific situation, the services provided, and Medicare guidelines.
Durable Medical Equipment (DME) Costs
Some home health care may include the use of durable medical equipment (DME), such as wheelchairs, walkers, hospital beds, oxygen equipment, and certain diabetes-related supplies.
For Medicare-covered DME, you may be responsible for the Part B deductible (if it has not been met) and typically 20% coinsurance of the Medicare-approved amount. Costs can vary depending on the equipment and supplier, so it’s important to confirm details before receiving equipment.
What Medicare Doesn’t Cover
Medicare home health benefits do not cover certain non-medical or custodial services, including:
- 24-hour care at home
- Meal delivery services
- Homemaker services such as shopping, cleaning, and laundry when these are the only services needed
- Outpatient prescription drugs (these are generally covered under Medicare Part D, not the home health benefit)
Before services begin, home health agencies are required to inform you—both verbally and in writing—about any services Medicare may not cover and any potential costs you may be responsible for.
How Medicare Advantage Plans Handle Home Health Services
If you have a Medicare Advantage plan (Part C), your home health coverage may work differently than it does under Original Medicare, although plans are required to cover Medicare-covered home health services.
Medicare Advantage plans must cover eligible home health services that are covered by Original Medicare, such as skilled nursing care and certain therapy services, when coverage requirements are met. However, plan rules, access to providers, and cost-sharing may vary.
Many Medicare Advantage plans use provider networks, which may require you to receive care from in-network home health agencies for services to be covered at the lowest cost. In some cases, using out-of-network providers may result in higher costs or may not be covered, depending on the plan.
Before arranging home health services, it’s important to contact your plan to understand provider network requirements, whether prior authorization is needed, and what your potential out-of-pocket costs may be.
During eligible enrollment periods, you may also have the opportunity to review your current coverage and compare plan options based on your healthcare needs.
How to Choose a Home Health Provider
You can choose your Medicare-approved home health agency. Making the most informed choice ensures you receive the quality care you need.
Keep in mind that not all home health agencies accept Medicare. Medicare-approved agencies meet federal health care standards and regulations, ensuring quality care and proper billing practices.
Use Medicare’s search tool to find certified home health agencies covered by Medicare in your area. This database provides ratings, quality measures, and other information to help you compare agencies.
What to Consider When Choosing an Agency
When evaluating potential agencies, it’s important to consider several factors:
- Reputation: Research the agency’s reputation in your community and read reviews from other patients.
- Staff Qualifications: Are nurses and therapists properly licensed and experienced?
- Services Offered: Assess the range of home health care services offered and whether they match your needs.
- Scheduling Availability and Flexibility: Will the agency accommodate your preferred visit times?
- Communication: The agency should always keep you and your doctor informed about your care progress.
- Emergency Situations: How do they handle emergencies or urgent needs?
Special Considerations for Medicare Advantage Plans
If you’re enrolled in a Medicare Advantage plan, know that some plans may require you to use agencies contracted with the plan. Check with your plan administrator before selecting an agency to ensure your choice is within your plan.
Your Rights Regarding Agency Selection
Medicare beneficiaries have rights regarding home health care services and agency decisions:
- Agencies cannot be changed without your knowledge or consent.
- If you’re unhappy with your current agency, you have the right to switch to another Medicare-approved provider.
- Agencies must discuss and get your consent before changing the frequency of visits or making significant modifications to your care plan.
How to Maintain Medicare Home Health Benefits and Your Rights
Once you’re receiving home health care services, maintaining coverage requires ongoing attention and communication.
1. Stay Connected with Your Care Team
Maintain regular contact with your healthcare provider and home health agency to ensure ongoing coverage. Your plan of care must remain current and accurately reflect your ongoing healthcare needs.
If your condition changes—either for the better or worse—notify your doctor and home health agency promptly.
2. Following Medicare Guidelines
Follow Medicare guidelines to maintain your active home healthcare benefits. This includes allowing access to your home for scheduled visits, participating actively in your care plan, and promptly reporting any changes in your health or care requirements to your provider.
3. Understanding Your Patient Rights
As a Medicare beneficiary receiving home health services, you have extensive rights and protections, including the right to:
- Be informed about your care
- Participate in care planning decisions
- Have your property and person treated with respect
- Voice grievances about your care without fear of retaliation and have those complaints addressed promptly
You also have the right to privacy and confidentiality regarding your medical information and treatment. Home health agency staff must respect your home and possessions while providing care.
4. When to Review or Change Your Care Plan
Your care needs may change over time. Perhaps you’ve improved and need fewer services, or maybe your condition has deteriorated and you require additional support.
Regular reviews with your doctor and home health agency ensure your plan of care adapts to your current needs. Medicare may require periodic recertification to continue home health services. Coverage is generally reviewed in 60-day certification periods, and a healthcare provider must confirm that services remain medically necessary for care to continue.
Next Steps: Getting Started with Medicare Home Healthcare
If you believe you need home healthcare services, start by talking with your doctor. Your physician must certify your need for care and create a plan specifying the services you require. Be honest about your limitations and needs—this helps your doctor understand the full scope of care you might benefit from.
Once your doctor certifies your need, work together to select a Medicare-approved home health agency. Use the resources at Medicare.gov to research agencies in your area, comparing quality ratings and services offered. Contact agencies directly to ask questions about their staff, availability, and approach to care.
When the agency conducts its initial assessment, be prepared to discuss your medical history, current medications, home environment, and family support system. This comprehensive evaluation helps the agency develop an effective care plan tailored to your specific situation.
Additional Resources and Support
Navigating Medicare home health benefits doesn’t have to be a solo journey. Contact your healthcare provider or Medicare for assistance with home health care benefits. Visit Medicare.gov for detailed information on coverage of home health services, including tools to find and compare agencies in your area.
The Medicare hotline (1-800-MEDICARE) can also connect you with representatives who can answer specific questions about your eligibility and coverage.
Medicare School is also here to provide you with the information you need about home healthcare benefits. Learn more with our free Medicare workshop.
Medicare Home Health Benefits Frequently Asked Questions
Q: How often can I receive home health visits under Medicare?
A: There’s no set limit on the number of home health visits. Your doctor determines the frequency based on your medical needs. Visits are typically intermittent (part-time) rather than daily, and your care plan specifies the schedule.
Q: Will I have to pay anything for a home health nurse visit?
A: Medicare may cover eligible home health services when requirements are met. You may have no out-of-pocket cost for the covered home health visit itself, but costs can still apply for items like durable medical equipment, which may require the Part B deductible and 20% coinsurance.
Q: Can I receive home health services if I also have family helping me?
A: Yes, having family support doesn’t disqualify you from Medicare home health benefits. In fact, agencies often work with family caregivers, providing training and coordination to ensure comprehensive care.
Q: What if I need more help than Medicare home health provides?
A: Medicare home health covers medically necessary skilled care only. If you need additional personal care or homemaker services, you may need to hire private help or explore Medicaid home care options if you qualify.
Q: How long can I receive Medicare home health care?
A: As long as you remain homebound, need skilled care, and your doctor certifies the ongoing need, you can continue receiving services. Care is reviewed and recertified regularly, typically every 60 days.
Q: Can I choose a different home health agency if I’m unhappy with my current one?
A: Yes, you have the right to choose your Medicare-approved home health agency and can change agencies at any time. Discuss your concerns with your doctor, who will need to refer you to the new agency.