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Medicare Home Health Care & Eligibility

Published January 11, 2023

Home health care is a valuable benefit that provides in-home medical care to millions of seniors and people with chronic illnesses. Treatments provided at home are more convenient, less expensive, and may be more effective than the care you’d receive at a doctor’s office or hospital.

Unfortunately, if you’re a senior or caregiver for someone with Medicare health coverage, it’s easy to get confused by the details. Home health care — also simply known as “home health” — has a unique set of eligibility requirements that set it apart from other in-home services. We’ll be exploring these requirements and coverages in greater detail below. But first, let’s start by defining what home health care is.

What Is Home Health Care?

Medicare defines home health care as a wide range of medical services provided at home to treat an illness or injury. The need for home health care has grown as medical science and technologies have improved, leading many treatments that were once exclusively available in a hospital to become treatable at home. Examples of home health care services include:

  • Injections
  • IV therapy
  • Physical therapy
  • Wound care

Two main types of home health care are available to seniors and families. The most common arrangement is Medicare home health care through a home health care agency. In this type of care, a patient agrees to be “admitted” to the agency and receives care from its employees. The company bills Medicare or other health insurance for the services. Also, it takes responsibility for meeting the patient’s medical, nursing, rehabilitative, social, and discharge planning needs.

The alternative type is called private duty home care. In this form of home health, a patient or family hires a medical or nursing professional to provide services in the home. Usually, they pay out-of-pocket. Some long-term care insurance policies cover private duty home care or reimburse some of the expenses.

Both types of care help seniors and those living with chronic illnesses to:

  • Improve or maintain their health
  • Prevent complications
  • Avoid emergency room and hospital visits

Home health care also helps the elderly age in a comfortable and familiar setting. The main difference is who pays for the cost of care. If you want home care to be paid for by the insurance, then Medicare home health care may be your best option.

Who Is Eligible for Home Health Care with Medicare?

You can receive home care covered by Medicare if you meet three areas of criteria set by the Centers for Medicaid and Medicare Services (CMS). To be eligible for Medicare home health care, you must:

  • Have a doctor oversee your home health
  • Require medical services from a “skilled” licensed nurse or therapist
  • Have difficulty leaving your home and be certified homebound by your doctor

In Medicare, “homebound” means that you need assistance when leaving your home. Help may include equipment such as a wheelchair, walker, or cane. It may also mean physical help from friends or relatives. Your doctor must attest that leaving home requires a major, or “taxing,” effort because of your health condition.

Before a home health company can provide services to you, your doctor must send notes, orders, or other documentation to show that you qualify for care.

Aside from these, there are no other specific age, disability, or health requirements.

What Home Health Care Will Medicare Cover?

Most patients and families want to know: Does Medicare cover home health? Additionally, their next question is usually: What home health care is covered by Medicare? In short, Medicare pays for home health when certain requirements are met. We’ve already looked at three criteria a person must meet to qualify. Now, let’s look at the services that are paid for by Medicare in-home care.

Medicare covers:

  • Skilled Nursing
  • Physical Therapy
  • Occupational Therapy
  • Speech Therapy
  • Medical Social Work
  • Home Health Aide Services

The services must be:

  • Reasonable and necessary to treat an illness or injury
  • Intermittent (part-time)
  • Skilled, meaning they require the skills of a nurse or licensed therapist

One confusing piece of the puzzle is “unskilled” home care services by a home health aide. Medicare pays for a home health aide only for qualified individuals while receiving nursing care or therapy.

What About Hospice?

The goal of short-term home health care is to provide treatment for an illness or injury. The overall aim is for the patient to get better, regain their independence, and become as self-sufficient as possible.

Hospice differs from home health care in that a person with a terminal illness typically requires a higher level of care than home health can provide. Hospice care changes the focus to comfort care (palliative care) to relieve pain and manage symptoms instead of seeking to cure the patient’s illness. Medicare pays for hospice when a doctor certifies that a beneficiary is terminally ill, with six months or less to live.

The Medicare rules for hospice say you can only get hospice care for two 90-day periods. However, each is followed by unlimited 60-day recertification periods. This recertification process must include documentation that a hospice physician or nurse practitioner had a face-to-face encounter with the patient and that their prognosis reflects a life expectancy of six months or less.

On the other hand, home health care allows patients unlimited benefit periods — as long as the criteria (skilled, part-time, reasonable, and necessary) are met for each care episode.

Home Services Medicare Doesn’t Cover

Some of the services not covered include:

  • Housecleaning
  • Laundry Service
  • Meal Delivery
  • Personal Shopping
  • Fitness Training
  • “Sitter Services”

Though these may be helpful for seniors or those living with disabilities, unfortunately, they are not covered by Medicare or other health insurance.

How Medicare Pays for Home Health Care

Medicare pays for home health care services directly to the home health agency every 30 days. Home health services can be “recertified” or renewed an unlimited number of times as long as the eligibility criteria are maintained.

When a home health client improves and no longer needs home health, the agency will provide an Advanced Beneficiary Notice (ABN). The ABN will state why the patient is no longer eligible — such as no longer homebound, or no skilled need — and give instructions on how to appeal the decision.

Alternatively, Medicare may decide that a person no longer meets the requirements. When this happens, it will deny the home health agency’s claim and stop paying.

When Medicare stops paying for in-home nursing care, the home health company must notify the patient in writing. They will provide a form called the Home Health Change of Notice (HHCN) at least 48 hours before they cancel care or discharge the patient. This notice will give instructions on how to appeal the decision if the patient believes they are someone who qualifies for home health care services.

What Are the Costs If I Qualify?

The good news is that Medicare and most insurance plans cover 100% of home health care. In other words, there’s no co-payment or out-of-pocket expense as long as the eligibility requirements are met.

How to Get Home Health Care Services with Medicare

If you want to get home health care services with Medicare, here are the steps to follow:

  1. Call your doctor’s office or make an appointment to see your doctor.
  2. Tell them you would like a referral to home health care. The doctor’s office can start the paperwork and tell you what services are available in your area.
  3. Your doctor may send the orders right away. If that’s the case, the next step is to wait for the home health agency to call you and schedule an initial meeting.
  4. Alternatively, the doctor might give you a list of home health care agencies to choose from if there are options where you live. If you’re in charge of making the decision, you can compare home health care agencies in your area using the Medicare.gov database. You can also use this checklist to compare companies.
  5. If you still need help with the decision, contact OpenMedicare experts for more assistance.

Medicare can be a complicated program to understand; however, don’t let its myriad components hinder you from getting the care you need. If you prefer the assistance of a professional, you can call OpenMedicare at (844) 910-2061 to be connected with a licensed insurance agent.


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