Understanding Medicare Home Health Care: Who’s Eligible and What’s Covered

Home health care in the United States is really expensive. The national daily average cost of a home health aide is $154, according to the 2021 Cost of Care Survey by Genworth, a long-term care insurance company.

That’s $56,160 a year to hire a home health aide to work 40 hours a week.

Medicare — the federal health insurance program for people ages 65 and older and some younger people with disabilities — covers certain home health care services.

Home health care is usually less expensive, more convenient and just as effective as getting care in a hospital or skilled nursing facility.

Understanding what’s covered under Medicare — and what’s not — can save you and your family lots of precious time and money.

We’ll explain Medicare’s definition of home health care, the types of services covered, limitations, eligibility requirements and cost.

Understanding Medicare’s Definition of Home Health Care

Medicare defines home health care as skilled nursing care and therapy services provided in a patient’s home to treat an illness or injury. It’s meant to provide support on a part-time basis and doesn’t include around-the-clock custodial care.

Home health care is provided by licensed health care professionals, including registered nurses, physical therapists and occupational therapists.

Medicare covers home health care services for a limited period, usually following a hospital stay or after a physician certifies the need for skilled care.

To be eligible for coverage, the care must be intermittent, meaning you don’t require daily attention or 24/7 supervision. Additionally, the services must be provided by a Medicare-certified home health agency.

Home Health Care Services Covered by Medicare

While Medicare provides coverage for certain home health care services, it doesn’t cover everything.

Here’s what is covered:

• Skilled nursing care: This includes services like wound care, medication management, intravenous therapy and teaching you and your caregivers about prescription drugs or diabetes care. Services are provided by a registered nurse or licensed practical nurse.
• Physical therapy: Medicare covers physical therapy services aimed at restoring mobility, improving strength and promoting overall physical well-being. Services are provided by a licensed physical therapist.
• Occupational therapy: These services focus on helping you regain skills necessary for daily activities, such as bathing, dressing and eating.
• Speech-language pathology: Speech therapy services are covered for beneficiaries who require assistance with communication or swallowing difficulties.
• Medical social services: This can include counseling or help finding resources in your community, and it’s provided by a licensed social worker. However, Medicare won’t cover medical social services unless you’re getting other skilled care at the same time.

Medicare will cover these services if you receive care less than seven days a week or less than eight hours each day over a period of 21 days (or less) with some exceptions in special circumstances.

If you have dementia and meet the criteria for services, you can get up to 35 hours a week of covered home health care services.

How Do You Qualify for Medicare Home Health Care?

To be eligible for Medicare-covered home health care services, the following conditions must be met:

• You must be enrolled in Medicare Part A and/or Part B.
• You must be under the care of a doctor who certifies the need for home health care services.
• Your doctor must issue a plan of care that details your requirements for one or more of the covered services mentioned earlier. This personalized plan details the type of professional you need, frequency of services, any necessary medical equipment and expected results from the care.
• You must be homebound, meaning leaving the house requires a considerable effort or may pose a risk to your health and well-being.
• The plan of care must be reviewed and recertified by your doctor and home health team at least once every 60 days.
• You need to have an in-person visit with your doctor either 90 days before starting home health services or within 30 days after services begin.
• Home health care services are provided by Medicare-certified agencies. Agency personnel will coordinate and provide the services you need as ordered by your doctor.

Once your doctor refers you for services, staff from a home health agency will contact you and set up an appointment to come to your home and assess your condition.

You can learn more about home health care services, including how to pick a home health agency and file an appeal, by checking out Medicare’s Home Health Care Handbook.

How Much Does Medicare Home Health Cost?

According to Medicare’s website, people enrolled in Original Medicare who meet the above criteria pay $0 for covered home health care services.

Medicare Advantage plans, administered by private insurance companies, also cover home health care because they have the same benefits as Original Medicare.

However, Medicare Advantage plans require you to choose health care providers within the plan’s network. Different rules and costs may also apply, so it’s important to contact your specific plan provider to learn more.

Before you start getting services, the home health agency should give you all the details about what Medicare will cover. They should be transparent about any items or services that won’t be covered by Medicare and let you know how much you’ll need to pay for them. They should provide this information both verbally and in writing.

You might come across something called the Advance Beneficiary Notice of Noncoverage, or ABN, before the agency offers you services or supplies. The ABN is a notice that explains why Medicare probably won’t pay for certain services. For example, something may not be covered if the home health agency doesn’t believe it’s medically necessary.

Remember: Medicare does not cover 24/7 custodial care, which includes assistance with activities of daily living such as bathing, dressing and meal preparation. Housekeeping, meal delivery and transportation aren’t covered either.

Keep in mind that you may have to foot the bill for any services or supplies Medicare won’t cover. So, it’s essential to understand the costs involved beforehand. Speak with a staff member at the home health agency if you have any questions about your ABN.

And here’s an important tip. If you prefer, you can ask the home health agency to send your claim directly to Medicare if you think the service or supply should be covered. This way, Medicare will review the claim and make a decision about payment.

It’s your right to have the agency bill Medicare, so don’t hesitate to do so.

Will Medicare Pay for Family Caregivers?

While Medicare’s coverage for home health services is rather narrow, Medicaid offers additional support in the form of caregiver payment programs.

All 50 states and the District of Columbia offer some kind of program through Medicaid that lets clients choose a family caregiver who is paid with Medicaid funds for providing care to their loved ones at home.

Medicaid is a health insurance program for people with lower incomes. In 2023, about 12.5 million people were eligible for both Medicare and Medicaid, a situation known as being dual-enrolled.

Each state has its own Medicaid program, so eligibility criteria and payment structures for family caregivers vary by state. Eligibility is usually based on the beneficiary’s functional and financial needs.

You can find state-specific eligibility criteria here. If you’re already enrolled in Medicaid, contact your state’s Medicaid office for more information.

To learn more, check out our article on how to become a paid caregiver for a family member.

Rachel Christian is a Certified Educator in Personal Finance and a senior writer at The Penny Hoarder. She focuses on retirement, Medicare, investing and taxes.