How to Qualify for Home Health Care Under Medicare?
Published January 27, 2025 by Jody Guerrieri, RN. in Caregiver Tips
Caring for an elderly family member can be challenging, and sometimes, additional support is necessary after a hospitalization or for ongoing health management. Medicare offers home health care options that provide skilled nursing and therapy services at home, but eligibility and coverage specifics can be confusing. This guide breaks down the requirements to help you determine if you or a loved one qualify for Medicare’s home health benefits.
Who Is Eligible for Home Health Care Under Medicare?
Medicare offers limited home health benefits under Original Medicare (Parts A and B), with specific qualifications and services covered based on individual needs. Coverage through Medicare Advantage (Part C) can vary by plan, so it’s essential to verify your specific coverage.
For eligibility under Original Medicare:
- Intermittent Care Requirement: Medicare defines intermittent skilled nursing care as care provided less than seven days a week or less than eight hours a day for up to 21 days.
- Coverage Exclusions: Medicare does not cover 24-hour care, home meal delivery, or home aides for daily activities like bathing, dressing, and meal prep.
- Care Requirements:
- The patient must be under a doctor’s care, with a documented care plan regularly reviewed.
- Skilled nursing or therapy services must be required on an intermittent basis.
- The patient must be homebound, meaning they have difficulty leaving home without assistance.
- Services must be provided by a Medicare-certified home health agency.
- An in-person doctor visit must confirm and monitor the need for care.
How Long Will Medicare Pay for Home Health?
Medicare will cover home health services as long as they are medically necessary, with a doctor re-evaluating the care plan every 60 days. While there is no annual limit on covered visits, care is generally limited to short-term needs and long-term 24/7 support is not covered.
Does Medicare Cover In-Home Care for People With Dementia?
Medicare covers some in-home services for dementia patients if they meet the criteria for skilled nursing or therapy services. Still, daily non-medical care—like help with dressing or bathing—is not covered. Other non-medical, long-term care options might include Medicaid (for those with limited income) or private long-term care insurance.
Differences Between Home Health Care vs. Home Care
While both support in-home care, they serve different needs:
- Home Health Care:
- Home Health Care involves skilled medical services like physical therapy, typically on a short-term basis for recovery or treatment. It is often covered by Medicare.
- Home Care:
- Home Care provides non-medical services such as personal care, companionship, and housekeeping, which Medicare does not cover.
Aspect | Home Health Care | Home Care |
---|---|---|
Services | Medical, skilled nursing, and therapy services | Non-medical, daily living assistance |
Providers | Licensed professionals through Medicare-certified agencies | Caregivers or aides, often non-medical |
Insurance Coverage | Often covered by Medicare if medically necessary | Not covered by Medicare; limited Medicaid/private insurance coverage |
Duration | Typically short-term for specific medical needs | Long-term, ongoing support for daily needs |
Home Health Care: Original Medicare vs. Medicare Advantage
Medicare Advantage (Part C) plans, provided by private insurers, offer coverage similar to Original Medicare (Parts A and B) but often include additional benefits, like vision, dental, and wellness programs, which Original Medicare doesn’t cover. However, Advantage plans may have stricter requirements, such as prior authorization for certain services.
Original Medicare
Medicare Advantage plans cover the same core home health services as Original Medicare but may require prior authorization for skilled care, such as physical therapy, occupational therapy, and nursing. Many plans operate within networks, meaning beneficiaries may need referrals for specialists and could face limitations on out-of-network services. A major benefit of Medicare Advantage is its annual out-of-pocket maximum, offering protection against high healthcare costs.
What Is Home Health Covered by Medicare?
Home health services aim to support homebound individuals who need skilled care, helping them receive essential medical assistance from the comfort of their homes. Medicare covers certain aspects of these services, provided the patient meets specific eligibility criteria outlined below:
- Skilled Nursing Care: Includes wound care, injections, and vital sign monitoring.
- Therapies: Physical, occupational, and speech therapy to assist with recovery or rehabilitation.
- Medical Supplies: Durable equipment like wheelchairs and walkers.
- Home Health Aide Services: Limited to help with personal care (e.g., bathing), under the supervision of a nurse.
Limitations of Medicare Home Health Coverage
While Medicare provides critical home health benefits, it does not cover:
- Continuous or Daily Care: Medicare only covers intermittent skilled care, not around-the-clock or daily long-term care.
- Non-Medical Services: Homemaking, personal care, and companionship are not included.
- Custodial Care: Medicare covers this only in certified facilities after 20 days if medically necessary.
How to Access Home Health Services
Follow this step-by-step process to get these Medicare-covered home health services.
- Consult a Healthcare Provider: Discuss your health needs with a doctor to determine if home health services are suitable.
- Obtain a Doctor’s Order: A written care plan must detail the specific home health services needed.
- Choose a Medicare-Certified Agency: Only services provided through certified agencies are eligible for Medicare reimbursement.
- Schedule Regular Reviews: Care plans must be updated periodically by a healthcare provider to ensure ongoing eligibility.
Conclusion
Qualifying for Medicare home health care can provide essential medical support for seniors and those with chronic conditions. Eligibility generally requires that a patient be homebound, need skilled medical care, and have a care plan prescribed by a doctor. While Medicare covers necessary care like skilled nursing and therapy, it doesn’t pay for non-medical services like homemaking or long-term custodial care. Understanding these guidelines can help families make informed decisions and access appropriate support for their loved ones.
If you have questions about senior home
care services or if you want to start care:
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