Medicare Coverage of Home Health Care

When you need part-time skilled nursing care or therapy, Medicare will pay for home health care visits.

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Progressive health care professionals often encourage people to get out of hospitals and nursing facilities and into their own or family members’ homes while recovering from injury or illness. With less honorable motives, insurance companies also pressure hospitals to release patients earlier so that if they continue to receive care, it will be a less costly variety at home.

In response to both these movements, many new home health care agencies have sprung up. You’re increasingly likely to find such an agency in your local area. Most are able to provide care for patients who no longer need high-level care in a hospital but who still require part-time nursing or rehabilitative therapy.

When Medicare Will Cover Home Health Care

For your home heath care to be covered by Medicare, your situation must meet this list of requirements.

  • Your doctor must have prescribed home health care for you.
  • You must require part-time skilled nursing care or physical, speech, or occupational therapy.
  • The home health care must be provided by a Medicare-approved agency.
  • You must be confined to your home by an injury, illness, or other medical condition. (If you need nursing care or other medical services but you are physically able to leave home to receive it, you might not be eligible for Medicare home health care coverage.)
  • Your doctor must help set up a care plan in cooperation with the home health care agency.

Medicare sometimes used to also require that your condition be expected to improve with home health care, but a recent change allows you to qualify for home health care just to maintain your condition or to slow deterioration of your condition.

If you require full-time nursing care, Medicare will not approve home health care, but it could cover a skilled nursing facility. For more information, see our article on Medicare coverage for skilled nursing care.

What Medicare Will Pay For

Medicare Part A pays 100% of the cost of your covered home health care, and there is no limit on the number of visits to your home for which Medicare will pay. Medicare will also pay for the initial evaluation by a home care agency, if prescribed by your physician, to determine whether you are a good candidate for home care. (Note that Medicare Part A only pas for home health care that follows a prior three-day hospital stay. Otherwise Medicare Part B (medical insurance) pays for home health services.)

Medicare will pay for 100% of the following services related to home health care:

  • part-time skilled nursing care—usually two to three visits per week in a plan certified by a physician
  • physical therapy
  • speech therapy, and/or
  • occupational therapy.

If you are receiving home health care for one of the above, Medicare can also pay for:

  • personal care by part-time home health aides
  • medical social services, and
  • medical supplies and equipment provided by the agency, such as a hospital bed, a walker, or respiratory equipment.

What Medicare Will Not Cover

Medicare will not pay for a number of services sometimes provided as part of home health care, including:

  • drugs and biologicals administered at home
  • personal care by part-time home health aides if this is the only care you need
  • meals delivered to your home
  • housekeeping services, or
  • full-time nursing care.

If you require durable medical equipment, such as a special bed or wheelchair, as part of your home care, Medicare will pay only 80% of the costs.

For more information on Medicare coverage of home health care, read Medicare’s online publication Medicare and Home Health Care at http://www.medicare.gov/Pubs/pdf/10969.pdf.

Pros and Cons of Home Health Care

The benefits of properly administered home health care can be enormous. The fact that Medicare will pay for an unlimited number of home health care visits — with no copayments — makes home care a very good financial value compared to recovery in a hospital or nursing facility—in addition to the recuperative benefits of being at home.

Being in your own home or even that of a friend or relative is often more conducive to a speedy recovery than the impersonal and sometimes frightening environment of a hospital. You have familiar things around you, your friends and family can come and go without worrying about “visiting hours,” and they can lend a hand with your care. You have greater privacy and are free from dreadful hospital routines and late-night noise and lights.

On the other hand, home health care is not always the best solution. Hospitals sometimes push people out the door before they are well or strong enough, and as a result the people may take longer to recover at home, or suffer more pain and discomfort at home, than they would have if they had remained in the hospital just a few days more. This is particularly true when a patient does not have family or friends available to supplement the care provided by a home care agency.

Finding a Home Health Care Agency

If you are interested in home health care after a stay in the hospital, or as an alternative to a stay in a hospital or nursing facility, contact a home health care agency recommended by your doctor or the hospital discharge planner. The discharge planner can even contact an agency for you. You may also get help in locating home health care agencies from a community health organization, visiting nurses association, United Way, Red Cross, or neighborhood senior center. Medicare.gov lists home health care agencies in your area and allows you to compare the quality of their service depending on past performance.

How to Start Home Health Care

If your doctor has not mentioned home care to you but you feel it would be a good idea, make your wishes known. If you are looking at a long period of convalescence, home health care can be a better alternative to a long siege in the hospital or nursing facility. Most doctors will prescribe home care, can give you a referral to a Medicare-approved agency, and will cooperate with the home health care agency.

by: Attorney Joseph Matthews

Updated by: , J.D.

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