Medicare Coverage of Home Health Care

Health care providers and insurance companies increasingly encourage home recovery from an illness or injury over extended hospital stays. The trend toward earlier discharge from hospitals has made home health care more accessible than ever.

Today, many local home health agencies offer part-time skilled nursing and rehabilitative therapy for patients who no longer need full-time hospital care but still require professional support.

Medicare will pay for many types of home health care services for those with original Medicare Part A and Part B—whether or not you have medigap coverage. This article discusses home health care coverage under regular Medicare, including:

• how to qualify for home health care under Medicare
• what types of home health care are covered, and
• how to find a covered home health care agency in your area.

If you have a Medicare Advantage plan (Part C), the company managing your health care coverage likely covers at least some home health services (check with your managed care provider).

When Does Medicare Cover Home Health Care?

You can qualify for home health care under Medicare only if your health care provider prescribes it to improve or help maintain your health or to slow the deterioration of your condition. Medicare requires that your health care provider has documented a face-to-face visit with you regarding your need for home health care. All of the following must also apply to you:

• Your prescribing health care provider is one of the following allowed providers:
• a doctor (M.D. or D.O.)
• a nurse practitioner
• a clinical nurse specialist, or
• a physician assistant.
• You require one of the following types of skilled care:
• part-time skilled nursing care
• physical therapy
• speech therapy, or
• continuing occupational therapy.
• A Medicare-certified agency provides the home health care.
• Your health care provider works with the home care agency to set up your care plan.

Your health care provider must also certify that you're homebound, meaning you have trouble leaving your home without help because of an illness or injury, or leaving your home isn't recommended because of your condition. You must normally not be able to leave home at all, but when you do, it must require "considerable and taxing effort" (Medicare Benefit Policy Manual, Ch. 7, Section 30.1.1.)

Medicare considers "part-time" skilled nursing care to be less than 8 hours a day and fewer than 7 days per week, for up to 21 days. If you require more than that (full-time nursing care), Medicare won't approve home health care, but it might cover a skilled nursing facility. Learn more about when Medicare pays for skilled nursing facility care.

What Home Health Care Services Does Medicare Cover?

Medicare Part A (hospital insurance) pays for home health care that follows a prior three-day hospital stay. Otherwise, Medicare Part B (medical insurance) pays for home health services.

Medicare pays the cost of an initial evaluation by a certified home care agency. Medicare also pays 100% of the cost of part-time skilled nursing care and therapy. And if you're receiving skilled care, Medicare will also pay for the following services if they're prescribed by your health care provider and considered reasonable and necessary to improve or maintain your condition:

• personal care by part-time home health aides
• medical social services (like counseling)
• medical supplies and equipment provided by the agency, such as a hospital bed, a walker, or respiratory equipment, and
• home infusion therapy services if you need to receive certain intravenous or subcutaneous drugs in the home, including:
• nursing visits
• caregiver training, and
• patient monitoring.

Under Medicare guidelines for home health care, you might be able to get skilled nursing care or therapy and home health aide services as many days per week as needed, as long as the combined total is fewer than 8 hours per day and no more than 28 hours per week (up to 35 hours a week in some limited situations).

What Home Health Care Services Won't Medicare Cover?

Medicare won't pay for some services that are sometimes provided as part of home health care, including:

• a home visit that's only to have blood drawn
• routine foot care
• personal care by part-time home health aides (dressing, bathing, and so on) if it's the only care you need
• meals delivered to your home
• housekeeping services, or
• full-time nursing care.

If you require home infusion therapy services or durable medical equipment, such as a special bed or wheelchair, as part of your home care, Medicare Part B will pay only 80% of the costs. You must pay the remaining 20% of home infusion therapy services, equipment, and supplies.

Learn more about Medicare coverage for home health care in Medicare's online publication, Medicare & Home Health Care.

Pros and Cons of Home Health Care Under Medicare

Properly administered home health care can have enormous financial and recuperative benefits. With no copayments for skilled nursing care and therapy, home health care under Medicare is a very good financial value compared to recovery in a hospital or nursing facility.

Being at home or with a friend or relative rather than in a hospital can help speed your recovery. You can benefit from familiar surroundings and flexible visits from friends and family who can lend a hand with your care. You also have greater privacy and don't have to tolerate unpleasant hospital routines, late-night noise, and lights.

But home health care isn't always the best solution. If you're discharged before you're well enough, recovery at home might take longer and involve more pain and discomfort than staying a few extra days in the hospital. That can be especially difficult for patients without family or friends to help supplement the care provided by a home care agency.

(Learn how to appeal if you think you're being discharged too soon.)

How to Start Home Health Care

If your doctor hasn't mentioned home care to you but you feel it would be a good idea, make your wishes known. If you're looking at a lengthy recovery period, home health care can be a better alternative to an extended hospital, rehabilitation, or nursing facility stay. Most doctors will prescribe home care and can refer you to a Medicare-approved agency. Many will also work with the home health care agency to develop your care plan and monitor your progress.

Finding a Medicare Home Health Care Agency

If you're 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 health care provider) or the hospital discharge planner. The discharge planner can even contact an agency for you. Remember to check that the home health agency is certified by Medicare to ensure coverage.

You might also get help in locating home health care agencies from other organizations, such as:

• a community health organization
• a visiting nurses' association
• United Way
• the Red Cross, or
• your neighborhood senior center.

You can find Medicare-certified home health agencies in your area using the provider search tool at Medicare.gov. The tool allows you to compare agencies based on the quality of their service and patient ratings.