January 15, 2025

What does Medicare cover for home health services?

By: Paul Kent
Client Relations Manager, Global Care of Massachusetts

Medicare provides a critical safety net for older adults and people with disabilities, and one of its key offerings is coverage for home health services. These services allow beneficiaries to receive medical care and assistance in the comfort of their own homes, helping them to recover from illness or surgery, manage chronic conditions, or improve their overall quality of life. However, Medicare coverage for home health services has specific requirements and limitations. In this article, we’ll explore what Medicare covers, who is eligible, and how to access these services.

What is Covered by Medicare for Home Health Services?

Medicare Part A (Hospital Insurance) and Part B (Medical Insurance) typically cover home health services, but only if certain conditions are met. The services covered under Medicare generally include the following:

1. Intermittent Skilled Nursing Care

Medicare covers skilled nursing services if they are necessary for your recovery. These services are provided by registered nurses (RNs) or licensed practical nurses (LPNs) and typically include things like:

• Monitoring and managing your health conditions

• Wound care

• Administering intravenous (IV) medications

• Health assessments and care planning

• Education and training for caregivers

Medicare covers skilled nursing care on an intermittent basis, which means it’s provided only as often as needed—usually a few times a week.

2. Physical, Occupational, and Speech Therapy

Medicare covers therapy services provided by licensed professionals, such as:

• Physical therapy (PT): Exercises and treatments to improve mobility, strength, and function.

• Occupational therapy (OT): Techniques to help you perform daily activities (like bathing, dressing, or cooking) that may be impacted by illness or injury.

• Speech-language pathology (SLP): Therapy for speech or swallowing problems.

These services are typically provided on a short-term basis, and Medicare will cover them if they are medically necessary and ordered by a physician.

3. Medical Social Services

If your condition requires assistance beyond medical care, such as support with accessing community resources or counseling services, Medicare may cover social services. These services can be especially helpful for patients dealing with mental health challenges, adjusting to chronic illness, or managing complicated care needs.

4. Home Health Aide Services

Medicare covers home health aide services if they are part of a plan of care established by a doctor. Aides can help with activities of daily living (ADLs), such as:

• Bathing

• Dressing

• Using the toilet

• Eating

These services are typically provided on a part-time or intermittent basis and are only covered when a registered nurse or therapist is also involved in your care.

5. Durable Medical Equipment (DME)

Medicare may cover certain types of durable medical equipment (DME) that are necessary for your care at home. Some examples of DME that Medicare may cover include:

• Wheelchairs or walkers

• Hospital beds

• Oxygen equipment

• Blood sugar monitors

• Prosthetics or orthotics

Equipment must be prescribed by your doctor, and it must be medically necessary for you to manage your condition at home.

Eligibility for Medicare Home Health Services

To qualify for home health services under Medicare, you must meet the following criteria:

1. You Must Be Homebound

You must be considered “homebound,” meaning that leaving home requires a considerable and taxing effort. This doesn’t mean you have to be bedridden, but it does mean that you are unable to leave your home without significant difficulty due to illness or injury.

2. You Need Skilled Care

The services you require must be of a skilled nature, meaning they are provided by qualified healthcare professionals like nurses, therapists, or social workers. Medicare typically covers intermittent services for skilled care, not long-term care or custodial services.

3. You Must Have a Doctor’s Orders

Home health services must be prescribed by a doctor. Your doctor will evaluate your condition, develop a plan of care, and determine if home health services are necessary. The doctor must also certify that you need home health services and review your progress periodically.

4. Care Must Be Provided by a Medicare-Certified Agency

To ensure that the services meet Medicare’s standards, home health services must be provided by an agency that is certified by Medicare. This certification ensures that the agency meets specific quality and safety standards.

How Much Does Medicare Pay for Home Health Services?

Medicare typically covers 100% of the cost for home health services that are medically necessary and meet the criteria mentioned above. However, there are a few important considerations regarding costs:

• No Copayment for Home Health Care Services: For most home health services, Medicare does not require a copayment or coinsurance. This includes skilled nursing care, therapy services, and medical social services, as long as they are part of your approved plan of care.

• Durable Medical Equipment: While Medicare covers DME, you may need to pay a portion of the cost. For instance, you may be responsible for the 20% coinsurance for most covered DME items, after you meet your Part B deductible.

• Home Health Aide Services: If you need home health aide services, Medicare will only cover them if they are part of a comprehensive care plan that includes skilled services. If the aide services are not covered, you may need to pay for them out-of-pocket.

• Short-Term, Not Long-Term: Medicare home health benefits are typically meant for short-term care. If you need long-term, ongoing care, such as assistance with daily activities or custodial care, Medicare will not cover those costs.

How to Access Medicare Home Health Services

To access home health care under Medicare, follow these steps:

1. Talk to Your Doctor: Your doctor will evaluate your condition and determine if home health care is appropriate for you.

2. Choose a Medicare-Certified Agency: Once your doctor orders home health services, they will refer you to a Medicare-certified home health agency. You can search for certified agencies using the Medicare website or ask your doctor for a recommendation.

3. Get an Evaluation: After you are referred to a home health agency, a nurse or therapist will typically visit your home to assess your needs and develop a care plan.

4. Receive Care and Review Progress: The agency will provide services based on your doctor’s care plan, and your doctor will review your progress periodically. If your condition changes, the plan of care may need to be updated.

Conclusion

Medicare home health services offer significant support for beneficiaries who require medical care and assistance at home. From skilled nursing and therapy services to durable medical equipment, Medicare provides comprehensive coverage for many essential services. However, eligibility requirements and coverage limitations should be carefully reviewed, and services must be ordered by a doctor and provided by a Medicare-certified agency.

If you’re considering home health care, it’s crucial to communicate with your doctor and choose an accredited home health agency that can help you navigate the process and ensure that you’re receiving the care you need.