Home Health Care Basics
Home health care includes a wide range of health and social services delivered in your home to treat illness or injury. Services covered by Medicare’s home health benefit include intermittent skilled nursing care, therapy, and care provided by a home health aide. Depending on the circumstances, home health care will be covered by either Part A or Part B.
Part A covers inpatient hospital stays, skilled nursing facility care, hospice care, and some home health care.
Part B covers certain doctors’ services, outpatient care, medical supplies, and preventive services.
Medicare covers your home health care if:
- You are homebound, meaning it is very difficult for you to leave your home and you need help doing so.
Medicare considers you homebound if you meet the following criteria:
- You need the help of another person or medical equipment (crutches, walker, wheelchair) to leave your home, or your doctor believes that your health or illness could get worse if you leave your home
- And, it is difficult for you to leave your home and you typically cannot do so
Your doctor should decide if you are homebound based on their evaluation of your condition. If you qualify for Medicare’s home health benefit, your plan of care will also certify that you are homebound. After you start receiving home health care, your doctor is required to evaluate and recertify your plan of care every 60 days.
Generally your plan of care will include:
- The types of health services and items you need
- How often you will receive services
- The predicted outcomes of treatment
Even if you are homebound, you can still leave your home for medical treatment, religious services, and/or to attend a licensed or accredited adult day care center without putting your homebound status at risk. Leaving home for short periods of time or for special non-medical events should not affect your homebound status.
You need skilled nursing services and/or skilled therapy care on an intermittent basis.
You have a face-to-face meeting with a doctor within the 90 days before you start home health care, or the 30 days after the first day you receive care. This can be an office visit, hospital visit, or in certain circumstances a face-to-face visit facilitated by technology (such as video conferencing).
Your doctor signs a home health certification confirming that you are homebound and need intermittent skilled care. The certification must also state that your doctor has approved a plan of care for you and that the face-to-face meeting requirement was met.
Your doctor should review and certify your home health plan every 60 days. A face-to-face meeting is not required for recertification.
And, you receive care from a Medicare-certified home health agency (HHA).
- Intermittent means you need care at least once every 60 days and at most once a day for up to three weeks. This period can be longer if you need more care, but your care needs must be finite.
- Medicare defines skilled care as care that must be performed by a skilled professional, or under their supervision.
- Skilled therapy services refer to physical, speech, and occupational therapy.
Note: You cannot qualify for Medicare home health coverage if you only need occupational therapy. However, if you qualify for home health care on another basis, you can also get occupational therapy. When your other home health needs end, you can continue receiving Medicare-covered occupational therapy under the home health benefit if you need it.
If you meet all the requirements, Medicare should pay for skilled care in your home and/or home health aide services. If you have questions or experience billing issues, call 1-800-MEDICARE.
Medicare coverage is based on 3 main factors
- Federal and state laws.
- National coverage decisions made by Medicare about whether something is covered.
- Local coverage decisions made by companies in each state that process claims for Medicare. These companies decide whether something is medically necessary and should be covered in their area.
What’s not covered by Part A & Part B?
Medicare doesn't cover everything. If you need certain services Medicare doesn't cover, you'll have to pay for them yourself unless:
- You have other insurance that covers them
- You have a Medicare health plan that covers them
Even if Medicare covers a service or item, you generally have to pay your deductible, coinsurance, and copayment.
Some of the items and services that Medicare doesn't cover include:
- Long-term care (also called custodial care)
- Most dental care
- Eye exams related to prescribing glasses
- Cosmetic surgery
- Hearing aids and exams for fitting them
- Routine foot care
Home health care for chronic conditions:
If you meet Medicare’s home health eligibility requirements, Medicare should cover your care regardless of whether your condition is temporary or chronic. Medicare covers skilled nursing and therapy services as long as they:
- Help you maintain your ability to function
- Help you regain function or improve
- Or, prevent or slow the worsening of your condition
Providers and agencies may be concerned that Medicare will not cover skilled home care if you are no longer showing signs of improvement. However, Medicare should not deny your home care because your condition is chronic or unchanging, or when additional care will not improve your ability to function—as long as the care is medically necessary to maintain your condition or to prevent or slow deterioration.
Is my test, item, or service covered?
Find out if your test, item or service is covered before you undertake it. Medicare coverage for many tests, items, and services depends on where you live. This list includes tests, items, and services (covered and non-covered) if coverage is the same no matter where you live.
Drug coverage (Part D)
This is an optional prescription drug program for people on Medicare. Medicare Part D is insurance for your medication needs. You pay a monthly premium to an insurance carrier for your Part D plan. In return, you use the insurance carrier's network of pharmacies to purchase your prescription medications.