Does Medicare cover home health care?

Key points

• Home health care is covered by Medicare Part A and Part B plans.
• There are specific requirements you must meet to qualify for home health care under Medicare.
• Long-term care, for example, would not be included in home health care services.
• If you qualify, you may be able to get home health care for free through Medicare.

When you’re injured or sick, it can help to recover in an environment you’re used to. For some, that could mean getting home health care, which includes services designed to treat an illness or injury in the comfort of your own home. It’s also usually less expensive than receiving that same care at a hospital or skilled nursing facility.

If you have Medicare, you may already have coverage for these kinds of services. But not all types of services are covered, and there are qualification requirements. Here’s what you should know.

Medicare coverage for home health care

If you have Medicare Part A and/or Part B, you have coverage for certain home health care services. That includes things like:

• Part-time or “intermittent” skilled nursing care (more on this later).
• Physical therapy.
• Occupational therapy.
• Speech-language pathology services.
• Part-time or intermittent home health aide care.
• Injectable osteoporosis drugs for women.
• Durable medical equipment.
• Medical supplies for use at home.

In order for a service to qualify as part-time or intermittent skilled nursing care, it must occur fewer than seven days per week or fewer than eight hours per day over a maximum of a 21-day period. There are, however, some exceptions in the event of a special circumstance. You’ll have to contact your local Medicare office to find out if your circumstances qualify as an exception under your plan.

Qualifying for home health care under Medicare

To qualify for home health care, you have to meet certain conditions. You must:

• Be under the care of a doctor.
• Be receiving services under a plan of care created and reviewed regularly by a doctor.
• Be homebound, as certified by a doctor.

The services that you need have to be specific. “It’s more skilled-care services,” said Elizabeth Gavino, who uses her insurance training as a Life Underwriter Training Council Fellow to help people understand their Medicare options. “A doctor needs to deem you as needing these types of services.”

A doctor must certify that you need one of the following types of services:

• Intermittent skilled nursing care (excluding drawing blood).
• Physical therapy, speech-language pathology or continued occupational therapy services.

The latter therapies also have specific conditions that must be met to count as a qualified service. For instance, those are only covered when they’re considered to be “specific, safe and an effective treatment for your condition.” You must also meet at least one of the following requirements:

• You’re expected to improve in a reasonable and generally predictable period of time.
• You need a skilled therapist to safely and effectively make a maintenance program for your condition.
• You need a skilled therapist to safely and effectively do maintenance therapy for your condition.

Keep in mind that your home health agency must also be approved by Medicare in order for Medicare to cover those costs.

Tip: You can find home health care providers through Medicare’s provider directory.

Home health care services that are excluded

While your Medicare policy may cover certain home health care services, there are some common exclusions. These include:

• 24-hour-a-day home care.
• Home meal delivery.
• Homemaker services (shopping, cleaning, laundry, etc.) that are unrelated to your care plan.
• Custodial or personal care for help with daily activities (like bathing, dressing or using the bathroom), assuming you don’t need any other care.

Again, the point of home health care is to help you get better without having to go to the hospital, not long-term assistance.

As Gavino points out, home health care “is not homemaker services or custodial care, as these would be covered under a long-term care policy.” This is a key distinction since, in general, long-term care isn’t covered by Medicare.

That’s why it’s important to look into your long-term care options well before you may need them.

“Most people look into long-term care when it’s too late for them to obtain coverage. Usually, I get the calls when someone is already diagnosed with medical conditions that require care. That’s way too late,” said Gavino. “Consider shopping for long-term care when you are in your 50s, when the premium is much cheaper and you can get better and richer coverage for the future.”

How much home health care costs under Medicare

Medicare covers up to the full cost of approved, medically necessary home health care services. That means you could pay $0 for covered services.

The one exception here is Medicare-covered medical equipment covered under Part B. In that case, you’d pay up to your deductible ($226) and Medicare would then cover 80% of the costs over the Medicare-approved amount. So if you need a $500 wheelchair, you’d pay $226, plus 20% of the remaining balance. That’s a total of $281.30.

Your home health care agency must tell you how much Medicare will pay toward the services you’ll be receiving. The agency should also be clear upfront about any services that are not covered by Medicare, so you can make informed decisions about your care and finances.

And, if you live in Florida, Illinois, Massachusetts, Michigan or Texas, you may be able to submit a request for a pre-claim review of coverage for home health services to Medicare. That way, you and the care agency will know early in the process what is and isn’t covered.