Home health care is a major industry, with over 3.7 million employees in the United States. It provides invaluable services to people with chronic conditions and distinct health care needs. Unfortunately, these services are costly, and insurance coverage presents its own complexities and challenges. 

You may be wondering, “Does Medicare cover home health care?” The answer to that question is complicated because it relies on many different variables. The good news is that, once you know what those are, you can plan accordingly. 

This article covers the factors that impact Medicare coverage of home health services. Keep reading to find out how they might apply to your unique situation. 

What Is Home Health Care?

Home health care refers to medical or related services that an individual receives at home. These include things like infusions, medication management, and post-surgical monitoring or assistance. It also can include physical, occupational, or speech therapy. 

Home health care is distinct from “home care.” The latter usually includes supportive care or assistance with activities of daily living (ADLs). 

Home health care, on the other hand, is specifically intended to treat acute injuries or illnesses. The goal is for the patient to recover and regain independence. 

Medicare Basics

Before we can to how Medicare relates to home health care, it’s important to understand its basic parameters and structures for coverage. If you’re someone who will enroll in the near future, this could help you determine the best Medicare coverage options based on your anticipated health needs. 

Medicare is a federal health insurance program primarily designed for individuals who are 65 years of age or older. However, some younger people with disabilities and specific health conditions can participate in the program as well. These include things like end-stage renal disease.

Beyond Medicare eligibility requirements, there are also certain times when individuals can sign up. For instance, there is an initial enrollment period. It begins three months before an individual turns 65, includes the month you turn 65, and runs for seven months in total. There’s also a general enrollment period at the beginning of each year. 

Medicare Components

Medicare is divided into four main parts. Each one covers distinct health care services. 

Medicare Part A 

Medicare Part A is hospital insurance. It provides coverage for inpatient hospital stays, as well as skilled nursing and hospice care. In some instances, it will pay for home health care services (more on that below).  

Most people do not pay a premium for Medicare Part A, especially if they or their spouse paid Medicare taxes while working. However, there may be deductibles and coinsurance when using Part A. 

Medicare Part B

Medicare Part B is basic medical insurance. This covers outpatient services, including doctor visits. It also extends to preventive care, like flu shots, and some “medically necessary” services not covered by Part A. 

Medicare Part B requires a monthly premium, which is income-based. Like Part A, there are also deductibles and coinsurance. 

Medicare Part C

Medicare Part C is also referred to as “Medicare Advantage.” It’s a private insurance plan that has been approved and is purchased through the Medicare program. 

It combines the coverage areas of Part A and Part B. It also could include additional benefits like vision, dental, and hearing. Like regular private insurance plans, Medicare Part C plans have in- and out-of-network providers. 

Also, like private insurance, costs for Medicare Part C can vary depending on the coverage level. It almost always requires monthly premiums, deductibles, co-payments, and co-insurance.  

Medicare Part D

Medicare Part D is a prescription drug coverage policy. Like Part C, it’s offered through private insurance companies. 

Premiums for Medicare Part D are income-based. There also are usually co-payments and co-insurance, as well as an annual deductible.  

Medigap

Medigap is not a policy made available through Medicare but is meant as supplemental insurance. As the name suggests, covers expenses not covered by traditional Medicare.  

What Are the Benefits of Home Health Care?

Beyond medical necessity, there are many different reasons that someone would seek out home health care services. One is comfort and convenience. For individuals who have physical limitations, transportation issues, or otherwise find it difficult to visit a physician’s office outside their place of residence, home health care is a suitable alternative. 

Another advantage of home health care is the level of personalized attention that patients receive. It makes it easier for providers to tailor services around individual needs and preferences. Also, home care makes it easier for family or personal caregivers to be more directly involved in treatment or assistance. 

Finally, home health care can also save lots of money. It’s a far less expensive alternative to inpatient or long-term care inside facilities. 

How Much Does Home Health Care Cost?

Home health services can be more or less expensive than alternative treatments, depending on the specific service. As mentioned, you can expect it to be an economic alternative to inpatient care. However, things like physical or occupational therapy, performed in the home, will likely cost a premium (compared to receiving these services in a clinic). 

In general, regular home health care can cost thousands of dollars a month. However, the average costs can vary widely by state and location. That is why it’s important to work with a reputable home health agency to ensure that the services being provided meet the criteria for Medicare coverage.  

Does Medicare Cover Home Health Care?

Both Medicare Part A and Part B will cover limited home health services. Note that Medicare Advantage plans could provide additional benefits.  

Coverage levels can vary widely, depending on the policy. So, it’s important for people purchasing Medicare Advantage to look closely at these details before deciding on a plan. 

In general, for traditional Medicare to cover home health care, services need to fall within one of these categories: 

Skilled Nursing Care

The most common example is skilled nursing care. This includes medical attention from registered nurses (RNs) and licensed practical nurses (LPNs). Common services are medication management, monitoring vital signs, injections, intravenous (IV) therapy, wound care, and other procedures that require the attention of a trained health professional. 

Physical and Occupational Therapists

Home health care can include physical therapy, carried out by a licensed physical therapist. This can involve treatments to improve movement, balance, and coordination, or to build strength.  

Likewise, it can include services from occupational therapists. They can help patients recover from injuries or illness, and regain skills needed for daily activities, like dressing, bathing, and cooking. 

Speech-Language Pathology

Home health care can extend to speech therapy and other treatments related to language and communication. It can also include treatment for swallowing disorders. These are all typical with patients who have experienced a stroke or neurological disorders. 

Social Services

Home health care can include medical social workers. These are professionals who might provide counseling or other assistance with emotional issues. They also can help individuals access community resources. 

Home Health Aides

Another area of home health services includes aides for personal care. This includes for accomplishing activities of daily living (ADL), such as bathing and dressing.

Equipment

A final category of home health care deals with equipment needed for some of the treatments or medical needs explained above. Common examples include wheelchairs, walkers, and oxygen equipment. 

Criteria for Qualification

Beyond the type of service being received, various standards must be met for Medicare coverage to kick in. Here are the main conditions or circumstances that indicate the need, which are vital to consider when answering “Does Medicare cover home health care?”. 

Homebound Status

A major criterion is that a person is homebound. If leaving one’s home requires considerable effort or is inadvisable for medical reasons, then home health care is likely needed. Note that this does not mean the individual is bedridden, but only that there are obstacles to them leaving their home for health care services. 

Doctor’s Orders

Next, Medicare will cover home health services that are part of a treatment regimen being provided by a licensed physician. Also, the doctor must prescribe the specific home health services as part of the treatment plan. These must fall within one of the following categories:

  • Intermittent skilled nursing care (other than drawing blood)
  • Physical therapy
  • Speech-language pathology services
  • Occupational therapy
  • Home health aide services

Also, any home health care services that an individual receives must be considered medically necessary by a health care provider. 

Medicare Certified Home Health Agency

The services being provided must be by a Medicare-certified home health agency. These healthcare physicians must be carrying out the exact services indicated by the prescribing physician’s plan of care, in order to achieve Medicare coverage. 

Face-to-Face Meeting

Finally, a physician or health care professional must have an in-person meeting at their residence with the home health recipient within 90 days of beginning care. As an alternative, they can schedule a face-to-face meeting within 30 days after care begins that does not have to be in the home setting.

Limitations on Coverage

Even if Medicare coverage is achieved, there are limitations. Here are the major ones to take into account. 

Duration of Services

A major limitation of home health care is the frequency and duration of services. Medicare coverage is generally for intermittent or part-time care. 

Medicare does not cover custodial care or 24-hour care. If the patient is receiving skilled nursing services, for instance, they must be fewer than eight hours in any given day and no more than 28 hours in a week. Home health aides and medical social services also must be part-time.

For things like hospice care, Medicare will cover medically necessary services that an individual is otherwise receiving. They may not, however, cover long-term palliative care services. 

Specificity of Services

Another limitation of Medicare coverage is the specificity of treatment or products. For medical supplies, Medicare will not cover biologics or prescription drugs. It will, however, pay for supplies like wound dressing. 

For Medicare to cover speech-language, physical, or occupational therapy, these services must be deemed an effective treatment for their condition by a licensed physician. The doctor may also need to detail the specific type of therapy they’re receiving and demonstrate that it’s safe. 

Non-Medical Services

Medicare does not usually cover custodial care. This refers to assistance with activities of daily living, like personal care, household chores, or meal preparation. 

For instance, if a person is receiving home health aide or medical social services, then they must also be receiving skilled nursing care. Also, Medicare may cover things like assistance with bathing or dressing, but not cover assistance with household chores. 

Costs

Finally, even if Medicare covers home health care services, there could still be out-of-pocket costs for the individual. For instance, for services covered under Medicare Parts A and B, the patient may be responsible for as much as 20 percent of the costs for things like medical equipment or physical therapy. There also may be deductibles for traditional Medicare as well as Medicare Advantage plans.

Other Considerations for Ensuring Medicare Pays for Home Health Care

Getting Medicare coverage is important from a financial standpoint, but it also can have practical implications. For instance, your home health agency may deny or cut back care because they believe Medicare will not pay for services. 

In these instances, the agency must send you a Home Health Advance Beneficiary Notice (HHABN). This document explains the reason they believe Medicare will not cover the prescribed services. Examples include them being outside the scope of medical necessity or requiring them longer than 28 hours a week. 

If your doctor believes that you still need home health care and that Medicare should continue coverage, you can request a decision from Medicare. The HHABN should include instructions on how to make this appeal.

Learn More About Medicare Benefits and Home Care

Now that you have an answer to the question “Does Medicare cover home health care?” you will have a more informed perspective about services that are likely to be covered. A qualified home health care agency can further advise you on strategies for ensuring Medicare coverage. 

Quick Care Connect simplifies the scheduling process through a platform where providers and patients can quickly request and accept care. It allows patients to view and rate providers and manage their treatment plans. Sign up today to get connected with qualified health professionals with the specific skills to help you meet your health needs and goals while saving time.