Home health care provides a range of services in your home to help you recover from an illness or injury. It’s an important part of medical care for people with disabilities or older adults who have difficulty getting out. Since you don’t have to travel to a clinic or hospital for treatment, this type of care is very convenient.
If you need home health care, you’ll want to understand your insurance coverage so that you’re not left with any unexpected bills. With Medicare Parts A and B, some home health care services are covered. Here’s more information on those services, who qualifies for them, and which parts of home health care may be ineligible for Medicare coverage.
- To have your home health services approved by Medicare, you must meet specific conditions.
- Parts A and B (Original Medicare) provide some coverage for home health care services, including various therapies, intermittent skilled nursing care, and part-time home health aides.
- Original Medicare doesn’t cover 24-hour care and meal delivery or other services like homemaker and personal care when they are the only care you need.
- Some options for additional coverage for your home health care needs include Medicare Advantage, Medigap plans, or long-term care insurance.
Who Qualifies for Home Health Care With Medicare?
- You must have a doctor overseeing your care, and they must regularly review your care.
- Your doctor must certify that you need intermittent skilled nursing care and/or therapy services (including physical therapy, speech-language pathology, and continued occupational therapy)
- Your doctor must certify that you are homebound.
- A Medicare-certified agency must provide your care.
- You must meet face to face with your doctor or health care professionals who work with a doctor within the required time frames about your need for home health care.
Even when deemed “homebound,” you are still able to leave for medical treatment or for a short, infrequent nonmedical reason, such as a haircut, a religious service, or attending a funeral or family reunion.
Notice that you must seek care from Medicare-certified agencies. These agencies have agreed to be paid by Medicare and to accept only the Medicare-approved amount for their services. They cannot engage in balance billing. By using an approved agency, you’ll reduce your out-of-pocket costs.
How Long Does Medicare Coverage Last for Home Health Care?
Medicare coverage for home health care is designed for those who need intermittent skilled nursing care for a short period. It isn’t meant for an extended period.
“Intermittent” is defined as care that’s needed for:
- Fewer than 8 hours each day
- Fewer than 7 days a week
- Up to 21 days
The 21-day limit for Medicare-covered home health care may be extended if your doctor can predict how much longer you’ll need skilled nursing care.
What Home Health Services Does Medicare Cover?
Medicare covers specific types of home health care services, including:
- Intermittent skilled nursing care: This could include injections, tube feedings, wound care, diabetes care, or patient and caregiver education.
- Physical, occupational, or speech-language pathology therapy: To qualify for these services, they must be safe and effective for your condition. Additionally, the services must be complex and require qualified therapists to perform them.
- Home health aide services and personal care: You must also be receiving skilled nursing care or therapy to qualify for these services.
- Medical social services: If you’re getting skilled care, you may also qualify for social services that a doctor deems necessary. These include counseling or connecting you with community resources.
- Medical supplies: Medicare covers medical supplies, such as dressings for your wounds, if your doctor orders them.
Coverage for durable medical equipment works differently than home health care. The equipment your doctor orders, such as a wheelchair or a walker, must meet specific criteria. Based on that, Medicare typically pays 80% of the approved amount for the equipment.
Services Medicare Doesn’t Cover
Though Medicare can be a huge help in covering home health care, it doesn’t cover everything. Here are some of the services that aren’t included as part of these benefits:
- Around-the-clock care
- Meal delivery
- Personal care services (such as bathing or dressing) if you don’t also require skilled medical care or therapy
- Homemaking services (such as shopping and cleaning) if you don’t also require skilled medical care or therapy.
Before your care starts, your Medicare-certified home health agency should present you with a breakdown of the charges and what Medicare will pay. This notice should also include how much you’ll be required to pay out of pocket.
If the agency wants to provide care that isn’t covered, it’s required to give you an Advance Beneficiary Notice (ABN). This notice explains the treatment plan, directions for getting Medicare to decide on coverage, and instructions for filing an appeal.
Expanded Home Health Care Coverage
If you’re looking for additional coverage for home health care beyond what Medicare includes, you do have some options. These can help you save money on home health care.
Medicare Advantage Plans provide an all-in-one alternative to Medicare Parts A and B. These plans must include at least the same level of benefits that Original Medicare offers. However, many offer additional coverage.
In 2019, Medicare Advantage plans were approved to provide supplemental benefits that aren’t offered with Medicare Parts A or B if the benefits meet certain conditions. For instance, chronically ill patients can receive meal delivery in some cases. Home environment services can also be offered if they help improve a patient’s overall condition, such as carpet shampooing costs for a patient with asthma to help prevent an asthma attack.
Since the plans differ, you’ll want to check with your insurer to see what coverage options you have.
Medicare Supplement Insurance (Medigap)
Medicare supplement insurance, or “Medigap,” can help fill in some of Medicare’s coverage gaps. These private plans can help reduce your out-of-pocket expenses.
For instance, if you require durable medical equipment such as a hospital bed for your home care services, Medicare only covers 80% of the cost—leaving you responsible for the rest. But if you have additional coverage with Medigap, your coinsurance costs may be covered.
Long-Term Care Insurance
Medicare isn’t meant for long-term in-home care. It’s designed for those who need help for a short time while in recovery.
If you think you’ll need care for an extended period, consider purchasing long-term care insurance. Coverage varies by plan, but this type of policy typically includes care in your own home or a nursing facility. If you get the right insurance plan, long-term care insurance can help fill this gap.
You may be denied long-term care insurance if you’re already sick or have preexisting health conditions. It’s best to consider and purchase such coverage when you’re healthy.
The Bottom Line
Medicare does cover some home health care. However, there are strict conditions you must meet to qualify. In addition, the services are often limited in scope and duration.
If you want more extensive home health care coverage, consider switching from Original Medicare to a Medicare Advantage Plan. Some plans offer additional home health services. You can also consider purchasing a Medigap plan or long-term care insurance policy to help pay for your care.
Frequently Asked Questions (FAQs)
How long does Medicare pay for home health care services?
Medicare typically pays for home health care services considered “intermittent” for up to 21 days. However, extensions are sometimes granted if the doctor has an estimated time when you’d no longer need the care.
How many hours of home health care does Medicare cover?
Medicare covers intermittent home health care. This is defined as care that’s needed fewer than seven days a week for fewer than eight hours a day. Additionally, intermittent home health care is not meant to exceed 21 days.
Does Medicaid cover home health care?
Medicaid covers home health care for people who meet the eligibility requirements. These include being a resident in the state where you applied and meeting certain financial and functional conditions. If you aren’t eligible for Medicare, Medicaid might be a good alternative if you qualify.