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Medicare Home Health Care Coverage and Eligibility

Getting older can be a difficult experience. You may struggle with limited mobility and completing tasks that were once simple, such as getting dressed or cooking meals. Home healthcare can provide critical assistance to seniors experiencing difficulty during the aging process, allowing them to stay in their homes longer, offering a higher quality of life, and offering the opportunity to save money on residential care. However, it’s important to know the extent of the coverage if you are relying on Medicare to pay for home healthcare services.

This article will discuss whether or not Medicare covers home healthcare services and what other options may be available. By understanding your coverage options, you can make sure you can access the necessary care and support that will allow you to remain independent in your own home for as long as possible.

Does Medicare Cover Home Healthcare Services?

Medicare pays for in-home healthcare services, but only for a limited time and under specific circumstances. For example, Medicare will cover those services if you’re homebound and under the care of a doctor who prescribes part-time skilled nursing care or physical, speech, or occupational therapy.

However, there are some limits to Medicare coverage. Medicare won’t pay for full-time care at your home or homemaker services, like cleaning and laundry, that is unrelated to your care plan or diagnosis. Further, it won’t cover custodial care or help with daily activities like bathing or dressing if this is the only care you need.

Eligibility for Home Health Care Coverage  

To be eligible for Medicare home health coverage requires meeting all of the following conditions:

  • You have Medicare Part A and/or Part B
  • You’re under the care of a doctor who is regularly reviewing your plan
  • You need intermittent skilled nursing, physical, speech, or occupational therapy. Medicare defines intermittent nursing care as care received less than seven days a week and fewer than 8 hours a day. Patients receive nursing care for up to 21 days, but the doctor can recommend extending the care period if needed. 
  • Your condition will improve in a reasonable amount of time
  • A doctor certifies that you are homebound. Medicare defines homebound individuals as having difficulty leaving home due use of mobility aids like a walker or requiring special transportation. 

Those with Medicare Part C, also known as Medicare Advantage, are also likely to receive covered at-home care as part of their insurance. However, given that Medicare Advantage is administered by private insurers, eligibility requirements may vary. Contact your insurance provider directly to determine whether your plan includes home health care coverage.

Caregivers vs. Skilled Care  

To understand the services covered by Medicare, it helps to know the distinction between skilled care and unskilled care.

Health professionals like nurses and physical, occupational, or speech therapists provide what is known as skilled care. A doctor must recommend and supervise the care for Medicare to cover it. Further, the condition being treated should improve in a reasonable and predictable amount of time, such as recovering after surgery or an illness.

Medicare does not pay for unskilled care, such as homemakers who come in to help with daily activities like dressing and light housekeeping, if it is the only type of care you need. However, if it is part of the care plan designed by the doctor, Medicare pays for unskilled care while you are receiving skilled care. 

Home Health Care Services Covered By Medicare

Medicare covers an array of skilled services to allow seniors to recover at home rather than in a skilled nursing facility. Covered services include skilled nursing, therapy, and equipment. 

Part-time Skilled Nursing Care  

Your Medicare Part A benefits cover part-time skilled nursing care at home when your doctor determines that the service you need is reasonable and necessary to treat your illness or injury. Registered nurses or licensed practical nurses provide skilled nursing services. Skilled nurses give injections, administer medication, including IV drugs, change dressings, change catheters and monitor your overall health. Nurses also provide direct care and teach you and your caregivers how to manage your care. 

Medicare defines part-time or intermittent care as providing less than 8 hours a day for less than seven days per week. Benefits cover up to 21 days of care, but doctors can extend the limit. People who need more than intermittent care do not qualify for home health services. 

Postmenopausal Osteoporosis Treatment Injection  

Osteoporosis is a condition where bones become weak, brittle, and susceptible to fractures. Hormonal changes, sometimes caused by menopause, increase the risk of osteoporosis, with its prevalence increasing with age. Medicare Part A and Part B pay for visits from a home health nurse and an injectable drug to treat osteoporosis. 

To be eligible for home osteoporosis treatment, you must be a woman with Medicare Part B who has suffered a bone fracture caused by osteoporosis. You also must be eligible for home health services and have your doctor certify that you and your caregivers cannot give you the drug by injection.

Part-time Home Health Aide Care  

A home health aide helps with personal services like bathing, toileting, and dressing. This is custodial care to help with the activities of daily living, but it doesn’t improve your condition. In contrast, a doctor supervises skilled care from health professionals, and it helps you recover from illness or injury. 

If you need skilled care, Medicare will pay for a home health aide if it is part of your care plan. It won’t pay for personal care if you don’t need skilled care.

Physical Therapy  

Physical therapists use exercises, massage, or other therapies to ease pain and help you function and move better. Doctors prescribe physical therapy for ailments such as recovering from a sports injury, adjusting after a stroke, or learning to use assistive devices like a walker or cane. If your doctor or other health provider recommends it, Medicare Part B pays for physical therapy services.

To be eligible for in-home physical therapy, you must have a condition that requires a PT plan. Also, the condition treated should improve in a reasonable amount of time. 

Your cost for physical therapy is 20% of the Medicare-approved amount after you pay the Part B deductible.

Occupational Therapy  

If you have pain or a disability that makes it hard for you to do daily activities, occupational therapy helps you adapt. If you have a condition like arthritis and chronic pain, stroke, joint replacement, or multiple sclerosis, occupational therapy can help. 

People often confuse occupational therapy and physical therapy. Physical therapy focuses on how to move and manage pain. In contrast, occupational therapy shows you how to do things, like cook or get dressed.

Treatment involves having an occupational therapist observe how you perform certain tasks and help you adapt. The therapist recommends ways to change your movements or use assistive devices to get things done.

Medicare Part B pays for occupational therapy. Your cost is 20% of the Medicare-approved amount after the Part B deductible.

Speech-language Pathology  

Health issues like a stroke or dementia can lead to problems with communication or swallowing. Speech-language pathologists address those issues with therapy, including: 

  • Diagnosis, assessment, and treatment for communication issues or problems swallowing.
  • Providing cues to remember or recognize words and practicing conversational speech.
  • Offering rehabilitation services for adults with hearing loss
  • Therapy to help you re-learn communication skills
  • Teaching new ways to communicate if you’ve lost your speech

As with other types of therapy, Medicare Part B covers speech-pathology services. You pay 20% of the Medicare-approved amount after meeting your deductible. 

Medical Social Worker Services  

Medical social workers help seniors and families navigate the healthcare system. They can direct you to resources like transportation services and help you access counseling for social and emotional issues. 

Medicare covers social services when your doctor orders it to help you cope with your illness. To be eligible, you must also be receiving skilled care.

Equipment and Supplies for Home Use  

If you need durable medical equipment like a wheelchair or walker, Medicare typically pays 80% of the cost. A doctor orders the equipment, and it must meet certain criteria, often needing to be relevant to the treatment of a specific injury or disorder. However, a home health agency should supply your equipment or order it for you. 

Home Health Services Not Covered By Medicare  

For treatment, services, or equipment to be covered by Medicare, it must be medically necessary and prescribed by a doctor. Therefore, Custodial Care that is not performed by a skilled professional cannot be paid for using your Medicare coverage.

Some of the common exemptions from Medicare’s home healthcare coverage include:

  • Home care 24 hours a day.
  • Homemaker services like laundry, cleaning, and shopping.
  • Meals delivered to your home.
  • Custodial care like bathing, dressing, and toileting if you are not receiving skilled care.

Keep in mind that should you become diagnosed with a condition that requires those services, they may be covered for the duration of the treatment. This is at the discretion of your healthcare provider and doctor. See your doctor immediately if you think you may require services due to a medical issue.

Additional Resources

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