Medicare home health coverage: the basics

Who qualifies

Medicare.gov says you must meet both of these:

1. You need part-time or intermittent skilled services (such as skilled nursing, physical therapy, speech-language pathology, or continued occupational therapy).
2. You’re “homebound.” Leaving home isn’t recommended because of your condition, or you have trouble leaving without help (like a cane, wheelchair, walker, special transportation, or another person), and you’re normally unable to leave home and leaving takes a lot of effort.

You can leave home for medical treatment, or for short, infrequent non-medical reasons like religious services, and still be considered homebound. You can also still get home health care if you attend adult day care.

Provider requirements

• A doctor or other health care provider (like a nurse practitioner) must see you in person, confirm you need home health care, and order your care.
• The care must come from a Medicare-certified home health agency.
• Your provider should give you a list of agencies that serve your area, and must tell you if their organization has a financial interest in any agency on the list.

What’s covered

• Medically necessary part-time or intermittent skilled nursing care (for example wound care, patient and caregiver education, IV or nutrition therapy, injections, and monitoring serious illness)
• Physical therapy, occupational therapy, and speech-language pathology services (if you meet certain conditions)
• Medical social services
• Part-time or intermittent home health aide care, only if you’re also getting skilled nursing or therapy at the same time
• Injectable osteoporosis drugs for women who meet certain criteria
• Durable medical equipment and medical supplies for use at home

What’s not covered

• 24-hour-a-day care at home
• Home meal delivery
• Homemaker services unrelated to your care plan
• Custodial or personal care when that is the only care you need

What you pay

Per Medicare.gov, you pay nothing for covered home health services. For Medicare-covered durable medical equipment, after you meet the Part B deductible you pay 20% of the Medicare-approved amount.

Before care starts, the agency should tell you how much Medicare will pay and, verbally and in writing, about any items or services Medicare won’t cover and what you’d owe. You should get an Advance Beneficiary Notice (ABN) before receiving services or supplies Medicare doesn’t cover.

How often

If you qualify, Medicare.gov says you can get unlimited home health visits. In most cases “part-time or intermittent” means skilled nursing and home health aide services combined of up to 8 hours a day, with a maximum of 28 hours a week (sometimes more for a short time if your provider decides it’s necessary).

If you have Medicare Advantage

If you get Medicare through a Medicare Advantage Plan (Part C) or another Medicare health plan, check with your plan about your home health benefits and which agencies you can use.