One of the biggest worries many families face is figuring out how to pay for help at home when a loved one’s health starts to change. The question comes up again and again: does Medicare cover any of this care?
Sorting through the rules can feel confusing, especially when all you want is reassurance that your parent, or you, can get the support needed without draining savings.
Here’s the encouraging part: yes, Medicare does cover some home health care, but only under certain conditions. Understanding these guidelines helps you know what to expect, what’s covered, and where you may need to look for additional resources.
This guide lays out Medicare’s role in home health care in clear, simple terms, so you’ll feel more confident navigating your options.
Quick Rundown: Does Medicare Pay for Any Home Health Care?
- Yes, With Limits: Medicare covers skilled home health services, but only when medically necessary and ordered by a doctor.
- What’s Included: Nursing care, physical therapy, occupational therapy, speech therapy, and medical social services may be covered.
- What’s Not Covered: Routine personal care like bathing, meal prep, or 24/7 in-home support is not typically paid for.
- Eligibility Rules: You must be homebound, under a doctor’s care, and receive services from a Medicare-approved agency.
- Short-Term Support: Coverage is designed for recovery and rehabilitation, not for long-term custodial care.
Here’s how it works, let’s walk through the qualifications, what services are included, and how families can fill the gaps Medicare doesn’t cover.
However, these costs can vary significantly based on location. (source: Senior Resource)
Thus, you may want to try Medicare to help cover out of pocket costs.
But, does Medicare pay for any home health care? Medicare does cover some home health care services, but its coverage is limited to certain conditions and types of care. The following is a list of benefits and exclusions:
Medicare will pay for most home health care, including:
- Durable medical equipment
- Medical supplies
- Medical social services
- Skilled therapy services
- Skilled nursing services
That said, Medicare will not cover:
- Part-time or intermittent skilled nursing care
- Occupational therapy
- Speech-language pathology services
- Medical social services
- Home health aide services (if you’re also receiving skilled nursing or therapy)
In this article, we will clearly explain the instances in which a senior may require home health care.
We’ll also talk about the coverage you can get, the length of coverage, the differences between Medicare Part A and Part B, and more. Keep reading!
What Does Medicare Cover For Home Health Visits?
In the intro, we talked briefly about the services that Medicare would cover for home health visits. Let’s expand on these now, as well as the list of what’s not covered.
Medicare pays for home health care if the services are:
- Medically Necessary: The care must be prescribed by a doctor and deemed medically necessary.
- Intermittent Skilled Care: Includes skilled nursing care (e.g., injections, wound care) or therapy services (physical, occupational, or speech therapy).
- Provided by a Medicare-Certified Agency: The home health agency must be certified by Medicare.
Conditions for Coverage
To qualify, you must:
- Be Homebound: Leaving home must require a considerable effort and only happen for medical treatment or short, infrequent outings.
- Have a Doctor’s Certification: A physician must certify that you need home health care and create a care plan.
We’ll start with what should get covered by Medicare – in most cases:
Durable Medical Equipment (DME)
Durable medical equipment (DME) is defined by Medicare as:
- durable
- used for a medical reason
- will be used in your home
- is not something that is usually used by someone who is not injured or sick
- has a general lifetime of at least three years
Durable medical equipment would be something along the lines of bathtub benches for showering, walkers, wheelchairs, canes, oxygen equipment, and the like do get paid for by Medicare, but rarely in full.
Instead, after meeting your annual deductible, you will have to pay 20 percent of the coinsurance rate for each piece of equipment you need.
Also keep in mind that you must have a written order from a Medicare-enrolled doctor or the claim for durable medical equipment will not be covered.
And, you can’t just go into any supplier to get the DME – the equipment must come from a Medicare-enrolled supplier who is “participating”, meaning they will accept assignment for the cost of the equipment.
Medical Supplies
Unlike durable medical equipment, Medicare generally pays for the entire cost of most medical supplies.
From catheters to thermometers, bandaging, bedding, and everything in between, you shouldn’t have to cover for these items out of your own pocket.
Medical Social Services
If you need guidance on which resources are available for the elderly or if you want therapy for a senior, these services fit under the umbrella of medical social services.
Medicare will pay for these so you don’t have to.
Skilled Therapy Services
Occupational therapy, speech therapy, and physical therapy by a licensed therapist all count as skilled therapy services.
More than likely, Medicare will cover the costs under your insurance plan so a senior can get the therapy they need.
The only exception is occupational therapy, as we said in the intro. In some instances, it’s covered, but not in most.
Coverage depends on whether the senior also needs further home health care. Otherwise, you will have to shell out the money yourself for occupational therapy.
Skilled Nursing Services
With skilled nursing services, a nurse can take care of doing medical evaluations, create and adjust a care plan, care for a wound and change out a catheter.
They can also feed the senior via a tube if they have one inserted and administer injections as needed.
Most skilled nursing services should be included under the scope of your insurance plan so you don’t have to pay for them.
If you get services from a home health agency in Florida, Illinois, Massachusetts, Michigan, or Texas, you may be affected by a Medicare demonstration program. Under this demonstration, your home health agency, or you, may submit a request for pre-claim review of coverage for home health services to Medicare. This helps you and the home health agency know earlier in the process if Medicare is likely to cover the services. Medicare will review the information and cover the services if the services are medically necessary and meet Medicare requirements.
Your Medicare home health services benefits aren’t changing and your access to home health services shouldn’t be delayed by the pre-claim review process. For more information, call us at 1-800-MEDICARE.
Medicare website
Medicare does not cover things like long term care, routine foot care, dental care and dentures, eye exams for prescribing glasses, or hearing aides, even if they are necessary for someone who is receiving home health care.
When Is Home Health Care Needed?
Home health care encompasses a variety of services for seniors. It’s an alternative to sending an elderly loved one to a nursing home facility or getting them care in a hospital.
Home health care often costs less compared to those services, as well.
If you have a senior loved one who is experiencing the following, you might want to consider getting them home health care:
- Gradual physical or mental decline
- Becoming more dependent on others for care
- An illness, whether from a short-term sickness or a long-term condition
- An injury, be that a recent one or a nagging injury that causes chronic pain
Who Qualifies For Home Health Care Services?
Not everyone who applies for home health care services will necessarily get them, as older adults must be qualified for this form of Medicare.
According to the Medicare website, one must meet the following parameters for insurance coverage:
- The senior cannot require more than intermittent nursing care or that which is classified as beyond part-time care.
- They’re home bound and have been declared such by a doctor. Medicare Interactive.org defines being home bound as a person having great trouble leaving the house, enough so that they rarely do. They may also require a wheelchair, a walker, or crutches to get around.
- On Medicare’s website, they do mention that the senior can go out at times, such as for church or religious services as well as for doctor’s appointments or other care.
- The person also requires the following:
- A physical therapist for therapy to alleviate pain.
- A maintenance program for pain or a condition, often created by the therapist.
- A good recovery prognosis.
- The senior must be consistently seeing a doctor, who administers a treatment plan or care services.
How Long Does Medicare Pay For Home Health Care?
You’ve just found out that Medicare will pay for many of the home health care services your senior needs. That’s great news! The question now becomes, how long will that care last?
If you’re looking for care for your senior that is provided 24/7 around the clock, you’ll have to consider a nursing home or another option. Medicare doesn’t provide coverage for this type of care.
Instead, they emphasize that the care that is required must be “intermittent.” In other words, the senior either needs “Fewer than 7 days of care each week or need daily care for less than 8 hours each day for up to 21 days.”
Additionally, Medicare also notes that it may extend the three week limit in exceptional circumstances if your doctor can predict when your need for daily skilled nursing care will end.
Is Home Health Covered Under Part A Or Part B Medicare?
Actually, it turns out that both Medicare Parts A and Part B cover certain aspects of home health care.
As you probably know, original Medicare is broken down into several parts. Once your insurance approves a senior for Medicare, they’ll get coverage under either Part A or Part B.
You may have heard of these terms in passing, but now that they apply to someone you love, you’ll want to learn about them as much as you can.
Learn about the essential things to consider for Medicare Annual Open Enrollment.
What Is Part A and Part B Medicare?
With some exceptions, Medicare Part A is hospital insurance and it covers services such as:
- Hospice care
- Home health care
- Non-custodial, non-long term care in a skilled nursing facility
- Inpatient hospital care
Medicare Part A usually lacks a monthly premium for most people who are age 65:
- Those who get it premium-free are people who get Social Security retirement benefits or retirement benefits from the Railroad Benefit Board.
- You also won’t pay a premium if you are 65 and eligible for Social Security or Railroad benefits but have delayed filing for them because you’re letting the benefits build up (increase) or if you or your spouse had Medicare-covered government employment.
- Keep in mind that some people under the age of 65 can also get free Medicare Part A if they meet certain requirements.
If a senior does have to pay a premium for Medicare, the premium they pay is based off the amount of years the senior worked and paid their taxes.
For example, those who worked and paid Medicare taxes for between 30-39 quarters (a little less than a decade of work) would, as of 2023, be charged $278 as a premium per month.
If a senior worked and paid Medicare taxes for under 30 quarters, they would pay a monthly premium of $506.
Part B Medicare is more like traditional medical insurance. Part B Medicare pays for many things that could be part of a home health care setting, including:
- Durable medical equipment
- Medical supplies
- Physical therapy
- Doctor’s appointments
- Ambulance services
Part B also covers other medical services that may not fall under home health care, such as:
- Self-management therapy
- Screenings
- Second opinions before surgery
- Outpatient counseling and therapy
- Chemotherapy
- Most shots
- Preventive services
Medicare Part B does have a premium. As of 2023, it is $164.90 per month for most people, however this premium could be higher depending on your earnings.
For example, if the person’s modified adjusted gross income is higher than $97,000 for a single person or $194,000 for joint filers, they will also have to pay an additional monthly Income Related Monthly Adjustment Amount (IRMAA). This would increase their premium to $230.80 per month.
To determine the Part B premium amount, Medicare reviews the last two years of the senior’s income tax returns.
Medicare Part B has rules and exclusions that come into play when receiving medical care. Also, Medicare relies on an agreement known as Medicare assignment that you must follow.
Plus, despite paying a premium for coverage, seniors will usually also have to pay a certain portion of the Part B bills (an exception is for preventive services rendered by a medical provider who accepts Medicare assignments).
There is an annual deductible of $226 that they will likely have to meet, as well as an amount they will have to pay per service. Medicare agrees to this amount, of which the senior will pay a copay of 20 percent.
