As the population ages, many individuals are seeking care while in the comfort of their own homes. One of the most common questions people ask is: how Medicare covers home healthcare? In some cases Medicare provides some coverage; although there are some important limitations and conditions Medicare enrollees and their families need to be aware of.
In-Home Health Care
In-home health care refers to a range of medical services patients may receive at home. This can include skilled nursing, physical therapy, occupational therapy, speech-language pathology, and certain types of personal care.
What Medicare Covers
Medicare Part A and/or Part B may cover in-home health services if the beneficiary meets specific conditions. These include:
1. They Must Be Homebound
Medicare defines “homebound” as being unable to leave your home without considerable effort or assistance due to illness or injury. The beneficiary may leave for things like medical appointments or religious services, however they must not be able to leave home on regular outings.
2. Care Must Be Medically Necessary
Any Medicare services received must be (medically necessary) a doctor or a qualified healthcare provider must order the care. They must also create and regularly review a care plan for the beneficiary.
3. Individuals Must Require Skilled Services
Medicare provides coverage for home health services such as; intermittent skilled nursing care, physical therapy, speech-language pathology, or continued occupational therapy. If a beneficiary requires services for personal care alone (dressing or bathing), Medicare will not cover them unless it’s part of a broader medical plan involving skilled care.
4. Only Medicare-Certified Home Health Agencies Can Provide Care
To receive coverage, services must be provided by an agency that is certified by Medicare.
What’s Covered
- Skilled nursing care (part-time or intermittent only)
- Physical, occupational, or speech therapy
- Medical social services
- Home health aide services (if you’re also receiving skilled care)
- Durable medical equipment (DME) like walkers, oxygen tanks, or wheelchairs (covered under Medicare Part B)
Please Note: Medicare does not cover; 24-hour home care, meals delivered to your home, or homemaker services if they are the only care you need.
Out-of-Pocket Costs
For most eligible home health services:
- Beneficiaries pay $0 for covered home health care services.
- Typically, the out-of-pocket amount for Medicare-approved durable medical equipment is 20% of the cost.
No copay or deductible is required for the care itself, assuming the beneficiary meets the qualifying criteria.
Examples of How Medicare Covers In-Home Health Services
Let’s say Jack, age 78, recently had hip surgery and his doctor prescribes in-home physical therapy for recovery. This is prescribed in-home because; he is temporarily unable to travel to outpatient therapy due to mobility issues. Because he meets the homebound requirement and the care is medically necessary and ordered by a doctor, Medicare will likely cover the services.
In contrast, if Leo needs help cooking, cleaning, and taking medications but does not need skilled nursing or therapy, Medicare would not cover a home health aide for him.
How to Initiate In-Home Healthcare Through Medicare
- Beneficiaries must talk to their doctor. A doctor’s order is required before any service is authorized for payment.
- Choose a Medicare-certified home health agency. Beneficiaries can request suggestions from their doctor’s office or their Medicare insurance carrier or the Home Compare Tool Link below.
- The beneficiary’s provider and the agency will work together to develop a care plan.
The Medicare’s Home Health Compare tool to find certified agencies in the local area.
Medicare can be an important source of support for those recovering at home or managing chronic health conditions. However, its coverage of in-home health care comes with specific conditions that must be met. Understanding these rules helps beneficiaries and caregivers plan effectively and avoid unexpected expenses.
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