MEDICARE BENEFITS
Does Medicare Cover Home Health?
by Ken Williams
12 JUL 2023
A common question people with Medicare or those caring for people on Medicare have is whether or not Medicare covers home health care. Oftentimes, people are trying to understand what is covered and how it compares to Medicare coverage for nursing home care and, in some cases, hospice. In this article, we explore Medicare’s coverage of home health benefits, including how this varies by type of plan.
Under Original Medicare, specifically Medicare Part A and/or Medicare Part B, eligible home health services that are covered:
- Part-time or intermittent skilled nursing care at home
- Physical therapy (PT) or occupational therapy (OT)
- Speech-language pathology (SLP) services
- Medical social services
- Part-time or intermittent home health aide services (personal hands-on care)
- Injectable osteoporosis drugs for women
- Coordination of the services your doctor orders for you by a home health care agency
However, within home health Medicare does not cover.
- 24-hour-a-day care at home
- Meals delivered to your home
- Homemaker services (like shopping, cleaning, and laundry), if this is the exclusive need
- Custodial or personal care (like bathing, dressing, or using the bathroom), if this is the only care you need
CLAIRE’S PERSPECTIVE
As with many of these types of services, there are important differences in how this may be covered if you have Medicare through Original Medicare, with or without a Medicare Supplement plan (also known as Medigap), or through a Medicare Advantage (MA, also known as Part C) plan. In addition, Medicare Advantage plans vary based on where you live, meaning that the services that they cover may also vary. While this can be confusing, you don’t have to navigate it alone. Reach out to your broker or to Ask Claire for support on understanding your home health options.
How Do I Know If I’m Eligible for These Services?
With Original Medicare, the Centers for Medicare & Medicaid Services (CMS) states that all people with Part A and/or Part B who meet all of these conditions are covered:
- You must be under the care of a doctor, and you must be getting services under a plan of care created and reviewed regularly by a doctor.
- You must need, and a doctor must certify that you need, one or more of these:
- Intermittent skilled nursing care (other than drawing blood)
- Physical therapy, speech-language pathology, or continued occupational therapy services. These services are covered only when the services are specific, safe and an effective treatment for your condition. The amount, frequency and time period of the services needs to be reasonable, and they need to be complex or only qualified therapists can do them safely and effectively. To be eligible, either: 1) your condition must be expected to improve in a reasonable and generally predictable period of time, or 2) you need a skilled therapist to safely and effectively make a maintenance program for your condition, or 3) you need a skilled therapist to safely and effectively do maintenance therapy for your condition. The home health agency caring for you is approved by Medicare (Medicare certified).
- You must be homebound, and a doctor must certify that you’re homebound.
You’re not eligible for the home health benefit if you need more than part-time or intermittent skilled nursing care. You may leave home for medical treatment or short, infrequent absences for non-medical reasons, like attending religious services. You can still get home health care if you attend adult day care.
How Much Do I Have to Pay for Home Health with Original Medicare?
Under Original Medicare, your costs are as below. Your cost-sharing will be different if you have added on a Medicare Supplement plan to help cover your Medicare costs.
- $0 for home health care services.
- 20% of the Medicare-approved amount for durable medical equipment (DME) .
- Before you start getting your home health care, the home health agency should tell you how much Medicare will pay. The agency should also tell you if any items or services they give you aren’t covered by Medicare, and how much you’ll have to pay for them. This should be explained by both talking with you and in writing. The home health agency should give you a notice called the Advance Beneficiary Notice (ABN) before giving you services and supplies that Medicare doesn’t cover.
CLAIRE’S PERSPECTIVE
As you might expect, if you Medicare through a Medicare Advantage plan, the costs and coverage of these benefits may vary as these types of plans have the flexibility to add additional benefits that may provide greater support for those looking for in-home care. Feel free to reach out to your broker or to Ask Claire for help in understanding what home health benefits may be available to you.