Does Medicare Pay for Home Health Care for Seniors?

Medicare is a federal health insurance program designed to provide healthcare coverage for individuals aged 65 or older. It also serves younger people with certain disabilities, End-Stage Renal Disease, or Amyotrophic Lateral Sclerosis (ALS). The program aims to assist with healthcare costs, though it does not cover all medical expenses. Home health care involves health services delivered within a person’s home to address an illness or injury. It offers a convenient alternative to hospital or skilled nursing facility care, allowing individuals to receive medical attention in their familiar home environment.

Medicare Eligibility for Home Health Care

To qualify for Medicare-covered home health care services, an individual must meet several specific conditions. A primary requirement is that the patient must be considered “homebound.” This means leaving home requires a considerable and taxing effort, often needing assistance from another person or a supportive device. Occasional, short absences for medical appointments, religious services, or adult daycare are permitted and do not disqualify someone from being homebound.

Another criterion is the need for intermittent skilled nursing care or skilled therapy services. This includes physical, occupational, or speech-language pathology services. Intermittent skilled nursing care means care provided fewer than seven days a week or less than eight hours a day for up to 21 days, with potential extensions. The care must be medically necessary to improve, maintain, prevent deterioration of, or slow the progression of the health condition.

A physician or allowed practitioner (e.g., nurse practitioner, physician assistant) must order the home health care. This order certifies the services are medically necessary and that the patient meets homebound and skilled care requirements. The physician must also conduct a face-to-face evaluation before certifying the need for home health services. The home health services must be provided by a Medicare-certified agency.

Covered Home Health Services

When an individual meets Medicare’s eligibility criteria, several specific services are covered. Skilled nursing care, provided by a licensed nurse, is a core component. This care can include wound care, injections, intravenous therapy, patient and caregiver education, observation and assessment of a patient’s condition, and management of care plans. These services are provided on a part-time or intermittent basis, generally less than eight hours per day and 28 hours per week, though up to 35 hours may be covered.

Physical therapy services help improve strength, mobility, and function following an injury or illness, involving exercises, gait training, and other techniques. Occupational therapy assists individuals in regaining skills for daily living activities, such as eating, bathing, and dressing. Speech-language pathology services address communication disorders and swallowing difficulties. These therapies must be reasonable and necessary for treating the illness or injury and performed by a licensed therapist.

Medical social services are covered, focusing on emotional and social concerns related to the patient’s illness. These services may include counseling or connecting patients and families with community resources. Home health aide services are covered only if the individual is also receiving skilled nursing care or therapy services. Home health aides assist with personal care activities such as bathing, dressing, and walking. Certain medical supplies, such as wound dressings and catheters, are covered when provided by a Medicare-certified agency.

Services Not Covered by Medicare

Certain types of care and services are generally not covered. Round-the-clock, 24-hour-a-day care in the home is excluded. Medicare does not pay for continuous care that extends beyond intermittent limits. The program is designed for medically necessary skilled care, not for constant supervision or assistance.

Homemaker services, such as general cleaning, laundry, or meal preparation, are not covered if they are the sole care needed. Similarly, personal care services like bathing, dressing, or using the bathroom are not covered if these are the only services an individual requires. Medicare does not cover these services if they are considered non-medical or custodial care without an underlying skilled need.

Most prescription drugs are not covered under the home health benefit. Prescription drug coverage falls under Medicare Part D or through a Medicare Advantage Plan that includes drug coverage. Other excluded services include home meal delivery. These exclusions underscore Medicare’s focus on short-term, medically necessary skilled care rather than long-term custodial or supportive services.

Accessing Medicare Home Health Benefits

Accessing Medicare home health benefits begins with a physician’s order. A doctor or other healthcare provider must certify home health care is medically necessary. This involves a face-to-face evaluation by the physician. The physician’s order forms the basis for Medicare coverage.

Next, select a Medicare-certified home health agency. Patients can find a list of certified agencies through the official Medicare website, by calling 1-800-MEDICARE, or by consulting their physician for recommendations. If a patient is in a Medicare health plan, they may need to use an agency that works with their specific plan.

The home health agency conducts an initial assessment of the patient’s needs. This assessment determines the types of services and frequency of visits. Following the assessment, a comprehensive plan of care is developed. This plan outlines specific services, frequency of visits, necessary medical equipment, and goals of care. The physician must approve and sign this plan of care.

Care management is ongoing. The plan of care is regularly reviewed and updated by the healthcare provider every 60 days to meet evolving medical needs. This review ensures the care remains medically necessary and appropriate. The home health agency manages the coordination and delivery of all services outlined in the plan.