How Much Does Medicare Pay for Home Health Care Per Hour?

Home health care provides a range of medical services for individuals recovering from an illness or injury, or those needing ongoing health support, all within the comfort of their own residence. This type of care often serves as a practical and cost-effective alternative to hospital stays or care in a skilled nursing facility. Medicare plays a significant role in covering these services, aiming to facilitate recovery and manage health conditions outside of institutional settings. Understanding Medicare’s specific coverage rules is important for beneficiaries seeking home health assistance.

Eligibility for Medicare Home Health Benefits

To qualify for Medicare home health benefits, an individual must meet specific conditions. A doctor or other authorized healthcare provider must certify a need for intermittent skilled nursing care or therapy services, such as physical, occupational, or speech-language therapy. Intermittent care generally means it is provided fewer than seven days a week or less than eight hours a day for periods of 21 days or less, though extensions are possible.

Another requirement is that the individual must be “homebound.” This means leaving home requires considerable effort, often needing supportive devices, special transportation, or assistance. Individuals may still leave for medical appointments, religious services, or brief, infrequent non-medical outings without losing their homebound status. The care plan must be established and regularly reviewed by a doctor. All home health services must be provided by a Medicare-certified home health agency.

Covered Services and Limitations

Medicare’s home health benefit covers various services medically necessary for treating an illness or injury. These include part-time or intermittent skilled nursing care, such as wound care, injections, intravenous therapy, and monitoring serious conditions. Physical, occupational, and speech-language therapy services are covered if reasonable and necessary for recovery or to prevent worsening of a condition. Medical social services, which address social and emotional concerns related to an illness, are also included.

Home health aide services, providing personal care like bathing, dressing, and walking, are covered only if part of a care plan that includes skilled nursing or therapy services. Medicare does not pay for home health aide services if they are the only care an individual needs. Medicare also does not cover 24-hour continuous care, meals delivered to the home, or homemaker services like cleaning or laundry. Home health aide services are covered on an intermittent basis, not as continuous hourly care. The program focuses on providing medical care and therapy to help individuals recover or maintain health, rather than long-term custodial care.

Medicare’s Payment Model for Home Health Care

Medicare does not pay for home health care services on an hourly basis; instead, it uses a prospective payment system. Since 2020, Medicare reimburses home health agencies through the Patient-Driven Groupings Model (PDGM). This model structures payments around 30-day periods of care, replacing the previous 60-day episode system. The payment amount for each 30-day period is a predetermined lump sum, adjusted based on patient characteristics.

Under PDGM, factors influencing the payment rate include the patient’s primary diagnosis, functional impairment level, and presence of secondary diagnoses or comorbidities. The model also considers the patient’s admission source and the timing within a series of care. This system aims to better align payments with the patient’s clinical needs and resource use, rather than the volume of therapy services provided. For all approved home health services, Medicare typically pays 100% of the approved amount directly to the Medicare-certified home health agency.

Costs and Alternative Funding for Home Health Services

For individuals who meet Medicare’s eligibility criteria, the program generally covers the full cost of approved home health care services, meaning beneficiaries typically pay nothing out-of-pocket for skilled nursing, therapy, or home health aide services. However, there is an exception for durable medical equipment (DME), such as wheelchairs, walkers, or hospital beds, which may be needed as part of the home health plan. For DME, Medicare usually pays 80% of the Medicare-approved amount, leaving the beneficiary responsible for the remaining 20% coinsurance after meeting the Part B deductible.

When home health needs extend beyond Medicare coverage, such as continuous hourly care or long-term personal care not tied to a skilled medical need, alternative funding options become relevant. Medicaid, a joint federal and state program, may cover broader home care services for eligible low-income individuals, including personal care and homemaker services Medicare does not. Long-term care insurance policies can also provide coverage for a wide range of home care services, depending on policy terms. Private pay arrangements, where individuals or their families pay directly, are a common option for non-covered care. State and local programs, as well as veterans’ benefits, may offer assistance for home health services outside Medicare’s scope.