Is In-Home Care Covered by Medicare?

Medicare-Covered In-Home Health Services

Medicare is a federal health insurance program for individuals aged 65 or older, certain younger people with disabilities, and those with End-Stage Renal Disease. This program assists with healthcare costs, although it does not cover all medical expenses or the majority of long-term care. In-home care refers to health care services an individual receives in their own home.

Medicare, primarily through Part A and Part B, covers specific in-home health services when medically necessary. These services help individuals recover, regain function, or maintain health at home. Covered care is part-time or intermittent, focusing on medical needs rather than continuous personal assistance.

Skilled nursing care involves services performed by a licensed nurse. This includes administering injections, wound care, monitoring unstable health conditions, and providing illness management education. Medicare covers this care on an intermittent or part-time basis, not 24 hours a day.

Therapy services are also covered, including physical therapy (PT), occupational therapy (OT), and speech-language pathology services (SLP). PT helps with mobility and pain, OT assists in regaining daily activities, and SLP addresses speaking or swallowing issues.

Home health aide services, such as help with bathing, dressing, and toileting, are covered when an individual also receives skilled nursing or therapy services. These personal care services are not stand-alone benefits; they must be provided with skilled care. Medical social services help individuals and families cope with illness-related challenges and connect with community resources.

Durable Medical Equipment (DME), such as wheelchairs, walkers, and hospital beds, may be covered under Medicare Part B for home use if prescribed by a doctor. Coverage for DME is distinct from the home health benefit.

Conditions for Medicare Home Health Care Eligibility

For Medicare to cover in-home health care, individuals must meet specific requirements. These conditions ensure the care is medically necessary and appropriate for a home setting, establishing the framework for eligibility.

A physician must certify the need for home health care and establish a detailed plan of care. This doctor’s order confirms medical necessity for the individual’s condition. The physician also regularly reviews the treatment plan to ensure it remains appropriate.

A person must be “homebound” to qualify for Medicare home health benefits. This means it is difficult to leave home without assistance or if leaving is medically inadvisable. Brief, infrequent absences for medical appointments or short, occasional non-medical reasons, such as religious services, are permitted.

The individual must require intermittent skilled nursing care or therapy services (physical, occupational, or speech-language pathology). This need for skilled care is a primary driver for eligibility, indicating professional medical intervention is necessary. The care must be provided by a Medicare-certified home health agency.

The care provided must be “part-time or intermittent,” not continuous or 24-hour care. Intermittent care means it is needed fewer than seven days a week or less than eight hours a day over 21 days or less. This period can be extended if the need for continued care is predictable and finite.

Services Not Covered by Medicare Home Health

Medicare’s home health benefit covers medically necessary, intermittent skilled care, but does not cover all types of in-home assistance. Understanding these exclusions helps manage expectations.

Continuous, around-the-clock care is not covered under the Medicare home health benefit. The program is designed for part-time or intermittent needs, not for individuals requiring 24-hour supervision or assistance. If an individual primarily needs custodial care, which involves non-skilled personal assistance like help with bathing or dressing, this care is generally not covered unless skilled care is also required. Custodial care alone does not qualify for coverage.

Non-medical services, such as homemaker services (cooking, cleaning, shopping), are not covered. Meal delivery services also fall outside the scope of the home health benefit. Prescription drugs are not covered under the home health benefit; these are covered under Medicare Part D.

Accessing Medicare Home Health Benefits and Costs

Initiating Medicare home health care involves a structured process, beginning with a medical assessment. Understanding the steps and associated costs helps ensure individuals can access eligible benefits.

The process begins with a physician’s assessment and referral. The doctor determines if the individual meets eligibility criteria and orders specific care. Individuals or caregivers should then choose a Medicare-certified home health agency. Medicare’s “Care Compare” website can assist in finding approved agencies.

Once an agency is selected, they conduct an initial assessment to confirm eligibility and develop an individualized plan of care. This plan outlines the specific services the individual will receive. Approved home health services can then begin.

Medicare Part A and/or Part B cover home health services. Medicare pays 100% of the approved cost for covered services, meaning there is no deductible or coinsurance for the services themselves. For Durable Medical Equipment (DME) supplied by the home health agency, individuals pay 20% of the Medicare-approved amount after meeting their Part B deductible.