Medicare – Home Health Care Benefit
The Bad News
Medicare does not provide coverage for homemaker services such as shopping, cleaning & laundry; nor does it pay for help with personal care such as bathing, dressing and toileting when this is the only care that you need.
Assistance with activities of daily living and housekeeping are custodial care services, and Medicare does not pay for custodial care.
Medicare Home Health Care Benefit Coverage is only available if you also require skilled care. Services that could be safely done by a non-medical person, or by yourself, without the supervision of a nurse, are not considered skilled care.
If you need skilled care, the good news
Medicare covers skilled care to maintain the functional status of persons with chronic conditions. Coverage does not depend on a beneficiary’s potential for improvement, independent self-care or return to prior level of functioning.
Medicare pays for skilled nursing and therapy services to prevent or slow the deterioration of an individual’s condition. You can continue to receive home health care services for as long as you continue to qualify.
Medicare pays for the full cost of home health care except for the 20% co-payment for durable medical equipment.
Medicare Part A covers the first 100 days of home health care after an inpatient hospitalization of at least 3 days, or a skilled nursing facility stay after a hospital stay. Additional days are covered under part b. There is no prior hospital stay requirement for Medicare Part B coverage of home health care.
Home health care services covered by Medicare
- Skilled nursing care – Examples of skilled nursing care include tube feedings, injections, wound care, observation & assessment of condition, and management of care plan.
- Home health aide services if you require skilled nursing and therapy services.
- Skilled therapy services for maintenance or rehabilitation purposes. Examples of skilled therapies include physical, occupational, and speech/language therapy.
- Medical social services
- Medical supplies and durable medical equipment
Qualifying for Medicare home health care
- You must be homebound:
- You require assistance of equipment (walker, wheelchair, crutches) or another person to leave home.
- It is difficult for you to leave your home and you do not routinely do so.
- Your doctor determines that leaving your home would be harmful to your health.
- You require intermittent skilled care:
- Skilled care refers to nursing care or rehabilitation therapy.
- Intermittent care means skilled services once every 60 days to once daily for three weeks (or longer for a finite and predictable period).
- A physician must certify that:
- You are homebound and require intermittent skilled care.
- A plan of care has been made and is regularly reviewed.
- A face-to-face encounter has confirmed that you qualify for home health care.
- You must receive care from a Medicare Certified Home Health Agency (CHAA).
Duration and frequency of Medicare home health care services
- Medicare beneficiaries typically receive four to ten hours per week combined of nursing, therapy and home health aide services.
- Your doctor must approve a new plan of care every 60 days for you to continue to qualify for Medicare home health care.
- Medicare will pay for up to 28 or 35 hours per week of home health care services based upon your need.
NOTE: If you are advised that your maintenance or rehabilitation services are to be discontinued, request written notice. The notice should state the reason for termination and the appeal process. Ask your doctor to write in support of necessary care.
Additional Information about Medicare
For information about the Medicare home health care benefit and appeals, we recommend the following links:
- Medicare Rights Center (MedicareInteractive.org)
Medicare Covered Services-Home Health Care Benefit Part A and B
- Medicare (Medicare.gov)
Medicare and Home Health Care Booklet
Medicare Home Health Services
- Center for Medicare Advocacy (MedicareAdvocacy.org)
Medicare Advocacy Self-Help Packet for Home Health Care
- Legal Services of Hudson Valley (LSHV.org)