Medicare covers medically necessary home health care services, allowing cancer patients to manage recovery and symptoms in a familiar setting. This coverage is not automatic; it depends entirely on the patient meeting specific requirements established by the federal program. Understanding these conditions is fundamental to accessing the benefit. This coverage is provided through Original Medicare, specifically Part A (Hospital Insurance) and Part B (Medical Insurance), and eligible individuals pay nothing for the covered services.
Defining Medicare-Covered Home Health Care
Medicare defines home health care as medically necessary services provided on a part-time or intermittent basis for treating an illness or injury. These services are skilled, requiring the expertise of a licensed professional. Primary services include skilled nursing care, such as administering intravenous infusions, managing complex medication schedules, and performing detailed wound care related to surgery or radiation. Skilled oversight also covers monitoring unstable health statuses or severe side effects from chemotherapy that require professional judgment.
Physical, occupational, and speech-language pathology services are covered when necessary to restore or maintain function impaired by cancer or its treatment. For instance, physical therapy may be needed to regain strength after major surgery. Home health aide services are also covered, but only when they are secondary to and provided in conjunction with skilled care. Aides assist with personal care activities like bathing or dressing, but Medicare stops coverage if skilled services are no longer required.
Key Eligibility Requirements for Coverage
To qualify for home health services, a patient must meet several criteria. First, a doctor must certify the necessity of the care and establish a formal plan of care that is regularly reviewed. The physician must also have a face-to-face encounter with the patient related to the need for home health services, occurring shortly before or soon after care begins.
A central requirement is that the patient must be certified as “homebound.” This means leaving the home requires a considerable and taxing effort, often needing supportive devices or the assistance of another person. Absences must be infrequent and of short duration, though exceptions exist for medical appointments, religious services, or attending a licensed adult day care center. Routine, independent outings, such as regular grocery shopping, can compromise this status.
The skilled care needed must also be intermittent, meaning it is not required on a continuous, 24-hour basis. Skilled nursing care is covered if needed fewer than seven days each week or for less than eight hours each day for a limited period. The patient must require at least one of the covered skilled services—intermittent skilled nursing, physical therapy, or speech-language pathology—to establish eligibility. While occupational therapy is covered, it cannot be the sole service used to initiate coverage.
Understanding What Medicare Does Not Cover
It is important to distinguish between the skilled care Medicare covers and the services it excludes. A significant exclusion is custodial care, which involves non-skilled, personal assistance like preparing meals or long-term help with bathing and dressing when this is the only care required. Medicare stops covering the home health aide’s services once the patient no longer requires a skilled service, such as nursing or therapy.
Medicare does not cover full-time, round-the-clock care, even for severe conditions, as the program is designed for intermittent, short-term needs. If a patient requires 24-hour supervision, those costs must be covered by other means.
Excluded Services
- Custodial care (when provided alone)
- Full-time, 24-hour-a-day care
- Prescription drugs (covered under Medicare Part D)
- Homemaker services, such as general house cleaning or grocery shopping
Steps for Initiating Home Health Care Services
Initiating Medicare-covered home health care begins with the patient’s treating physician. The doctor must determine that the patient requires skilled, intermittent care and is homebound, then issue a formal order for the services. This order initiates the process and must follow a recent face-to-face encounter with the certifying physician or an allowed practitioner.
The patient or caregiver must select a Medicare-certified home health agency, as services from non-certified agencies are not covered. Medicare provides online tools, such as the Care Compare website, to help patients select an agency that serves their area. Once chosen, the agency performs an initial assessment and works with the doctor to create an individualized plan of care.
This plan details the specific services the patient will receive, including the frequency and duration of skilled nursing visits and therapy sessions. The doctor must review and recertify the plan of care at least every 60 days to confirm the patient continues to meet all eligibility requirements. If coverage is denied, patients maintain the right to appeal the decision through Medicare’s formal review process.