Medicare Home Health Care covers skilled medical services and certain care services provided in your private residence following an illness or injury. This benefit is available through Original Medicare (Part A and/or Part B) and some Medicare Advantage Plans. The goal is to help patients recover, regain independence, and become self-sufficient while remaining in the comfort of their home environment. Understanding the requirements and process is the first step toward accessing this support.
Meeting the Medicare Eligibility Criteria
To qualify for Medicare-covered home health care, a patient must satisfy specific conditions demonstrating a medical need for services at home. The process begins with a physician’s certification that the care is medically necessary. The doctor must create a formal plan for the care and is responsible for overseeing the treatment plan through subsequent check-ins.
A fundamental requirement is the need for intermittent skilled nursing care or therapy services, such as physical therapy, speech-language pathology, or occupational therapy. Intermittent care generally means services are provided for less than eight hours per day and a maximum of 28 hours per week, though exceptions up to 35 hours per week are possible for a short time. Skilled nursing care involves procedures only a licensed nurse can safely provide, such as administering intravenous medications or performing complex wound care. Simple tasks like medication reminders or personal care alone do not qualify as skilled care.
Another requirement is that the patient must be considered “homebound,” or confined to the home. This status does not mean the patient must be bedridden, but leaving the home requires a considerable and taxing effort due to their illness or injury. The effort needed to leave must typically involve assistance from another person or the use of a supportive device like a walker or wheelchair.
Homebound patients are allowed to leave their residence for specific, limited reasons without jeopardizing eligibility. These exceptions include trips for medical treatment, such as doctor’s appointments or dialysis, and short, infrequent absences for non-medical reasons. Additionally, the selected home health agency must be certified by Medicare, confirming it meets federal health and safety standards.
Types of Approved Home Health Services
Once a patient meets the eligibility criteria, Medicare covers a defined set of services intended to treat the illness or injury. The core benefit is intermittent skilled nursing care, provided to manage and evaluate the patient’s condition. Covered skilled care includes injections, patient education for managing a new diagnosis, and monitoring unstable health statuses.
Therapy services are covered when medically necessary for treating the patient’s condition. Physical therapy focuses on regaining strength and mobility, including gait training or learning to use new equipment. Speech-language pathology services restore and strengthen speech, communication, and swallowing abilities.
Occupational therapy helps patients regain the ability to perform activities of daily living, such as dressing and eating independently. While skilled nursing, physical therapy, and speech-language pathology must be the initial qualifying services, occupational therapy can be the continuing service that maintains eligibility.
Medicare also covers medical social services to help the patient with social and emotional concerns related to their illness. These services include counseling or connecting the patient and family with community resources. Home health aide services are covered only if the patient is also receiving a skilled service, such as nursing or therapy. Aides provide hands-on personal care, like assistance with bathing or dressing, but are not covered if personal care is the only assistance needed. Medical supplies directly related to the care plan, such as wound dressings, are also covered.
Initiating the Care Process
Initiating home health services begins with a formal order from a physician who certifies that the patient qualifies for care. This order confirms medical necessity and the patient’s homebound status. Without this authorization, Medicare cannot cover the services.
Following the doctor’s order, the home health agency and the physician collaborate to establish the Plan of Care (PoC). This document outlines the types of services the patient will receive, the frequency of visits, and the measurable goals for recovery. The PoC serves as the clinical blueprint for all delivered care.
The home health agency then completes a comprehensive patient assessment known as the Outcome and Assessment Information Set (OASIS). This standardized tool evaluates the patient’s clinical condition, functional status, and living situation at the start of care and at specific points during treatment. Medicare uses the OASIS data to measure quality outcomes, determine necessary resources, and calculate agency payment.
The physician must formally certify the patient’s need for services every 60 days, marking the start of a new “episode of care.” If the patient continues to meet eligibility criteria and requires ongoing skilled services, the doctor will re-certify the Plan of Care for another 60-day period. Once certified, the agency begins delivering the skilled care and other services detailed in the Plan of Care.
Patient Costs and Choosing a Certified Provider
For all covered home health services, a patient with Original Medicare pays nothing. There is no coinsurance or deductible required for skilled nursing care or therapy visits. This full coverage helps ensure that financial barriers do not prevent patients from receiving necessary recovery and rehabilitation services at home.
An exception to the $0 cost is for Durable Medical Equipment (DME), such as a walker or hospital bed, often provided as part of the benefit. For DME, the patient is responsible for 20% of the Medicare-approved amount after meeting the Part B deductible. The home health agency supplies certain medical supplies, like wound care materials, which are covered in full under the home health benefit payment.
Before care begins, the patient must select a Medicare-certified home health agency. This certification guarantees the agency adheres to federal health and safety regulations. To help patients make an informed choice, Medicare provides the Care Compare tool on its official website.
This online resource allows patients to locate and compare local Medicare-certified agencies based on quality metrics, including star ratings. These ratings summarize an agency’s performance on measures like timely care initiation and improving patient outcomes related to mobility and self-care. Reviewing these quality scores helps patients select a high-quality provider.