As we age or recover from illness or injury, receiving medical care in the comfort of our own homes can be a vital part of the healing process. Fortunately, Medicare offers home healthcare benefits that help eligible beneficiaries access necessary medical services without needing a hospital or skilled nursing facility stay.
But what exactly does Medicare cover when it comes to home healthcare, and who qualifies for these benefits?
What is Home Healthcare?
Home healthcare refers to a range of medical and non-medical services provided to individuals in their homes due to illness, injury, or chronic conditions. It allows beneficiaries to receive necessary treatments while maintaining independence and comfort in familiar surroundings.
Types of Home Healthcare Services
Medicare considers home healthcare medically necessary care provided by skilled professionals. Services may include:
- Skilled Nursing Care: Monitoring health conditions, wound care, catheter care, injections, and intravenous (IV) therapy.
- Physical Therapy: Helps restore mobility, balance, and strength after an injury, surgery, or illness.
- Occupational Therapy: Assists individuals in regaining the ability to perform daily activities like dressing, eating, and bathing.
- Speech-Language Therapy: Helps patients with speech impairments, swallowing difficulties, or cognitive disorders.
- Home Health Aide Services: Assistance with personal care, such as bathing and dressing, when needed alongside skilled nursing care.
- Medical Social Services: Support for emotional, social, and financial challenges related to a medical condition.
What Home Healthcare Doesn’t Cover
Medicare’s home healthcare benefits do not cover:
- 24/7 home care or around-the-clock assistance
- Homemaker services, such as meal preparation, laundry, or housekeeping
- Custodial care (long-term personal care) without skilled medical needs
If an individual needs long-term, non-medical assistance, they may need to explore other options like Medicaid, long-term care insurance, or private-pay services.
More About Types of Home Healthcare Services and What Medicare Covers
Medicare Part A (Hospital Insurance) and Part B (Medical Insurance) provide coverage for home healthcare under certain conditions.
Skilled Nursing Care
Medicare covers part-time or intermittent skilled nursing care provided by a registered nurse (RN) or licensed practical nurse (LPN). This includes:
- Wound care
- IV therapy
- Medication administration
- Patient education for managing conditions
Therapy Services
Medicare covers physical therapy, occupational therapy, and speech-language therapy if they are necessary for recovery from an illness, injury, or surgery.
Home Health Aide Services
Medicare covers part-time home health aide services if they are required in conjunction with skilled nursing care. These services may include assistance with bathing, dressing, or personal hygiene. However, Medicare will not cover an aide for custodial care alone (such as help with cooking or housekeeping).
Medical Social Services
If a doctor determines that counseling or social services are necessary to cope with a medical condition, Medicare will cover these services as part of home healthcare.
Medical Supplies and Equipment
Medicare Part B covers certain durable medical equipment (DME), such as wheelchairs, walkers, and oxygen equipment, when prescribed by a doctor for home use. However, the patient may be responsible for 20% of the Medicare-approved cost.
Who Qualifies for Medicare Home Healthcare Benefits?
To be eligible for Medicare-covered home healthcare, a patient must meet the following criteria:
- Be Enrolled in Medicare Part A and/or Part B
- Original Medicare covers home healthcare services for eligible beneficiaries.
- Have a Doctor’s Certification for Home Healthcare
- A doctor or nurse practitioner must confirm that home healthcare is medically necessary.
- The doctor must create and regularly review a care plan.
- Be Considered “Homebound”
- The patient must be unable to leave home without significant effort or assistance (e.g., needing a walker, wheelchair, or caregiver help).
- Leaving home must be infrequent or for medical reasons, such as doctor visits.
- Use a Medicare-Approved Home Health Agency
- The services must be provided by a Medicare-approved home health agency.
If all these conditions are met, Medicare will cover 100% of approved home health services under Part A or Part B.
How Long Will Medicare Pay for Home Healthcare?
Medicare does not limit the number of visits for home healthcare as long as the patient remains eligible and the care is still medically necessary. However:
- The patient’s condition is reassessed every 60 days to determine if home healthcare is still needed.
- If a patient no longer meets the criteria, Medicare will stop covering home health services.
- If long-term care is needed, other programs (such as Medicaid) may need to be considered.
Medicare Advantage and Home Healthcare
If you have a Medicare Advantage (Part C) plan, your home healthcare benefits must match or exceed those of Original Medicare. However, plans may have:
- Different provider networks
- Additional requirements for approval
- Extra benefits (such as personal care or home modifications)
If you have Medicare Advantage, check with your plan provider to understand your coverage.
Need Help Applying or Have Questions About Coverage?
Medicare’s home healthcare benefits provide a valuable opportunity for seniors and disabled individuals to receive medical care at home while maintaining comfort and independence. However, it’s important to understand the eligibility criteria, covered services, and limitations to avoid unexpected costs.
If you believe you or a loved one may qualify for Medicare home healthcare, speak to one of our Medicare advisors today. We’ll walk you through the application process, ensure you have access to all of your options, help you review plans (including annually), ensure you apply on time, and more. We’re always here for you and want to ensure you get the Medicare coverage in Texas that you deserve.
Emily Trevino, Senior Managing Partner at Wise Insurance, leverages her extensive background in biology and business finance to master Medicare, health insurance, and retirement planning. With over a decade in the field, Emily has co-authored “Medicare Breakdown – The Alphabet Soup of Medicare,” marking her as a pivotal figure in insurance education. Her commitment extends through active participation in the National Association of Benefits and Insurance Professionals (NABIP) and speaking at major industry events. Emily’s drive for community service and personal resilience shines through her adventurous pursuits and dedication to societal well-being. Connect with Emily on LinkedIn to explore the future of informed insurance decisions.
