Getting Medicare to pay for home health care starts with one simple fact: Medicare covers home health care only if you are homebound and need skilled care from a nurse or therapist. You must also be under a doctor’s care, and that doctor must certify that you need the services. The care must come from a Medicare-certified home health agency. If those conditions are met, Medicare covers the care at no cost to you, though you may pay 20% of the Medicare-approved amount for durable medical equipment.
What Are the Medicare Requirements for Home Health Care?
Medicare does not pay for home health care just because you need help at home. The program has strict rules. You must meet all of the following conditions for Medicare to cover your care.
You must be homebound. This does not mean you are bedridden. It means leaving your home requires considerable effort. You may leave for medical appointments, religious services, or adult day care, but leaving home is difficult and generally infrequent.
You must need skilled care. Medicare covers part-time or intermittent skilled nursing care, physical therapy, speech-language pathology services, or continued occupational therapy. Custodial care alone — help with bathing, dressing, or meals — is not covered.
A doctor must certify your need. Your doctor must sign a plan of care confirming that you need the services and that the care is medically necessary. The doctor must re-certify your need periodically.
The agency must be Medicare-certified. Medicare only pays agencies that meet federal health and safety requirements. You can verify an agency’s certification on the Medicare website.
There is one more rule that surprises many people. Your doctor must have an in-person visit with you within 90 days before or 30 days after starting home health care. This visit must be related to the reason you need home care.
How Do I Get Medicare To Pay For Home Health Care: The Step-by-Step Process
The process is straightforward, but each step matters. Missing one can delay or deny your coverage.
Step 1: Talk to your doctor. Explain your symptoms and why you cannot leave home easily. Ask specifically whether you qualify for home health services under Medicare rules.
Step 2: Choose a Medicare-certified home health agency. Your doctor may recommend one, but you have the right to choose. Ask the agency to confirm they accept Medicare assignment. This means they accept Medicare’s approved amount as full payment.
Step 3: Get your doctor to order the care. The agency cannot start providing services until your doctor orders them and certifies your plan of care.
Step 4: Complete the in-person visit requirement. Your doctor must see you face-to-face within the required timeframe. The visit must be related to your need for home care.
Step 5: Receive care and monitor your coverage. Medicare sends you a notice called a Home Health Advance Beneficiary Notice if they believe a service will not be covered. Read it carefully. You have appeal rights if you disagree.
The agency handles the billing. You do not submit claims to Medicare yourself. You should receive a Medicare Summary Notice in the mail every three months showing what was billed and what Medicare paid.
What Does Medicare Cover and What Does It Cost?
Medicare Part A or Part B covers home health care depending on your situation. In most cases, Part B covers it. If you have both Part A and Part B, the coverage works the same way.
Medicare covers the following services when part of your plan of care:
- Part-time or intermittent skilled nursing care
- Physical therapy
- Speech-language pathology services
- Occupational therapy
- Medical social services
- Home health aide services for personal care, but only when you also receive skilled care
You pay nothing for covered home health care services. Medicare also covers durable medical equipment like hospital beds, walkers, or wheelchairs at 80% of the Medicare-approved amount. You pay the remaining 20%.
There is no limit on how long Medicare will cover your care as long as your doctor continues to certify that you need it. However, Medicare typically covers care for a limited period. The agency must review your plan of care regularly, and your doctor must re-certify that you still need skilled care.
Medicare does not cover 24-hour-a-day care at home, meal delivery, homemaker services, or personal care when it is the only care you need. These are custodial services, and Medicare does not pay for them.
What Does “Homebound” Really Mean?
The homebound requirement confuses many people. You do not need to be stuck in bed. The official rule is that leaving home requires considerable and taxing effort.
You may qualify as homebound if you use a walker or wheelchair, need help from another person to leave home, or have a condition that makes leaving home medically contraindicated. Your doctor must document this in your medical record.
You can still leave home occasionally without losing your homebound status. Trips to the doctor, religious services, or adult day care are allowed. Brief trips for necessities like groceries may also be acceptable, but this is evaluated case by case.
If your only problem is that you cannot drive, you are not homebound. If you can leave home independently without much effort, you do not qualify. The determination depends on your specific medical condition and how much effort it takes to leave.
What If Medicare Denies My Home Health Care Claim?
Denials happen. The most common reason is that the agency or doctor did not document your need properly. Another common reason is that the services provided were considered custodial rather than skilled.
If Medicare denies your claim, you have the right to appeal. The process starts with a detailed explanation from your doctor about why the care is medically necessary. Your doctor’s documentation is the most important part of any appeal.
The appeals process has five levels. Most denials are resolved at the first or second level. You can also file a complaint with your state’s Quality Improvement Organization, which oversees the quality of care for Medicare beneficiaries.
If you receive a notice that a service will not be covered, you can request an expedited appeal. This applies when you are currently receiving care and Medicare plans to stop paying.
Do not ignore a denial. Act quickly. There are strict deadlines for filing appeals. If you miss the deadline, you may lose your right to appeal.
Medicare Advantage and Home Health Care
If you have a Medicare Advantage plan instead of Original Medicare, the rules can be different. Medicare Advantage plans must cover everything Original Medicare covers, but they can have different requirements.
Many Medicare Advantage plans require you to use in-network home health agencies. Some require prior authorization before starting care. Your plan may also have different rules about how long care can continue.
Check your plan’s coverage rules before starting home health care. Ask your plan if the agency you want to use is in-network. Ask whether you need prior authorization. These steps can prevent surprise denials.
If your Medicare Advantage plan denies coverage, you have appeal rights just like with Original Medicare. The appeals process is similar, but you start by appealing to the plan itself.
How to Choose a Home Health Agency
Choosing the right agency matters. The agency handles billing, provides your caregivers, and communicates with your doctor.
Start by asking your doctor for recommendations. Then verify that each agency is Medicare-certified. You can do this on the Medicare website using the Care Compare tool.
Ask the agency directly whether they accept Medicare assignment. If they do, they cannot charge you more than the Medicare-approved amount for covered services. This protects you from unexpected bills.
Ask about their staffing. Who will come to your home? What training do they have? How quickly can they start? What happens if your regular caregiver is unavailable?
Read reviews and check for complaints. Your state health department can tell you if an agency has been cited for violations. This information is public.
Frequently Asked Questions
How long does Medicare pay for home health care?
Medicare covers home health care as long as your doctor certifies that you meet the requirements and need skilled care. There is no fixed time limit, but your plan of care is reviewed regularly and must be re-certified.
Does Medicare pay for family members to provide home care?
No. Medicare only pays Medicare-certified home health agencies. Family members cannot be paid by Medicare for providing care, even if they are qualified professionals.
Can I get home health care if I only need help bathing and dressing?
No. Medicare does not cover custodial care alone. You must need skilled nursing or therapy services. A home health aide may provide personal care, but only when you also receive skilled care.
What is the 20% coinsurance for home health equipment?
Medicare covers durable medical equipment like wheelchairs and hospital beds at 80% of the Medicare-approved amount. You pay the remaining 20% of the approved amount, not 20% of whatever the supplier charges.
