Want to stay in the comfort of your own home while getting the care you need? Medicare home health care can make that possible. For many seniors and people with disabilities, home health care is a lifeline—but the tricky part is figuring out if you qualify.
This guide will break down exactly how to qualify for home health care under Medicare, what services are included, and what steps you need to take.
MY BLOG: {Health Care Under Medicare}
Understanding Medicare and Home Health Care
What is Home Health Care?
Home health care is skilled medical care provided at your home, often after an illness, surgery, or hospitalization. It can include nursing, therapy, and assistance with recovery.
What Types of Services Does Medicare Cover?
Medicare covers skilled, medically necessary services like nursing care, physical therapy, and medical social services. It does not cover full-time custodial care like bathing or meal prep.
Difference Between Skilled Care and Custodial Care
Skilled care: Provided by licensed medical professionals (e.g., wound care, rehab therapy).
Custodial care: Personal care services like bathing, dressing, or cooking, usually not covered.
Basic Medicare Requirements for Home Health Care
To qualify for Medicare-covered home health services, you must meet ALL of these:
Must Be Under a Doctor’s Care
A doctor must certify that you need medical care at home.
Must Be Homebound
You don’t have to be bedridden, but leaving home should be difficult and require assistance.
Must Need Skilled Services
You must need intermittent skilled nursing or therapy services.
Home Health Agency Must Be Medicare-Certified
Only agencies approved by Medicare can provide covered services.
Who Qualifies for Medicare Home Health Care?
Original Medicare (Part A and B) Eligibility
You must have Part A and/or Part B.
The services must be medically necessary.
Medicare Advantage (Part C) Requirements
Medicare Advantage plans must cover the same services as Original Medicare, but they may have different network rules.
Qualifying Conditions and Examples
Recovering from surgery
Managing chronic conditions like heart failure or COPD
Needing physical therapy after a stroke
Specific Services Covered
Skilled Nursing Care
Wound care, injections, IV therapy, and monitoring serious illnesses.
Physical, Occupational, and Speech Therapy
Physical therapy to regain strength and mobility
Occupational therapy for daily activities
Speech therapy for communication/swallowing issues
Medical Social Services
Help with social or emotional concerns related to illness.
Part-Time Home Health Aide
Helps with basic personal care (bathing, dressing) as part of your care plan.
Services Not Covered by Medicare
24/7 round-the-clock care
Meal delivery or grocery shopping
Long-term custodial care for personal needs
Medicare focuses on short-term medical needs, not full-time caregiving.
Step-by-Step Guide to Qualifying
Step 1 – Get a Doctor’s Order
Your doctor must confirm that you need skilled care at home.
Step 2 – Create a Plan of Care
Your doctor and home health agency develop a written care plan.
Step 3 – Choose a Medicare-Certified Agency
You must pick an agency that accepts Medicare.
Step 4 – Confirm Homebound Status
Your doctor must certify that leaving home is difficult for you.
Understanding Homebound Status
What Does Medicare Consider “Homebound”?
You need help (like a walker or caregiver) to leave home.
Leaving home is not recommended due to your condition.
Exceptions for Medical Appointments
You can still leave home for short, infrequent trips like doctor visits, church, or family events.
Costs and Coverage
How Much Does Medicare Pay?
100% of covered home health services.
20% of the Medicare-approved amount for durable medical equipment like wheelchairs.
Are There Any Out-of-Pocket Costs?
No premiums for the services, but you may pay for non-covered personal care.
How Long Does Coverage Last?
As long as your doctor certifies you still need skilled care, coverage continues.
Common Misconceptions
Do You Have to Be Bedridden?
No! You just need difficulty leaving home without assistance.
Can You Get Home Care Only After a Hospital Stay?
No, you can qualify even without hospitalization if your doctor says it’s necessary.
Tips to Get Approved Faster
Keep detailed medical records.
Make sure your doctor clearly states why home care is medically necessary.
Verify the home health agency is Medicare-certified before starting.
Alternatives if You Don’t Qualify
Medicaid Home Health Benefits
Covers more long-term and custodial care for low-income individuals.
Private Home Health Insurance
Some policies cover more extensive in-home care.
Community and Nonprofit Programs
Local organizations may offer free or low-cost home care support.
Real-Life Examples
Scenario 1 – Post-Surgery Recovery
Mary, 72, had hip surgery. Her doctor orders physical therapy at home for six weeks. Medicare covers 100% of her therapy sessions.
Scenario 2 – Managing Chronic Illness
John, 80, has congestive heart failure. He receives skilled nursing visits weekly to monitor his condition, all of which are covered by Medicare.
Conclusion
Qualifying for Medicare home health care isn’t as complicated as it seems. The key is having a doctor certify medical necessity, being considered homebound, and using a Medicare-certified agency. If you meet these conditions, you can receive skilled nursing, therapy, and limited personal care at home—all at little or no cost.
FAQs
1. Can Medicare deny home health care?
Yes, if you don’t meet the criteria (i.e., you are not homebound, don’t require skilled care, or are not using a certified agency).
2. How long can you receive home health care under Medicare?
As long as your doctor recertifies every 60 days, you still need skilled care.
3. Does Medicare cover home health aides for personal care?
Yes, but only part-time and when combined with skilled services.
4. Can you work or leave home while receiving Medicare home care?
You can leave for short, infrequent trips, such as medical appointments, but not for regular outings.
5. How to appeal if Medicare denies coverage?
You can file an appeal through Medicare’s official process within 120 days of denial.