Medicare and Home Health Services: What Exactly Does It Cover?
One area that can confuse Medicare beneficiaries is if it covers home health services and, if so, what restrictions or requirements apply. Let’s take a closer look at these services.
What are home health services?
Home health services are performed by or under the supervision of a licensed or certified nurse to treat your illness or injury. Recovering at home can be more comfortable and less costly than in a hospital, but you may still need monitoring or medical care.
Certain home health services are eligible for coverage under Original Medicare’s Part A (hospital insurance) and Part B (medical insurance).
A Medicare-certified home health care agency usually coordinates the services ordered for you by your doctor. Medicare defines “eligible home health services” as including:
Part-time or “intermittent” skilled nursing care, defined as under seven days a week or 8 hours a day
Physical or occupational therapy
Speech-language pathology services
Medical social services, such as counseling or community support
Part-time or intermittent home health aide care (if connected to other skilled services)
Injectable osteoporosis drugs for women
Durable medical equipment (DME)
Medical supplies for use at home
Not included are:
24-hour in-home care
Meal deliveries to your home
Homemaker services unrelated to your care plan (such as shopping and cleaning)
Custodial or personal care (such as bathing and dressing) if it’s the only care needed
Who is eligible for home health services?
If you have Part A and/or Part B, you will be eligible if you meet all of the following requirements:
You are under the care of a doctor who creates and monitors the care plan calling for the services.
The doctor certifies your need for intermittent skilled nursing care and/or physical, occupational or speech-language therapy by a skilled therapist (subject to additional specific conditions).
The doctor certifies that you are homebound, meaning you need help to leave your home.
You can leave home for medical treatment or short absences, including attending adult day care. But you cannot need more than part-time or “intermittent” care.
What do home health services cost?
If you have Original Medicare, there will be no cost for your covered home health care services. However, you may need durable medical equipment such as wheelchairs, oxygen equipment or a hospital bed. If so, after you meet your Part B deductible ($164.90 in 2023), you will still be responsible for the 20% that Medicare does not cover of the approved amounts for covered medical equipment. You will also have to use Medicare-approved suppliers.
How does coverage of home health services differ between Original Medicare and Medicare Advantage?
Remember that Medicare Advantage (Part C) is legally required to provide everything Original Medicare offers, so this basic information extends to Part C beneficiaries. However, your Medicare Advantage plan may offer different rules, restrictions and costs. Here are some differences:
You will have to select a home care health agency that is in-network under your Medicare Advantage plan.
You will likely need prior authorization or a referral before receiving home health services.
You may have a copayment for your care, whereas Original Medicare fully covers the cost after any applicable deductible.
Your Part C plan may also provide additional benefits and coverage that Original Medicare does not. Because of the value that in-home services bring to members, plan providers continue to expand those available services.
Takeaway action step: Before signing any agreements for home health services, contact your Medicare Advantage plan provider to find out precisely what is covered, what isn’t and what costs you might incur.
What should you watch out for with home health services?
Your doctor or another healthcare provider could recommend home health services that Medicare doesn’t cover – or more frequent use of services than it covers. To avoid having to pay for uncovered costs, ask questions of your provider or Medicare. Be especially careful when it comes to durable medical equipment.
The home health agency you are working with is a good source of information regarding what Medicare will pay for and what it won’t. In fact, you should request a notice called the “Advance Beneficiary Notice” before the agency provides any services or supplies that Medicare won’t cover.
Takeaway action step: Be sure to obtain and review an Advance Beneficiary Notice from your home health agency so you know your exact financial exposure for the services offered.
A few states (Florida, Illinois, Massachusetts, Michigan and Texas) provide the option of a Medicare demonstration, which allows you to submit a request to Medicare to review the services being considered before you get started. That way, you know early on if they will be covered. This pre-claim review process does not affect your home health service benefits.
Takeaway action step: If you live in one of those five states, submit a Medicare demonstration pre-claim review. Medicare will determine if the services are medically necessary and meet Medicare’s requirements. Find out more by calling Medicare at 1-800-MEDICARE (1-800-633-4227).