The short answer
Medicare covers home health services if you are homebound and need part time or intermittent skilled nursing care or therapy, ordered by a provider and given by a Medicare-certified agency. You pay nothing for the covered services. If you qualify, the number of visits is unlimited.
You are told you qualify for home health care as long as you are homebound, and the word lands like a sentence. It sounds like a rule about never going out. Medicare's own definition is about how hard leaving is, and it names three trips that do not break it.
Does Medicare cover home health care?
Medicare covers certain home health services if you are eligible, and it carries the benefit under both Part A and Part B. The care is delivered where you live rather than in a facility. You pay nothing for the covered services, although other costs can still apply.
Medicare describes home health as a wide range of health care services you can get in your home for an illness or injury. It names three different purposes: to help you get better, to maintain your current condition or level of function, or to slow your rate of decline.
That third purpose is the one worth holding on to. A benefit that covers slowing a decline is not only a recovery benefit, and Medicare states the three purposes side by side rather than ranking them.
Medicare also draws a comparison of its own. It says home health care is usually less expensive, and more convenient, than care you get in a hospital or a skilled nursing facility, and that depending on your needs it can also be just as effective. The hedges in that sentence are Medicare's own words, not softening added here.
If your Medicare comes through a Medicare Advantage Plan or another Medicare health plan, the instruction is different. Medicare says to check with your plan for more information about your home health benefits.
Who qualifies as homebound?
Homebound is a two part test. Leaving home is not recommended because of your condition, or you have trouble leaving without help such as a cane, wheelchair, walker, crutches, special transportation or another person, because of an illness or injury. And you are normally unable to leave, and leaving takes a lot of effort.
Both conditions have to be met. The first is about difficulty or medical advice. The second is about effort, and Medicare's phrase is that leaving takes a lot of effort rather than that leaving is forbidden.
| The situation | Still homebound | The trap |
|---|---|---|
| Leaving home for medical treatment | Yes | Thinking any trip out ends the benefit |
| Short, infrequent trips for other reasons | Yes | Reading short and infrequent as never |
| Attending religious services | Yes | Assuming only medical trips are allowed |
| Attending adult day care | Yes | Thinking care elsewhere replaces care at home |
Medicare names those trips itself. You may leave home for medical treatment, or for short and infrequent absences for non-medical reasons such as attending religious services, and you can still get home health care if you attend adult day care.
There is a disqualifier on the other side, and it catches people who assume more care is safer ground. You will not qualify for home health services if you need more than part time or intermittent skilled care.
So the benefit sits inside a band. Too little skilled need and there is nothing to order. Too much, and Medicare says this is not the benefit for it.
What services are covered?
The covered list starts with medically necessary part time or intermittent skilled nursing care. Medicare names wound care for pressure sores or a surgical wound, patient and caregiver education, intravenous or nutrition therapy, injections, and monitoring of serious illness and unstable health status.
Physical therapy, occupational therapy and speech-language pathology services are covered if you meet certain conditions, which Medicare states as a condition rather than as a checklist. Medical social services are on the list too.
Home health aide care carries a rule that changes who can get it. Part time or intermittent aide care is covered only if you are also getting skilled nursing care, physical therapy, speech-language pathology services or occupational therapy at the same time. The aide help Medicare names is walking, bathing or grooming, changing bed linens and feeding.
Three more items round it out: injectable osteoporosis drugs for women who meet certain criteria, durable medical equipment, and medical supplies for use at home.
Medicare also describes what the staff will actually do once they arrive. Its own examples include monitoring what you eat and drink, checking your blood pressure, temperature, heart rate and breathing, making sure you are taking your medicines and treatments correctly, asking about pain, and checking your safety in the home.
Two more sit on that list and they are about people other than the patient. Teaching you and the family or friends helping you to continue the care you need, and coordinating with your doctor and everyone else giving you care.
None of it starts without an order. A health care provider must assess you face to face before certifying that you need home health services, must order the care, and a Medicare-certified home health agency must provide it.
How many visits can I get?
Medicare's answer is unlimited. If you qualify, you can get unlimited home health visits. In most cases it then adds hour ceilings: skilled nursing care and home health aide services up to 8 hours a day combined, for a maximum of 28 hours a week.
There is a short term exception above that. You may be able to get more frequent care for a short time, at less than 8 hours a day and up to 35 hours a week, if your provider decides it is necessary.
Call this Unlimited Visits, Counted Hours, because the two halves of Medicare's answer count different things. Unlimited counts VISITS. The ceilings count HOURS. Both numbers are the government's, and neither one contradicts the other.
The distinction is ours, and it matters at the moment a family is doing arithmetic. Asking how many visits are left is asking about the half with no limit. Asking how many hours of help arrive in a week is asking about the half that is capped.
One more number runs alongside them and it is not a coverage period. Your provider and home health team should review your care plan as often as necessary, and at least once every 60 days. That is a review cadence rather than an expiry date.
The care plan itself is where the frequency actually gets set. Medicare says it may list the services you need, who should give them, how often you will need them, the equipment you need, and the results your provider expects.
What do I pay for home health care?
You pay nothing for covered home health services. Equipment is charged differently: after you meet the Part B deductible, you pay 20 percent of the Medicare-approved amount for Medicare-covered medical equipment. So the visits and the walker are on two different footings.
The agency has a duty to tell you the cost picture before the care starts, not after. Medicare says the agency should tell you how much Medicare will pay, and should tell you both verbally and in writing if Medicare will not pay for any items or services, and how much you will owe for them.
There is a named notice attached to that duty. The agency should give you an Advance Beneficiary Notice before giving you services and supplies that Medicare does not cover. What that notice is and how it works is a subject of its own, and this publication carries it in the Records section.
A demonstration program runs in five states and it changes paperwork rather than benefits. If your agency is in Florida, Illinois, Ohio, North Carolina or Texas, it may submit a request for pre-claim review of your home health coverage to Medicare.
Medicare states the purpose and the reassurance in the same breath. The review helps you and the agency know earlier whether Medicare is likely to cover the services, your home health benefits have not changed, and your access should not be delayed by the process.
What is not covered?
Medicare names four things it does not pay for under home health. Round the clock care at your home. Home meal delivery. Homemaker services such as shopping and cleaning that are unrelated to your care plan. And custodial or personal care, when that is the only care you need.
Read the third and fourth items together, because both carry a condition rather than a flat ban. Homemaker services are excluded when they are unrelated to your care plan, which leaves the ones inside the plan on a different footing.
Personal care works the same way. Help with bathing, dressing or using the bathroom is excluded when it is the only care you need, and the covered list already includes aide help with bathing and grooming alongside skilled care.
The first item is the flattest of the four. Twenty four hour a day care at home is not covered, and Medicare attaches no condition to that one at all.
That is the whole published list for this benefit. Medicare states these four and no more, and this page does not go and assemble a longer one from pages it has not read.
What this means for you
Medicare covers home health care when two things are true at the same time: you are homebound in Medicare's own two part sense, and you need part time or intermittent skilled care that a provider has ordered and a Medicare-certified agency delivers.
Homebound does not mean housebound. Medical treatment, short and infrequent trips, religious services and adult day care are all named by Medicare as things you can do and still qualify.
The visits are unlimited and the hours are capped, which are two different questions with two different answers. The covered services cost you nothing, and the Coverage section carries skilled nursing facility care and hospice for the two routes beside this one.
FAQ
Can I leave the house and still be homebound?
Yes, and Medicare names the trips itself rather than leaving it to interpretation. You may leave home for medical treatment. You may take short, infrequent absences for non-medical reasons, and the example Medicare gives is attending religious services. You can still get home health care if you attend adult day care.
None of those ends the benefit. The test underneath them has two parts and both must be true. Leaving is not recommended because of your condition, or you have trouble leaving without help such as a cane, wheelchair, walker, crutches, special transportation or another person, because of an illness or injury.
And you are normally unable to leave, and leaving takes a lot of effort. Homebound is a description of difficulty, not a promise to stay indoors.
Does home health include help with bathing and dressing?
It can, and the answer turns on what else is happening. Home health aide care covering help with walking, bathing or grooming, changing bed linens and feeding is covered part time or intermittently, but only if you are also getting skilled nursing care, physical therapy, speech-language pathology services or occupational therapy at the same time.
Without one of those running alongside it, the aide help has nothing to attach to. That is the same line Medicare draws in its exclusions, where custodial or personal care that helps with daily living activities is not covered when it is the only care you need.
Personal help is inside the benefit as a companion to skilled care and outside it as a substitute.
Who decides how often the nurse comes?
Your provider does, working with the agency, and it is written down. A health care provider must assess you face to face before certifying that you need home health services, must order your care, and a Medicare-certified agency must deliver it. Medicare says home health staff should visit you as often as your provider orders.
The document that records this is your care plan, which the agency creates with your doctor, and which may list the services you need, the professionals who should give them, how often you will need them, the equipment involved, and the results your provider expects.
Your provider and the home health team should review that plan as often as necessary and at least once every 60 days.
What is the pre-claim review in Florida, Illinois, Ohio, North Carolina and Texas?
It is a Medicare demonstration program, and it changes paperwork rather than coverage. If you get services from a home health agency in one of those five states, your agency may submit a request for pre-claim review of your home health coverage to Medicare.
Medicare's stated purpose is that this helps you and the agency know earlier in the process whether Medicare is likely to cover the services, and it says it will review the information and cover the services if they are medically necessary and meet Medicare requirements.
Medicare adds two reassurances directly: your home health benefits have not changed, and your access to home health services should not be delayed by the review process.
Will the agency tell me before something is not covered?
Yes, and Medicare states this as a duty on the agency rather than as a courtesy. Before your home health care starts, the agency should tell you how much Medicare will pay.
If Medicare will not pay for any items or services the agency gives you, it should tell you that both verbally and in writing, and tell you how much you will have to pay.
Attached to that duty is a named document. The agency should give you a notice called the Advance Beneficiary Notice before giving you services and supplies that Medicare does not cover. What that notice does, and what your options are once you hold one, are carried in this publication's Records section.
