Medicare does cover home health services, but only under specific conditions

Medicare Part A and Part B together cover home health services when a doctor orders them and you meet certain requirements. You must be homebound (unable to leave home without considerable effort), have a medical need for skilled care, and be under the care of a physician who orders the services. The services must be provided by a Medicare-certified home health agency. Medicare does not cover custodial care — help with bathing, dressing, or meals alone — unless it is part of a skilled service like physical therapy or wound care.

The key difference is between skilled care and custodial care. Skilled care is medical treatment that requires a nurse, therapist, or other trained professional. Custodial care is personal information that does not require medical training. Medicare pays for skilled care; it does not pay for custodial care by itself.

Key Takeaways

  • Medicare covers home health services only if a doctor orders them, you are homebound, and the care is skilled rather than custodial.
  • Part A covers skilled nursing, physical therapy, occupational therapy, and speech therapy with no copay if you are homebound and meet medical criteria.
  • Part B covers some home health services if Part A does not explore, though you may owe a 20 percent copay.
  • A Medicare-certified home health agency must provide the services; Medicare does not pay for independent caregivers or unlicensed helpers.
  • If you need only personal care or help with daily activities, Medicare does not cover it, but Medicaid or private pay may.

What Medicare Part A covers at home

Part A covers skilled nursing visits, physical therapy, occupational therapy, and speech-language pathology when ordered by your doctor and provided by a Medicare-certified agency. You pay nothing out of pocket for these services as long as you remain homebound and the services are medically necessary. The agency bills Medicare directly.

Part A also covers medical equipment and supplies — such as oxygen, wound dressings, diabetic supplies, and walkers — as part of home health. You typically pay 20 percent of the Medicare-approved amount for equipment, though some items have no copay. Home health aides (personal care assistants) are covered by Part A only when they are helping with a skilled service, such as assisting a nurse with wound care or helping a patient bathe before physical therapy.

Part A coverage is limited in time. If you are hospitalized for at least three consecutive days and then discharged to home health, Part A covers up to 60 days of services in a benefit period. If you do not meet the three-day hospital stay requirement, Part B may cover some services instead, though the rules are stricter.

What Medicare Part B covers at home

Part B covers home health services when Part A does not explore — usually when you were not hospitalized for three days before coming home. Part B covers the same types of skilled services: nursing, therapy, and medical equipment. You pay a 20 percent copay on the Medicare-approved amount for most services and equipment.

Part B home health is less generous than Part A. There is no automatic limit on the number of visits, but Medicare reviews the medical necessity of ongoing care. If your doctor orders home health through Part B and Medicare denies it as not medically necessary, you have the right to appeal the decision.

How to start home health services through Medicare

Your doctor must order home health services and document that you are homebound and need skilled care. The doctor submues a home health referral to a Medicare-certified agency. You do not choose the agency directly in most cases — your doctor or hospital discharge planner refers you to one. If you want to use a different agency, ask your doctor to refer you to that agency instead, provided it is Medicare-certified.

Once the agency receives the referral, a nurse visits to assess your needs and create a care plan. This initial visit is covered by Medicare. The agency then schedules skilled visits based on the plan. You should receive a document explaining your rights and responsibilities as a home health patient. Ask the agency for a list of what Medicare covers and what you may owe.

If you use a Medigap or Medicare Advantage plan, the referral process is the same, but your out-of-pocket costs may differ. Medigap plans often cover the 20 percent copay for Part B services. Medicare Advantage plans have their own networks of home health agencies and may require prior approval before services begin.

What Medicare does not cover at home

Medicare does not cover custodial care — bathing, dressing, grooming, toileting, or meal preparation — when it is the only service needed. If you need help with these activities but do not need skilled nursing or therapy, Medicare will not pay. Many people in this situation turn to Medicaid (if they meet income and asset limits), private pay caregivers, or family members.

Medicare also does not cover homemaker services, such as housecleaning, laundry, or grocery shopping, even if ordered by a doctor. It does not cover 24-hour care or live-in caregivers. It does not cover services from a family member, even if that person is a nurse or therapist. And it does not cover services from an agency that is not Medicare-certified.

If your home health agency stops visiting because Medicare denies further coverage as not medically necessary, you have the right to appeal. You can also ask for a detailed explanation of why the services were denied and what would need to change for them to be covered again.

When Medicaid covers home care that Medicare does not

Medicaid is a joint federal and state program for people with low income and limited assets. Many states cover custodial home care and personal care services through Medicaid when Medicare does not. Medicaid rules vary widely by state — some cover extensive in-home support, while others cover very little.

If you have both Medicare and Medicaid (called "dual may be able to access"), Medicaid may cover the copays and deductibles that Medicare does not cover, and it may also cover custodial care and personal information. To find out what your state's Medicaid program covers, contact your state Medicaid office or call 211 to speak with a local benefits counselor who can explain your options.

Some people pay out of pocket for home care that Medicare and Medicaid do not cover. Others use long-term care insurance if they have it. A few states have programs that help pay for in-home support for older adults with limited income — ask your local Area Agency on Aging whether your state has one.

Understanding homebound status and medical necessity

To receive Medicare-covered home health, you must be homebound. This means leaving home requires considerable and taxing effort, and you cannot leave without help from another person or medical equipment. You do not have to be bedridden. A person who uses a walker and can walk to the mailbox but cannot safely travel to a doctor's office may still be considered homebound. The home health nurse assesses this during the first visit.

You must also have a medical necessity for skilled care. This means a doctor must order the services and document why they are needed. Common reasons include recovery from surgery, wound care, physical therapy after a fall, management of a chronic illness like heart failure or COPD, or skilled nursing for conditions like diabetes or kidney disease. The services must be ordered by a physician, nurse practitioner, or physician assistant.

Medicare reviews home health claims to verify that both conditions are met. If an agency provides services that Medicare later determines were not medically necessary or that you were not homebound, Medicare may deny payment and the agency may bill you. This is rare when a doctor has ordered the services, but it can happen. Ask your home health agency to explain the medical reason for each type of service before it begins.

Frequently Asked Questions

Do I have to pay anything for Medicare-covered home health?

If Part A covers your home health services, you pay nothing as long as you remain homebound and the care is medically necessary. If Part B covers your services, you pay 20 percent of the Medicare-approved amount for most services and equipment. If you have Medigap insurance, it may cover this 20 percent copay.

What happens if I need home care but I am not homebound?

Medicare will not cover home health services if you can leave home without considerable effort, even if you have a medical need. You may be able to receive outpatient therapy at a clinic or doctor's office instead. If you need personal care and are not homebound, Medicaid, private pay, or family support may be options depending on your situation.

Can I choose which home health agency provides my care?

Your doctor makes the referral to a specific agency, but you can ask your doctor to refer you to a different Medicare-certified agency if you prefer. If you have a Medicare Advantage plan, you may be limited to agencies in your plan's network. Always confirm that any agency you use is Medicare-certified before services begin.

How long does Medicare cover home health services?

If you may have access to through Part A after a hospital stay, Medicare covers up to 60 days of services in a benefit period. If Part B covers your services, there is no set limit, but Medicare reviews ongoing care for medical necessity. Your doctor and the home health agency work together to determine how long services should continue based on your progress.

What if I need help with bathing and dressing but not nursing care?

Medicare does not cover this type of personal care. You may be able to receive Medicaid-covered personal care information if you meet your state's income and asset limits. Otherwise, you can hire a private caregiver, ask family members for help, or contact your local Area Agency on Aging to learn about other community resources.