What Medicare will and won't pay for at home

Medicare covers some home care services, but not all of them, and the rules depend on whether you need skilled nursing care or help with daily tasks. Skilled home health care — nursing visits, physical therapy, occupational therapy, and speech therapy — is covered if a doctor orders it and you are homebound or mostly homebound. Custodial care — help with bathing, dressing, toileting, and meals — is not covered by Medicare, even if you need it every day.

The difference matters because it determines what you pay and who provides the care. If Medicare covers your service, you pay a copay per visit (usually $0 for skilled nursing, $15 to $20 for therapy). If it does not cover the service, you pay the full cost out of pocket, or you look to Medicaid, a long-term care insurance policy, or family help.

Home health care is different from home care aides or housekeeping services. A home health agency sends a nurse or therapist to your home; a home care aide comes to help you bathe and dress. Medicare pays for the first, not the second. Understanding which services you need and which ones Medicare covers will help you plan and budget.

Key Takeaways

  • Medicare covers skilled nursing care and therapy at home only if a doctor orders it and you cannot leave home without help or significant effort.
  • You must be discharged from a hospital or skilled nursing facility within the past 60 days, or your doctor must document that you need skilled care for a medical condition.
  • A home health agency must be Medicare-certified, and your doctor must submit an order before care begins.
  • Custodial care — help with bathing, dressing, and meals — is not covered by Medicare and requires payment through Medicaid, insurance, or out of pocket.
  • You can check whether a home health agency is Medicare-certified by searching the Medicare Care Compare tool on Medicare.gov.

The homebound requirement and what it means

To receive Medicare-covered home health care, you must be homebound or essentially homebound. This does not mean you never leave your house. It means leaving home requires considerable and taxing effort because of an illness, injury, or condition. You might be able to go to a doctor's appointment or to church with help, but you cannot manage regular outings or self-care without information.

Your doctor decides whether you meet this standard. They do not fill out a formal form; instead, they document in your medical record that you are homebound and need skilled care. The home health agency will ask your doctor to confirm this when they submit the order for care. If Medicare reviewers later question whether you were truly homebound, your doctor's notes are what protects the claim.

Common reasons Medicare approves home health care include recovery from hip fracture or joint replacement, stroke with weakness or speech problems, heart failure requiring monitoring, wound care after surgery, and conditions like COPD or diabetes that need skilled nursing management. If you are recovering from a hospital stay and your doctor thinks you need help at home, ask whether home health care might be covered.

How to start the process: doctor's order and agency selection

Home health care starts with a doctor's order. Your primary care doctor, cardiologist, orthopedic surgeon, or any doctor treating you can write the order. You do not need a referral from another doctor first. Tell your doctor that you are having trouble managing at home and ask whether home health care would help. If your doctor agrees, they will submit an order to a home health agency.

You can choose which Medicare-certified home health agency provides your care. Ask your doctor which agencies they work with, or search the Medicare Care Compare tool at Medicare.gov to see which agencies serve your area and what their quality ratings are. You can also ask your hospital discharge planner or social worker for recommendations. Once you choose an agency, your doctor sends the order there, and the agency schedules an initial assessment visit.

The home health agency will send a nurse to your home to evaluate your medical needs, your living situation, and what help you require. This visit is free. The nurse will discuss what services they can provide, how often visits will occur, and what your out-of-pocket costs will be. If you have a supplemental insurance policy or Medicaid, tell the agency so they can bill correctly.

What Medicare covers and what you pay

Medicare Part A covers home health care if you meet the homebound requirement and a doctor orders it. You pay nothing for the first 60 days of home health care in a benefit period. After 60 days, you pay 20 percent of the approved cost for each visit. A benefit period begins the day you start home health care and ends 60 days after your last visit.

The services Medicare covers include skilled nursing (wound care, medication management, monitoring), physical therapy, occupational therapy, speech-language pathology, and medical social work. Home health aides can come with the nurse to help with bathing and dressing, but only if a nurse or therapist is also visiting. Medicare does not pay for a home health aide to come alone.

Services Medicare does not cover include housekeeping, meal preparation, grocery shopping, laundry, and personal care without a skilled component. If you need help with these tasks, you will need to hire a private home care aide, use Medicaid if you may have access to, or ask family for help. Some agencies offer both Medicare-covered skilled care and private-pay services; you can use both at the same time.

The 60-day benefit period and what happens after

Home health care is measured in 60-day benefit periods. Your first period starts the day your first visit occurs. If you receive care for 30 days and then have no visits for 60 days, your benefit period ends. If you need care again after that gap, a new benefit period begins.

Within each 60-day period, you can receive as many visits as your doctor orders and Medicare approves. There is no visit limit written into the rules, but Medicare reviewers will question whether visits are medically necessary if the frequency seems high or if you are not making progress toward your goals. Your home health agency will track your progress and discuss with your doctor whether to continue, reduce, or end visits.

Once your 60-day period ends, you start fresh with a new period if you need more care. You do not lose coverage or have to reapply. Your doctor straightforward submits a new order, and the home health agency continues or restarts care. If you have a Medigap or Medicare Advantage plan, check your policy to see whether it covers home health care beyond what Original Medicare pays.

Medicare Advantage and other insurance options

If you have a Medicare Advantage plan (Part C), your coverage for home health care may differ from Original Medicare. Some Advantage plans cover the same services with the same copays; others have different rules or require prior approval. Call your plan's customer service number to ask what home health care is covered and what you will pay.

If you have a Medigap policy (supplemental insurance), it typically covers the 20 percent coinsurance you would pay after day 60 of home health care. Check your policy documents or call your insurance company to confirm. Medigap does not expand what Medicare covers; it only helps pay your share of covered services.

If you have Medicaid in addition to Medicare, Medicaid may cover custodial care and personal care that Medicare does not. Medicaid rules vary by state, so contact your state Medicaid office to learn what home care services are available to you. Some people may have access to for both Medicare and Medicaid (called "dual may be able to access"), and coordinating between the two programs can expand your options.

When to ask your doctor and what questions to ask

Ask your doctor about home health care if you are having trouble managing at home after an illness, surgery, or injury. Specific signs include difficulty bathing or dressing, trouble taking medications on time, wounds that need cleaning or dressing changes, weakness that makes walking unsafe, or recent hospitalization. You do not need to wait for your doctor to suggest it; you can bring it up yourself.

When you talk to your doctor, ask these questions: Do you think I need skilled nursing or therapy at home? Can you write an order for home health care? Which home health agencies do you recommend? How often do you think I would need visits? How long do you expect I will need this care? What should I do if I am not improving or if I have questions during care?

If your doctor says home health care is not necessary, ask why. Sometimes doctors are not familiar with what Medicare covers, or they think you need only personal care (which Medicare does not cover). If you disagree, you can ask for a second opinion or contact your local Area Agency on Aging for guidance on other resources.

When to seek care or contact Medicare

Contact your home health agency when ready if you develop new symptoms, fall, have chest pain, cannot take your medications, or notice your wound is getting worse instead of better. Your nurse can assess whether you need emergency care or a doctor's visit. Do not wait for your next scheduled visit if something feels wrong.

Contact Medicare directly if you believe a home health agency is billing you incorrectly, if you disagree with a decision to end your care, or if you want to file a complaint about the quality of care. Call 1-800-MEDICARE (1-800-633-4227) to speak with a representative. You can also file a complaint online at Medicare.gov or contact your state's home health ombudsman.

If your home health agency says your care will end and you disagree, you have the right to request a Quality Improvement Organization (QIO) review. The QIO is an independent group that can overturn Medicare's decision. Your home health agency must tell you about this right before they discharge you; if they do not, ask for it.

Frequently Asked Questions

Do I have to use a home health agency, or can I hire my own nurse?

Medicare only pays home health agencies that are Medicare-certified. You cannot use your own nurse or hire someone privately and have Medicare pay. However, you can hire a private home care aide or nurse in addition to the Medicare-covered agency if you want more help than Medicare provides.

What if I live alone and have no family to help?

Home health care can still work for you. The nurse or aide will come to your home on a schedule, and you can arrange for neighbors, friends, or a local senior center to check on you between visits. Some agencies also offer emergency alert systems or can coordinate with local meal delivery programs. Discuss your living situation with the home health agency during the initial assessment.

Can I get home health care if I was not recently in the hospital?

Yes. You do not have to be discharged from a hospital to receive home health care. Your doctor can order it if you have a medical condition that requires skilled nursing or therapy and you are homebound. For example, if you develop a pressure wound at home or have a flare-up of heart failure, your doctor can order home health care without a hospital stay.

Will Medicare pay for home health care if I have a home care aide already?

Yes, but only if you also have a skilled need. Medicare will not pay for a home care aide to come alone just to help with bathing and dressing. However, if a nurse or therapist is also visiting, the aide can come along and help with personal care on those days. If you need daily help with bathing but no skilled care, you will need to pay for the aide privately or through Medicaid.

What happens to my home health care if I move?

If you move to a new address in the same area, your current home health agency may still serve you. If you move out of their service area, you will need to switch to a Medicare-certified agency in your new location. Your doctor's order remains valid, so the new agency can start care quickly. Tell your current agency as soon as you know you are moving so they can help with the transition.