Does Medicare Cover Home Health Care?

America’s senior population is growing rapidly and with that growth comes an increased need for senior health care options. According to the Population Reference Bureau, in fact, the number of Americans over the age of 65 is expected to double from roughly 52 million in 2018 to around 95 million in 2060. For many of these seniors, home health care may be the answer.

Unlike entering retirement, assisted living or nursing homes, healthcare at home can offer seniors the option of aging in place as they remain in a comfortable, familiar environment. Home care assistance has drastically increased in popularity in the last decade with 2015 marking the first year that more money was spent nationally on in-home care than nursing homes.

In this guide, we’ll provide an overview of home health care services and how Medicare can help cover the costs.

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Home Health Care Basics

The U.S. Centers for Medicare & Medicaid Services defines home health care broadly as the range of services that one may obtain at home while recovering from an illness or injury. For seniors, this could mean a brief period of care within the home or extended support across a continuum of care.

Home care services typically have a number of upsides over residential care facilities, including lower overall costs, improved convenience and comparable health outcomes. In addition to reducing the quickly growing demand for senior living facilities, in-home care can also help seniors maintain an more independent lifestyle, improve or sustain their health status and maintain social connections with their current community.

This type of care can take many forms, but a few common examples can include:

Help with injection and medication management
Changing dressings and cleaning wounds after a surgery
In-home IV use
Skilled nursing for those with serious and unstable health conditions
Home safety and wellness visits
Health education for seniors and their daily caregivers
Nutrition support and monitoring
Checking common vital signs, such as heart rate, blood pressure, temperature and respiration
Assistance coordinating care between other providers
Help with pain management

How to Qualify

While home health aides are often less expensive than residential senior living facilities, the costs can still add up quickly. Fortunately, some forms of home health benefits are covered by Medicare.

To qualify, a recipient must be enrolled in Medicare Part A or B, be under the care of a physician and be homebound. When applying for home health assistance coverage through Medicare, it’s critical that the course of treatment is reviewed regularly and certified by a physician.

Without up-to-date documentation, such as a legal prescription for care, Medicare may not cover home care services. This care must also be provided by one of roughly 11,000 certified home health care agencies that is partnered with Medicare nationwide.

Coverage and Costs

Once Medicare has approved a course of home care, it may cover the entire cost of care for up to 60 days. Depending on the condition, type of care and provider availability, a physician may recertify the prescription for continuing 60-day periods of care.

There are two main types of home services covered by Medicare — intermittent skilled nursing and therapy services.

Medicare considers home health care intermittent if it occurs for fewer than seven days each week or less than eight hours over a 21-day period. Intermittent skilled nursing can include services such as support with activities of daily living, medication and wound management and vital sign monitoring. Though seniors must be deemed homebound to qualify for this care, they may occasionally leave home for brief nonmedical events such as church services, family gatherings and appointments.

Many in-home therapies may also be covered by Medicare. Three of the most common forms of home health therapy covered by Medicare are speech pathology, physical therapy and continuing occupational therapy.

When applying for home therapy, Medicare may impose some of the following requirements:

The therapy is for a specific condition with an established history of treatment with specialized therapists
The amount, frequency and duration of treatment must be deemed reasonable by Medicare
There is a reasonable expectation that the condition can be improved or status can be maintained with therapy
A therapist is necessary to help develop a course of treatment
This treatment can only be carried out by a specialized therapist
The requested therapist is associated with one of Medicare’s approved home health care providers

Medicare may cover the full cost of many home health care services, but not all. When applying for in-home services, the home health agency should provide detailed information about any additional costs that may arise. Recipients must be notified of any such fees by mail in an official notice called an Advance Beneficiary Notice.

Exclusions and Challenges

Home health care can be a versatile tool for aging in place, but there are some forms of care and assistance that Medicare doesn’t cover.

For example, housekeeping services such as cleaning, cooking, lawn and garden maintenance and laundry are usually not covered by Medicare. Despite many seniors’ reliance on home housekeeping aids, Medicare usually limits coverage to in-home medical services.

Some forms of medical equipment may also be excluded from coverage, such as walk-in bathtubs. Medical devices must be classified as durable medical equipment to qualify for Medicare coverage, so be sure to double check the approved list before investing in high-priced devices.

One common challenge for seniors is when doctors prescribe home health care services that Medicare deems excessive or unnecessary. In these cases, some seniors may opt to pay out-of-pocket for any overages. Alternatively, a physician may be able to work with Medicare representatives and approved home care agencies to develop alternative care plans that are fully covered.