Who is Eligible for Home Health Care Under Medicare?

Home health nurse discussing Medicare with her patient.

Written by Amedisys

Medicare is a federal health insurance program that serves as a vital support system for people aged 65 and older.  Patients may be eligible for Medicare earlier if they have certain disabilities, End-Stage Renal Disease or ALS.  Among Medicare’s unique benefits is home health care, which provides skilled nursing, therapies and other care services to those with specific health needs.

Basic Eligibility for Medicare Home Health Care Benefits

To be eligible for Medicare home health care benefits, the patient must meet several key criteria to help determine if the patient’s condition and home environment warrant home health care benefits.

Patients may be eligible for home health if they meet the following criteria:

Being Homebound

A patient is homebound if they are unable to leave their home or must go through considerable effort when doing so, or that leaving home is not recommended because of their medical condition. Homebound status is determined by the patient’s primary care physician based on physical limitations, such as disabilities, surgery recovery, severe illness or cognitive impairment.

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Demonstrating a Medical Need

In addition to being homebound, the patient must require intermittent skilled nursing care or skilled therapy services.

Physician Approval/Face-to-Face Encounter

The patient’s physician must authorize home health care services and review the patient’s care plan regularly.

The patient must have the required face-to-face encounter with their physician within the timeframes required by Medicare. The encounter must also be related to the primary reason you need home health care.

Choosing Medicare-Certified Home Health Agency

The agency providing care must be certified by Medicare. 

Common Conditions Among Patients Requiring Home Health Care

Home health care services cater to a wide range of conditions commonly experienced by patients aged 65 and above. These conditions often require comprehensive care by an interdisciplinary team.

A few of the conditions commonly found among patients of home health care include:

  • Congestive heart failure, hypertension and other heart conditions
  • Diabetes and accompanying issues
  • Chronic obstructive pulmonary disease (COPD) and other lung conditions
  • Stroke
  • Cancer
  • Recovery from total knee or hip or other orthopedic procedures
  • Wounds related to pressure injuries or other conditions
  • Chronic kidney disease
  • Dementia, Alzheimer’s Disease or Parkinson’s Disease

A home health care plan tailored to a patient's needs can effectively address these conditions, providing the necessary support to promote well-being, independence and quality of life for patients while helping to avoid unnecessary hospitalizations.

Circumstances That May Lead to Discharge from Home Health Care

Several circumstances may negate a patient’s basic eligibility and lead to the termination of home health care. These factors include:

  • No longer homebound: The patient’s condition improves to a point where they are no longer considered homebound by their primary care physician.
  • No longer requires skilled care: The patient no longer requires skilled nursing care or therapy services initially determined to be necessary.
  • Patient reaches established goals: The patient achieves the health goals established at the beginning of the care plan.
  • Patient desire to discharge home health care services: The patient expresses the desire to discharge from home health.

Types of Care Covered Under Medicare Home Health Care

Medicare home health care provides a wide range of skilled nursing, therapy and support services to address the medical and therapeutic needs of eligible patients depending on their needs.

Skilled nursing care includes:

  • Observation assessment: Nurses conduct a comprehensive head-to-toe assessment to determine if the patient can receive care safely from home. During observation and assessment, the skilled nurse evaluates changes in the patient’s condition and updates the patient’s physician to facilitate treatment plan changes. This includes monitoring the effectiveness of medications.
  • Hands-on care: Nurses provide care that requires medical expertise and training, such as wound care, catheter care, tube feeds, ostomy care, injection administration and other specialized treatments.
  • Teaching and training: Empowerment guides patients and their caregivers in managing their own health.
  • Medication administration: Nurses administer prescribed medications (injections and infusions), excluding oral medication, which is not covered as a skilled service.
  • Psychiatric nursing: Some home health agencies like Amedisys, in some markets, offer trained psychiatric nurses for mental health treatments.

Therapy services include:

  • Physical therapy helps patients manage pain and regain strength and mobility.
  • Speech therapy assists with speech and language disorders.
  • Occupational therapy aids patients in regaining or enhancing daily living skills (bathing, grooming, dressing and other self-care activities).

Additional dependent services are available once the patient has a qualifying need for skilled nursing or skilled therapy services, including:

  • Home health aides: Aide services assist the patient with hands-on personal care.
  • Medical social work services: Social workers help resolve social or emotional problems that impact the patient’s recovery or treatment plan.

Services Not Included in Medicare Home Health Care

It’s important to be aware of services not included in Medicare’s home health care benefit. Although some of these may be necessary for your needs, you don’t want to be in a situation in which you expect to have certain services covered but end up with a significant medical bill. Uncovered services include:

  • 24-hour care: Home health care is intermittent. Continuous, round-the-clock care is not provided.
  • Oral drug administration: Oral administration of medication is not covered. 
  • Homemaker services: This includes any non-medical assistance, such as housekeeping tasks and shopping assistance.

Supplemental Services Outside of the Medicare Home Health Care Benefit

Although Medicare covers core home health care services, certain services not covered by Medicare might be essential to a patient’s well-being. These home and community-based services may vary according to the patient’s location and program requirements. Patient eligibility is determined through a patient assessment with approval from a patient's primary care physician or social worker. Services like these include: 

  • Meals on Wheels
  • Homemaker services
  • Housekeeping
  • Shopping assistance

These non-medical services are generally funded through out-of-pocket payments or community resource programs. Patients eligible for Medicaid or Veterans Affairs (VA) benefits may receive additional support. To find out more, contact your insurance plan or a home health care agency that connects patients with these external resources. 

Costs for Medicare Home Health Care

Understanding associated costs is crucial for patients and their families when deciding to elect Medicare home health services. It’s always important to fully understand the cost of benefits from your agency of choice, but the following key points are a great place to start:

No Out-of-Pocket Costs for Medically Necessary Services

For eligible patients, Medicare covers the costs of all home health care services deemed necessary by the physician, ensuring that these patients do not have to pay out of pocket.

Transparency in Medicare Coverage

The home health care agency is responsible for informing the patient of all costs associated with Medicare coverage. This level of transparency allows patients to plan and manage their healthcare expenses.

Partial Responsibility for Medical Equipment

When a patient requires Medicare-covered medical equipment, Medicare may be responsible for covering 20 percent of the cost. Work with medical equipment provider to receive an estimate to help anticipate and manage out-of-pocket expenses.

Next Steps for Home Health Care

If you or your loved one has been diagnosed with a severe or chronic illness, open communication and timely action can significantly impact the quality of care and support. Take these recommended next steps if you think home health care is the right choice:

1. Facilitate open communication.

If possible, encourage your loved one to communicate their wishes and desires with you and other family members and caregivers. Ensure everyone involved is aware of your or your loved one’s preferences and goals for care.

2. Contact an agency for connections to resources.

A reputable agency can facilitate access to necessary resources. In addition to offering access to essential services, the right agency can provide comprehensive support for a seamless care experience.

3. Consider agencies with a full continuum of care.

A full continuum of care provides a comprehensive range of healthcare services that address an individual’s care needs across different stages of illness or recovery.

Choose an agency that offers a full continuum of care so you or your loved one can smoothly transition from one program to another, if necessary. This approach ensures they receive consistent, uninterrupted care tailored to their care needs.

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Home health eligibility under Medicare