Medicare covers home health services, but only for beneficiaries who meet strict eligibility requirements. In order to qualify, you must have Medicare homebound status.
Home Care Medicare Coverage
CMS says that home health refers to a range of healthcare services for illnesses or injuries that you can receive in your home. Eligible home health services are covered under Medicare Part A and Medicare Part B as long as you need part-time or intermittent skilled services and you are considered homebound.
Both home health services and equipment needed for home health services may be covered, including the following:
- Medically necessary part-time or intermittent skilled nursing care, such as wound care, injections or monitoring serious illness
- Part-time or intermittent home health aide care, such as help with walking, changing bed linens, bathing, grooming or feeding, only if you are also receiving skilled nursing care, physical therapy, speech-language pathology services, or occupational therapy
- Physical therapy
- Occupational therapy
- Speech-language pathology services
- Medical social services
- Injectable osteoporosis drugs (for women)
- Durable medical equipment
- Medical supplies for use at home
- Disposable negative pressure would therapy devices
Note that certain things are not covered. For example, Medicare doesn’t cover 24-hour-a-day care. Home meal delivery and homemaker services that are unrelated to your care aren’t covered, either, so you can’t use Medicare to cover things like shopping and cleaning even if you are sick.
Custodial and personal care services to help with daily living activities like bathing and dressing are only covered if you’re also receiving medically necessary care, such as skilled nursing services or physical therapy. Seniors who need long-term care services are sometimes surprised that this is not normally covered under Medicare.
Why Does the Medicare Homebound Status Matter for Home Health Services?
Home health services are attractive to many people dealing with health issues. According to CMS, home healthcare is typically less expensive and more convenient that the care you would receive in a hospital or skilled nursing facility, but it is just as effective.
Let’s face it – a hospital isn’t the most comfortable place to stay. While you might need to stay in a hospital for a few days, if your recovery is going to take weeks or even months, you’d probably rather return to the comfort and familiarity of your own home.
Unfortunately, even though home healthcare may be less expensive than in-patient care, it’s still expensive, and the average person may not be able to afford it without health insurance coverage. According to A Place for Mom, the national hourly rate for in-home care is $30 as of 2024. Even if you only need care for 20 hours a week, that’s $2,400 over a period of four weeks. If you need more care, the costs will increase.
If Medicare covers home health services, there may be no out-of-pocket costs. As a result, it’s important to meet Medicare’s eligibility requirements, and that includes qualifying as homebound.
What Are the Medicare Homebound Guidelines and Criteria?
To be considered homebound under Medicare’s definition, you need to meet the following criteria:
- You have trouble leaving your home without help because of an illness or injury, for example, if you need to use a cane, a wheelchair, a walker, or crutches, or if you require special transportation or help from another person.
- Leaving your home is not recommended due to your condition.
- You’re normally unable to leave your home because doing so is a major effort.
In addition to meeting the above criteria, you must require part-time or intermittent skilled services in order to qualify for Medicare coverage for home health services.
Medicare says that you can qualify for homebound status if you occasionally leave your home for short and infrequent non-medical reasons, for example, to attend weekly religious services. However, if you frequently leave to go shopping, meet with friends, have dinner out, or see movies, you will likely have a hard time convincing Medicare that it is difficult for you to leave your home and that you therefore need home health services.
How Can You Receive Care?
Even if you’re sure that you meet the eligibility requirements, you have to go through the official process before you can receive coverage for home health services.
- You must receive a face-to-face assessment from a doctor, nurse practitioner or other healthcare provider.
- The healthcare provider must then order your care.
- You must receive care from a Medicare-certified home health agency.
If you think you need home health services, talk to your doctor. If your doctor agrees, ask your doctor for a list of Medicare-certified home health agencies in your area. If you are scheduled for surgery and you think you will need home health services after your surgery, talk to your doctor ahead of time about your concerns.
To make sure your home healthcare services are fully covered, verify that the home care agency is approved by Medicare. Also make sure all of the services you’re receiving are covered. Medicare enrollees pay $0 for covered home healthcare services, but some services may not be covered. (Not that there are out-of-pocket costs for medical equipment needed for home care; enrollees pay the Part B deductible and then 20% of the approved cost.)
Medicare Homebound Status Examples
Whether or not you qualify for coverage will depend on your health provider’s assessment of your needs and Medicare’s determination of coverage. However, based on Medicare’s criteria, it’s possible to consider scenarios in which coverage is or is not likely.
- Scenario One: Mary is injured in a fall and requires hospitalization and surgery. After being released from the hospital, Mary cannot move around without a walker and assistance, and she needs physical therapy. She does not leave the house, and she also needs help with daily activities like bathing. In this case, Mary appears to meet the eligibility requirements because she experienced an injury and needs physical therapy as a result, and she has trouble leaving the house. As long as her doctor says she needs home care, it seems likely that the order will be approved.
- Scenario Two: Tom is having trouble caring for himself. He has severe mobility issues, and he wants assistance with daily activities, such as bathing and feeding. In this case, Tom is unlikely to qualify for home health services under Medicare because he only needs personal care services, not medically necessary care, and his needs are not part-time or intermittent in nature.
What If You Have Medicare Advantage or Medigap?
Your coverage may be different if you have a private Medicare plan.
- If you have Medicare Advantage, your benefits and out-of-pocket costs may be different. Depending on your plan, you may have benefits that are not covered under Original Medicare, such as meal delivery service. You may also need to use home health agencies that are in your plan’s network in order to qualify for coverage. Check with your plan to verify your coverage and eligibility requirements.
- If you have Medigap, also called Medicare Supplement Insurance, you may have additional coverage to help with some out-of-pocket costs. Provide your Medigap coverage information to your providers.
Navigating Medicare’s homebound status requirements can be confusing. The most important thing is to talk to your provider and check with your plan to determine whether you are eligible. If you think you may need home services in the future, this is good thing to consider when comparing your plan options. An agent can help you with this.