Medicare And Home Healthcare

Medicare And Home Healthcare

This topic covers something that is growing in popularity, home health care. Medicare beneficiaries have three choices when it comes to rehabilitation from an illness or injury, inpatient at a skilled nursing facility, outpatient therapy with a specialist, or receiving skilled care at their home.

In simple terms, the main goal of home health care is to treat an illness or injury at home so the beneficiary can get better and regain their independence.

What’s Covered?

• Intermittent skilled nursing care (not full-time care)
• Physical therapy, occupational therapy and speech-language pathology services
• Home Health Aide services
• Medicare Social services
• Medical supplies

Some examples of skilled care include would care for sores or a surgical wound, patient and caregiver education (if the caregiver isn’t part of the home health care agency), IVs or nutrition therapy, injections, and monitoring serious illness and unstable health status.

What’s Not Covered?

Medicare does not pay for:

• 24-hour-a-day care at home
• Meals delivered to your home (although some Medicare Advantage plans may provide post-discharge meals)
• Homemaker services like shopping, cleaning and laundry
• Custodial, or personal care, like bathing, dressing, and using the bathroom when this is the only care you need.

These are also called activities of daily living and are considered part of the care that you receive should you need Long Term Care, which Medicare does not cover.

According to the Medicare & You Handbook (page 49-50, 2020 version) states that Medicare does not cover Long Term Care, sometimes called long-term services and supports.

This includes non-medical care for people who have chronic illnesses or disabilities. Most Medicare insurance plans, including Medicare supplement insurance, do not pay for this care either. If a Medicare beneficiary is concerned about covering long-term care, there are other resources available.


You’re under the care of a doctor, and you’re getting services under a plan of care
You need, and a doctor certifies that you need, one or more of:

  • Intermittent skilled nursing care (other than drawing blood)
  • Physical Therapy
  • Speech-language pathology services
  • Continued occupational therapy
    Your doctor certified that you’re homebound, meaning:
  • You have trouble leaving your home without help because of an illness or injury, or leaving your home isn’t recommended because of your condition, or
  • You’re normally unable to leave your home, but if you do it requires a major effort
    The home health agency caring for you is certified by Medicare

Plan of Care

In order for Medicare to approve of a beneficiary’s home health care services, they must be under a plan of care that is established by their physician. This so-called game plan must include all of the following items:

• What services will be needed
• Which healthcare professionals should give these services (like a physician, nurse practitioner, therapist or other specialist)
• Visit schedule
• How often services will be required
• Needed medical equipment
• What results your doctor expects from the treatment

If a doctor doesn’t believe there will be some level of improvement, or that the beneficiary will need services for longer than 60 days, they may recommend long-term services instead.

After a plan of care has been established, the home health agency will schedule an in-home appointment with the beneficiary to talk about their needs and ask questions about their health.

The agency will also coordinate with their doctor at the beginning and through the treatment process. It’s important that the home health staff see the beneficiary as often as the doctor has prescribed.

What to Expect – this is just a sample list of things the beneficiary should expect if they receive Medicare-approved home health services.

Home Health Care Costs

The eligibility criteria for home health care is rigorous and thorough, that’s due to the fact that Original Medicare will pay for 100% of approved home health services with a few exceptions:

• 20% of the Medicare-approved amount for Medicare-covered equipment, like wheelchairs, walkers, hospital beds, and oxygen equipment, for example.
• Any non-Medicare covered services or supplies
It’s important for the beneficiary to ask the agency about the services that Medicare will pay for and what they won’t pay for from the start. It’s the responsibility of the home health agency to notify the beneficiary in writing of the cost of the services before starting care.

Advance Beneficiary Notice of Noncoverage (ABN)

Before the home health agency performs any service or provides any supplies that may not be Medicare covered, they must give the beneficiary an ABN which states the service/supply, an explanation of why Medicare may not pay, and an estimated cost for that item.

The beneficiary is required to sign the notice before the service/supply is given by the agency. Receiving an ABN from the agency does not mean the service/supply isn’t covered, it just means there’s a chance that Medicare may not pay.

Comparing Home Health Agencies

Beneficiaries must receive services from a Medicare-certified home health care agency. Because of this certification requirement, beneficiaries can search and review the agencies in there area through the website.

The site will give information about all Medicare-certified facilities include contact information, services offered, date of Medicare certification, type of ownership (for profit, government, non-profit) and star ratings on quality and beneficiary reviews.

Home Care vs. Home Health Care

Home Care, or non-medical/custodial care, is not covered by Medicare. Beneficiaries that receive home health care may also need some level of Home Care and would be required to pay for those services out of pocket if they do not have coverage through a separate insurance policy. Many Long Term Care Insurance and Short Term Care Insurance plans pay for Home Care services.

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