Are you wondering who qualifies for home health care services? As a Medicare recipient, you need to be enrolled in Part A and/or Part B AND meet the following conditions for home health care services coverage.
Medicare Qualifications For Home Health Services Coverage
Original Medicare eligibility for in home health care services depends on the recipient’s medical status. A physician should be regularly treating the person and have a plan of care. This plan of care must be reviewed every few months.
Medicare requires that people who receive the home health benefit be considered homebound.
What Is Considered Homebound?
A Medicare recipient must be considered homebound by the treating physician to receive coverage for home health services from Medicare.
Medicare considers someone is homebound if medical equipment or another person must help the beneficiary with their mobility. For instance, they need help walking from someone else, crutches, a walker, wheelchair, etc.
A homebound person may also suffer from health risks if they leave the house.
Those who may endure taxing effort to leave the house can also be considered homebound.
A doctor must evaluate a Medicare beneficiary’s condition and certify the person is homebound. Recertification is required every 60 days.
Homebound individuals are allowed to:
- Go to the doctor’s office for medical treatment.
- Participate in religious services.
- Attend a licensed or accredited adult day care center.
- Engage in family-related events, such as reunions, funerals and graduations.
- Take trips to the barber and salon.
In addition to being homebound, coverage is dependent on the need for intermittent skilled nursing care.
Eligibility for Skilled Nursing Care
Medicare will only pay for home health care services if the person’s treating physician recommends intermittent skilled nursing care (more than blood draws). This skilled nursing care may include one or more of the following therapy services:
- Physical Therapy
- Speech Therapy
- Occupational Therapy
Medicare is strict on what they want from skilled nursing services.
- The skilled nursing care services must be safe and effective for the person and should be managed by the physician.
- A skilled nursing facility must employ qualified therapists and other medical professionals to provide the services.
- The skilled services should be part-time and short term.
- Medicare will only pay for skilled nursing care services if the amount and frequency makes sense for the condition.
- The care providers must show the patient’s condition is improving with the services.
- The skilled nursing facility or home health agency must be certified by Medicare.
Durable medical equipment is often necessary for skilled nursing care services, and it is covered by the Medicare program.
Learn More: Who Qualifies for Home Health Care Services
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Medicare Advantage Plans for Home Health Care Services
A Medicare Advantage plan is a type of coinsurance that can help offset the costs of what Medicare Part A or Medicare Part B doesn’t cover. However, Medicare Advantage Plans do not offer long-term home health care coverage. They are similar to what Medicare covers when it comes to home health services.
Those who decide to use Medicare Advantage Plans to cover the costs of medical services, such as vision, dental and hearing have to pay a premium and may have copayments and deductible to pay. These plans are meant to offer more medical coverage for those who need it.
If you’re seeking additional health insurance coverage than what Medicare provides, you may want to consider Medicare Advantage plans. They are offered by private insurances and there are many insurance companies available to browse and consider. Each one has its own policies and rates, so it’s good to take time to research many of them to decide which one is best for your medical needs now and into the future.
What About Personal Care Services from a Home Health Aide?
Medicare does not cover personal care services, which could include assistance with activities of daily living, homemaker tasks, companionship and other home health aide services.
They will only pay for services offered by health care professionals, and often times, after a hospitalization for rehabilitation.
Those who require long-term care may be able to receive coverage from Medicaid or private insurance. Medicaid eligibility for home health services, nursing homes and assisted living depend on income and those income limits vary by state. Many seniors are not eligible for Medicaid benefits, so they need to turn to long-term care insurance company.
Many times, the cost of home health aide services is too expensive, so family members and other loved ones become caregivers.
Medicare Coverage for Home Health Care Services
If you’re looking for information on who qualifies for home health care services because you’re hoping to receive Medicare coverage for it, now you know that there are many factors involved in eligibility.
Your physician must certify that you need home health care to include skilled nursing care in the form of physical therapy, occupational therapy and/or speech therapy. You must be considered homebound and this status along with medical condition must be assessed regularly AND Medicare covers home health care services only for a short period of time.
1-800-Medicare and Medicare.gov offer assistance with understanding who qualifies for home health care services, but they are limited when it comes to understand the Medicare program, Medicare Advantage Plans, Medigap, and long term care insurance.
For help with all of your Medicare-related questions, turn to our Senior Advisors. We would be happy to help you learn, understand and choose the best solution for you based on your needs and desires. Contact us now.
This article was writen by Marcelina Hardy and was last updated on .
My name is Marcelina (Marcie) Hardy, and I’m a senior care advisor offering Medicare-approved home health care, nursing home, hospice, and long term hospital care options.