Who pays for home health: Medicare, Medicare Advantage and Medi-Cal

For most families, the first question about home health is the bill. Under Original Medicare the answer is short: people who qualify pay nothing for covered home health services.¹ It takes more explaining with a Medicare Advantage plan, with Medi-Cal, with both at once, or with VA coverage. This note goes payer by payer and ends with the questions to ask before care starts.

The short answer

• Original Medicare pays the full cost of covered home health services. Medical equipment costs 20% of the Medicare-approved amount after the Part B deductible.¹
• Medicare Advantage plans have to cover what Original Medicare covers, but they can require an agency in their network and approval ahead of time, and costs depend on the plan.^2,3
• Medi-Cal covers home health a physician prescribes under a written plan, with prior authorization after the first evaluation visit.⁴
• Medicare and Medi-Cal together: Medicare pays first, and Medi-Cal may pay for some things Medicare doesn’t.⁵
• Veterans enrolled in VA health care can get skilled home health through the VA when they qualify, and the VA tells them about any copay.⁶

Original Medicare

Under Original Medicare, covered home health services cost nothing.¹ That includes the nursing and therapy visits, medical social services and the home health aide visits that go with skilled care. Medical supplies the plan of care calls for, like wound dressings or catheter supplies, are covered as part of home health. Drugs aren’t part of it.⁷

Medical equipment is the exception. After the Part B deductible, the person pays 20% of the Medicare-approved amount for Medicare-covered equipment such as a walker.¹

Before care begins, the agency should tell the person, out loud and in writing, how much of the bill Medicare will pay.² If it expects Medicare won’t pay for a service or supply, it has to give an Advance Beneficiary Notice first, so the person can decide whether to get it and pay for it.^1,2

Original Medicare doesn’t pay for 24-hour care at home, meal delivery, homemaker services that aren’t part of the care plan, or personal care when that’s the only care the person needs.¹

Medicare Advantage

A Medicare Advantage plan has to cover the home health services Original Medicare covers, and since 2024 it has to follow Original Medicare’s coverage rules when it decides what’s covered.³

Two things work differently. The plan may require an agency in its network.² And it may require prior authorization, which means approval before care starts. Medicare limits how plans use it: only to confirm a diagnosis or other medical criteria and that care is medically necessary, and an approval for a course of treatment has to last as long as the treatment is medically reasonable and necessary.³

Someone who switches into a new Medicare Advantage plan in the middle of treatment gets a transition period of at least 90 days, when the new plan can’t require prior authorization for that treatment.³ What the person pays depends on the plan, so check the plan’s membership materials or call the number on the card before care starts.²

Medi-Cal

Medi-Cal covers home health services a physician prescribes, given in the person’s home under a written treatment plan the physician reviews every 60 days.⁴ Covered services can include part-time skilled nursing, therapy, medical social services, home health aide services, medical supplies and medical appliances.⁴

One evaluation visit in six months is covered without prior authorization. More visits need prior authorization, supported by the physician’s signed plan.⁴ If the person is in a Medi-Cal health plan, call the plan and ask how it handles approval.

Medicare and Medi-Cal together

People with both are called dual eligible. Medicare pays first for Medicare-covered services, and Medi-Cal pays after Medicare and any other insurance.⁵ Medi-Cal may also pay for some services Medicare doesn’t cover.⁵ With full Medi-Cal coverage, the state pays the person’s Medicare Part B premium too.⁵

Veterans

The VA’s Skilled Home Health Care program covers short-term care, and can support ongoing needs, through community home health agencies under contract with the VA. Enrolled veterans can get it when they’re eligible for community care and meet the clinical need.⁶ The VA social worker or case manager helps the veteran learn whether there’s a copay.⁶

Private insurance and paying privately

Employer and private plans cover home health in different ways, so call the number on the card and ask the questions below. Some families add private-pay home care for help that Medicare doesn’t cover, like a daily bath or someone overnight. That’s a separate service with its own costs. Home health or home care explains the difference.

Questions to ask before care starts

• Is the agency in our plan’s network?
• Does the plan need to approve home health first, and who asks for the approval?
• What will we owe for the visits, the equipment and the supplies?
• Will we get the costs in writing before care starts?
• If coverage ends, how much notice will we get, and how do we appeal? How long home health lasts explains the notices.