Who qualifies for home health care? Medicare’s rules in plain words

Families often first hear the words “home health” at a hospital discharge, when a lot is happening at once. The questions come later, at the kitchen table. Does Mom qualify? Will Medicare pay? Does she have to stay inside all day? This note answers them with Medicare’s own rules, in the order families tend to ask.

The short answer

Medicare pays for home health care when all of these are true.¹

• A doctor or another allowed provider has ordered the care, and a plan of care is in place that they review regularly.
• The person needs skilled care part time or now and then: nursing, physical therapy or speech therapy. Occupational therapy counts too, once one of the others has started.
• The person is homebound, the way Medicare defines it.
• A doctor or another allowed provider has seen the person in person and confirmed that home health is needed.
• A Medicare-certified home health agency gives the care.

If all five hold, covered home health services cost nothing.¹ The rest of this note explains each one, because the words carry more meaning than they seem to.

What homebound means, and what it doesn’t

Homebound is the condition families ask about most, and the one most often misunderstood. It doesn’t mean bedbound, and it doesn’t mean never leaving the house.

Medicare’s manual sets two tests, and a person must meet both.²

The first is about getting out the door. The person needs help to leave home, such as a cane, a walker, a wheelchair, special transportation or another person. Or their doctor has advised against leaving home because of their condition.

The second is about what leaving costs them. They normally aren’t able to leave home, and when they do, it takes a considerable and taxing effort.

Leaving home now and then doesn’t end eligibility. Medicare says absences for medical care are fine, and so are short, infrequent outings that aren’t medical, like attending religious services.¹ Its manual names adult day care, outpatient dialysis and outpatient chemotherapy or radiation as absences that don’t count against someone.²

If you’re unsure whether your loved one fits, describe a normal day to the intake nurse: how they get to the bathroom, whether they can manage the front steps, what happened the last time they went to the store. That picture answers the question faster than any checklist.

Skilled care, part time

Home health is skilled care, given by licensed nurses and therapists, in visits. It isn’t round-the-clock help.

Skilled nursing at home covers things like wound care, teaching the patient and family how to manage a condition, IV or nutrition therapy, injections, and watching a serious or unstable condition closely.¹ Physical, occupational and speech therapy are covered when their conditions are met, and a medical social worker can help with the practical side of illness.¹

Part time has a number attached. Medicare usually covers up to 8 hours a day of combined nursing and aide care, up to 28 hours a week, and sometimes up to 35 hours a week for a short period when the provider says it’s needed.¹ Someone who needs care around the clock doesn’t qualify for home health, though they may qualify for other kinds of care.

Home health aides help with bathing and dressing, but Medicare pays for an aide only while the person is also getting skilled care.¹

Getting better isn’t the only reason Medicare pays

Many families have heard that Medicare stops paying once a patient stops improving. That isn’t the rule.

In 2013 a federal court in Vermont approved the settlement in Jimmo v. Sebelius. CMS’s fact sheet on it is plain: “A beneficiary’s lack of restoration potential cannot, in itself, serve as the basis for denying coverage.”³ What matters is whether the care needs a skilled professional and is reasonable and necessary. Skilled care that keeps someone from getting worse can qualify. Care that someone without a license could give safely doesn’t.³

For a person with Parkinson’s disease, or after a stroke, that difference decides whether therapy continues.

What Medicare covers at home

When the conditions are met, Medicare covers:¹

• Part-time or intermittent skilled nursing
• Physical therapy, occupational therapy and speech-language therapy
• Medical social services
• Part-time or intermittent home health aide care, alongside skilled care
• Durable medical equipment and medical supplies for use at home
• Injectable osteoporosis drugs for women who meet certain criteria

What it doesn’t cover

Medicare doesn’t pay for:¹

• Care around the clock at home
• Meals delivered to the home
• Homemaker help like shopping or cleaning, when it isn’t part of the care plan
• Personal care like bathing or dressing, when that’s the only help someone needs

What it costs

For covered home health services, the patient pays nothing.¹ Equipment like a walker or a hospital bed is different: after the Part B deductible, the patient pays 20% of the Medicare-approved amount.¹

If an agency plans to give something Medicare won’t cover, it has to tell you in writing first, on a form called an Advance Beneficiary Notice, so a bill never arrives as a surprise.¹

If you have a Medicare Advantage plan or Medi-Cal

HealthView works with Medicare, Medi-Cal, CalOptima and other managed care plans. Plans other than Original Medicare cover home health too, but each sets its own steps and its own network. Our intake team checks a plan’s rules in one call, so families don’t have to.

How care starts with HealthView

There are two ways in, and you only need one.

You can call (562) 600-1000. A person answers any hour, nights and weekends included. Tell us what’s going on in your own words. Or your doctor, hospital or facility can send us a referral.

Either way, intake gets back to you the same day. We reach the doctor, check the insurance and gather the records, so your family’s job is to be there, not to do paperwork. A nurse’s first visit happens within 48 hours of the referral or of coming home, or on the start date the doctor orders.