Does Medicare Cover Home Health Care? Eligibility, Limits & Costs

Does home health care come under the Medicare? Yes, though there are significant restrictions that come as a surprise to families. Home health care in Medicare is not considered long-term assistance with activities of daily living but instead short-term, medically necessary services following a hospital stay or to manage a specific condition. To qualify, you must be homebound, need skilled care (nursing or therapy), and be under the active care of a doctor who certifies your need. Personal care such as bathing, dressing and preparing meals are only covered when they form part of a larger skilled care plan. Children in long-term custodial care are not taken care of.

This guide explains what medicare home health benefits include, strict eligibility requirements, what they do not cover and how home health and medicaid relate to each other in terms of long term care. Medicare.gov, CMS, and KFF are sources of information. 

Medicare home health care: what it is

Home health medicare is the skilled medical care that is done at your home by licensed professionals (nurses, physical therapists, occupational therapists, speech-language pathologists, and home health aides) when you can not easily leave home to receive treatment. The care should be considered as a short term care and related to a particular medical necessity, and not continuous assistance with activities of daily living.

Part A (following some qualifying hospital stay) and Part B (among those who do not have a recent hospital stay) are the areas of home health that Medicare covers. When you qualify, the amount you normally pay out of pocket is 0 towards covered services. Medicare provides the home health agency with direct payment in a prospective payment system.

The CMS data indicates that each year approximately 3 million Medicare beneficiaries are provided with home health care. One of the most cost-effective benefits in the Medicare program, the benefit allows recovery and rehabilitation to occur at home instead of a longer stay in a hospital or skilled nursing facility. 

Medicare home health benefits: what's covered

Medicare home health care coverage includes:

• Skilled nursing care: Wound care, IV medications, injections, catheter care, monitoring of unstable conditions

• Physical therapy: Restoring strength, mobility, balance after injury or surgery

• Occupational therapy: Recovery of daily skills after stroke, surgery, or illness

• Speech-language pathology: Speech and swallowing therapy after stroke or other neurological events

• Medical social services: Helping you and your family connect to community resources

• Home health aide services: Limited personal care (bathing, dressing) when part of a skilled care plan

• Medical supplies: Wound care supplies, catheters, ostomy supplies (delivered with care)

• Durable medical equipment: Wheelchairs, walkers, hospital beds (covered separately under Part B at 20% coinsurance)

The home health aide piece is where families get confused. Medicare covers home health aide services only when you also need skilled nursing or therapy. The aide is part of the care plan, not the entire plan. If your only need is help bathing, dressing, or meal prep, Medicare doesn't pay for it.

For specific per-hour rates, see our Medicare home health care cost per hour guide.

Medicare home health care eligibility: the four requirements

Medicare home health care eligibility requires meeting all four of the following criteria. Missing any one disqualifies you.

1. You must be under the care of a doctor. Your physician must certify that you need home health and create a plan of care that's reviewed regularly. The doctor can be your regular primary care provider, a specialist, or a hospitalist who saw you during a recent inpatient stay.

2. You must need skilled care. This means nursing care or therapy that requires a licensed professional. Help with daily activities (bathing, dressing, meal prep) by itself doesn't qualify. Skilled care must be intermittent (not full-time, not 24/7) and part-time, generally meaning fewer than 8 hours per day and 28 hours per week (with some flexibility up to 35 hours).

3. You must be homebound. This is one of the most-misunderstood rules. Homebound doesn't mean bedridden. It means leaving home requires considerable effort, and your doctor confirms that leaving regularly is medically inadvisable. You can still leave home occasionally for medical appointments, religious services, family events, and short outings without losing eligibility. You're not homebound if you can routinely drive or use public transportation without significant effort.

4. The home health agency must be Medicare-certified. Not every home health agency accepts Medicare. The agency must be certified by Medicare, and you should verify this before starting services. Medicare.gov's Care Compare tool lets you find Medicare-certified home health agencies in your area with quality ratings.

What home health care Medicare doesn't cover

Even when you qualify for medicare home health care, several services are excluded:

• 24-hour-a-day care at home

• Meal delivery (Meals on Wheels and similar)

• Homemaker services if that's the only care needed (cleaning, laundry, errands)

• Personal care (bathing, dressing) if that's the only care needed

• Long-term custodial care without skilled need

The largest disparity is the long-term custodial care. Most individuals think that Medicare will finance continued in-home assistance as their parent grows older. It won't. Custodial care of activities of daily living, when no skilled medical service is required, does not fall under the home health benefit under Medicare.

In long-term custodial in-home care, the primary payment options include out-of-pocket private pay, long-term care insurance (unless purchased prior to the need arising), Veterans benefits (to qualifying veterans), and Medicaid to low-income beneficiaries through Home and Community-Based Services (HCBS) waivers.

The coverage of in-home care in the long-term setting of the State Medicaid programs is very different. Majority of states have some form of in-home Medicaid coverage available to dual-eligible beneficiaries, under HCBS waivers, although waiting lists may be long and the eligibility requirements are restrictive.

How does Medicare pay home health agencies?

Medicare reimbursement on home health works is through a prospective payment system. Medicare directly pays the home health agency a fixed 30-day payment to each beneficiary, depending on the need assessment of the patient. The agency then gives whatever skilled care, therapy and aide hours the plan of care by the doctor demands in that payment.

This generally translates to no out of pocket costs of home health services to the beneficiary. Home health visits covered by Medicare do not apply to the Part B deductible and there is no coinsurance.

The exclusions include durable medical equipment (wheelchairs, hospital beds, oxygen) ordered along with the home health, which is a Part B deductible. That 20% is covered by a Medigap plan. 

Medicare home health care vs Medicaid home health

For people who qualify for both Medicare and Medicaid, the two programs cover different home care needs.

Dual-eligible beneficiaries can use both programs in sequence. Medicare covers the immediate post-hospital recovery period (typically 30 to 60 days). Medicaid then takes over for ongoing custodial needs through state-specific HCBS waiver programs.