Medicare and Insurance
Does Medicare Cover Home Health Care? Homebound Rules and What's Covered
Yes. Original Medicare covers home health care when four conditions are met. You need part-time or intermittent skilled care, you're homebound, a doctor or allowed provider certifies that need after seeing you, and a Medicare-certified home health agency provides the care (Medicare.gov). When you qualify, you pay nothing for covered home health services.
That's the short answer. The details are where families get stuck, especially the word "homebound," which doesn't mean what most people think it means.
Key Takeaways - Medicare Part A and Part B cover home health when you need part-time skilled care, are homebound and have a provider's certification (Medicare.gov). - Homebound doesn't mean bedbound. You can still go to medical appointments, religious services, adult day care and occasional short outings. - A provider must see you face to face within 90 days before or 30 days after care starts (CMS). - Covered services cost $0. Medical equipment is usually 20% after the Part B deductible (Medicare.gov). - Medicare doesn't pay for 24-hour care, meal delivery, or personal care when that's the only help you need.
The Four Requirements for Medicare Home Health
Medicare.gov spells out the eligibility rules in plain terms. Each one has to be true.
Skilled care is care that has to be given or supervised by a licensed nurse or therapist to be safe and effective.
- You need skilled care on a part-time or intermittent basis. That means services that need a nurse or therapist, such as wound care, injections, IV therapy or physical therapy.
- You're homebound. The next section explains this in full.
- A doctor or allowed provider has seen you and certified the need. They also sign off on your plan of care.
- A Medicare-certified home health agency provides the care.
Medicare.gov also states that "You won't qualify for home health services if you need more than part-time or intermittent skilled care" (Medicare.gov). Someone who needs a nurse at the bedside all day usually needs a different setting, such as a skilled nursing facility.
What "Homebound" Really Means
Homebound is Medicare's term for a person who can leave home only with real difficulty. It's the requirement families misread most often.
The CMS policy manual sets out two criteria, and you must meet both (CMS Medicare Benefit Policy Manual, Chapter 7).
Criterion one. You meet at least one of these. - Because of illness or injury, you need a cane, walker, wheelchair, crutches, special transportation or another person's help to leave home. - Leaving home is medically not recommended because of your condition.
Criterion two. You meet both of these. - You normally can't leave home. - Leaving home takes "a considerable and taxing effort."
What homebound doesn't mean
Being homebound doesn't mean you can never go out. Medicare.gov says you can still leave home for medical treatment, religious services and adult day care, and for short, infrequent non-medical outings like a trip to the barber or a family event (Medicare.gov).
Consider an 82-year-old in Reseda who just had a hip replacement. She uses a walker, needs her son's help to get into the car, and is exhausted after a short trip to the surgeon. She attends church on Sunday with help. She's very likely homebound under these rules, even though she leaves the house a few times a week.
The Doctor's Role and the Face-to-Face Visit
Home health starts with a provider's order. Medicare requires a physician or allowed practitioner to certify that you're homebound and need skilled care, and to approve a plan of care.
They also have to see you. A face-to-face encounter is an in-person or approved telehealth visit about the condition that makes home health necessary. CMS requires one that takes place no more than 90 days before the start of home health care, or within 30 days after it (CMS Medicare Benefit Policy Manual, Chapter 7). A hospital visit counts. So does an office visit, and in some cases a telehealth visit (Medicare Rights Center).
If your family member was just discharged, the hospital doctor often handles this before they leave. If care is starting from home, call the primary care doctor's office and ask about a home health referral.
What Medicare Covers at Home
When you qualify, Medicare.gov lists these covered services (Medicare.gov).
- Part-time or intermittent skilled nursing, such as wound care, injections, IV or nutrition therapy, monitoring of unstable health, and patient and caregiver teaching
- Physical therapy, occupational therapy and speech-language therapy
- Medical social services
- Home health aide care, but only when you're also getting skilled nursing or therapy
- Injectable osteoporosis drugs for women who meet certain criteria
- Durable medical equipment and medical supplies for use at home
How many hours are covered
Medicare.gov says skilled nursing and aide services combined are usually limited to 8 hours a day and 28 hours a week. A provider can approve short-term increases up to 35 hours a week. There's no cap on the number of visits as long as you keep qualifying (Medicare.gov).
Improvement isn't required
A common myth says Medicare stops paying once a patient "plateaus." The CMS manual says otherwise. Coverage for skilled care "does not turn on the presence or absence" of a patient's potential for improvement, and skilled care can be covered to "maintain the patient's current condition" or slow decline (CMS Medicare Benefit Policy Manual, Chapter 7). Someone with advanced heart failure or a slow-healing wound can still qualify.
What Medicare Doesn't Cover
Medicare.gov lists these exclusions for home health (Medicare.gov).
| Not covered | What it means for families |
|---|---|
| 24-hour care at home | Round-the-clock help has to come from family, private pay or another program |
| Meals delivered to your home | Look into local senior meal programs |
| Homemaker services | Cleaning or shopping not tied to the care plan isn't covered |
| Custodial or personal care alone | Help with bathing or dressing isn't covered when it's the only care you need |
This is where non-medical home care often fills the gap. Our article on what a skilled nursing home health visit includes compares the two in detail.
What You'll Pay
For covered home health services, Medicare.gov is direct. "You pay nothing for covered home health services." For durable medical equipment, such as a walker or hospital bed, you pay 20% of the Medicare-approved amount after the Part B deductible (Medicare.gov).
Before care starts, the agency should tell you, both verbally and in writing, which services Medicare won't cover and what you'll owe. If an item isn't covered, the agency should give you an Advance Beneficiary Notice before providing it (Medicare.gov).
If you have Medicare Advantage
Medicare Advantage plans must cover home health care, but rules for prior authorization and which agencies are in network vary by plan. Call the number on the back of your card before care starts, or ask the agency to verify benefits for you.
Recertification Every 60 Days
Home health is ordered in 60-day periods. If you still need skilled care at the end of a period, your provider can recertify you. The Medicare Rights Center notes that a new face-to-face visit isn't required for recertification (Medicare Rights Center).
Throughout care, the nurse keeps your doctor updated. If your needs change, the plan changes too.
Practical Steps to Get Started
- Ask the hospital discharge planner or your doctor for a home health referral.
- Confirm the face-to-face visit happened, or schedule one.
- Check that the agency you choose accepts your insurance and serves your area.
- Gather your medication list, insurance cards and discharge papers before the first nursing visit.
- Ask the agency what you might owe, in writing.
Families caring for someone after a hospital stay may also want our guide to the first 30 days after discharge.
Sources and Methodology
Editorial note. This article summarizes rules published on Medicare.gov and in the CMS Medicare Benefit Policy Manual, Chapter 7, with additional detail from the Medicare Rights Center. Medicare policy changes, and individual plans differ, so confirm your coverage with Medicare (1-800-MEDICARE) or your plan. Learn more about Violet Home Care Agency.
This article is general information, not legal, insurance or medical advice. If someone is having a medical emergency, call 911.
Get Help Figuring Out Eligibility
If you're not sure whether your parent or spouse qualifies for home health in the San Fernando Valley, we can help you sort through the requirements and coordinate with the doctor. Contact our Canoga Park office at 20944 Sherman Way, Suite 206-A. We serve Canoga Park, Woodland Hills, West Hills, Winnetka, Reseda, Chatsworth, Northridge, Tarzana, Encino, Van Nuys, Calabasas and Porter Ranch.
