If you have Medicare, you can use your home health benefits if you meet all the following conditions:
- You must be under the care of a doctor, and you must be getting services under a plan of care established and reviewed regularly by a doctor.
- You must need, and a doctor must certify that you need, one or more of the following.
The home health agency caring for you must be approved by Medicare (Medicare-certified).You must be homebound, and a doctor must certify that you're homebound. To be homebound means the following:
- Intermittent skilled nursing care
- Physical therapy
- Speech-language pathology services
- Continued occupational therapy
- Leaving your home isn't recommended because of your condition.
- Your condition keeps you from leaving home without help (such as using a wheelchair or walker, needing special transportation, or getting help from another person).
- Leaving home takes a considerable and taxing effort.
A person may leave home for medical treatment or short, infrequent absences for non-medical reasons, such as attending religious services. You can still get home health care if you attend adult day care, but you would get the home care services in your home.
If you meet the conditions above, Medicare pays for your covered home health services for as long as you're eligible and your doctor certifies you need them. If you need more than part-time or "intermittent" skilled nursing care, you aren't eligible for the home health benefit.
To decide whether you're eligible for home health care, Medicare defines part-time or "intermittent" as skilled nursing care that's needed or given on fewer than 7 days each week or less than 8 hours each day over a period of 21 days (or less) with some exceptions in special circumstances.
Hour and day limits may be extended in exceptional circumstances when your doctor can predict when your need for care will end.
What Medicare covers
If you're eligible for Medicare-covered home health care, Medicare covers the following services if they're reasonable and necessary for the treatment of your illness or injury:
What isn't covered?
Skilled nursing care
Physical therapy, occupational therapy, and speech-language pathology services.
Medical social services
Durable medical equipment, when ordered by a doctor, is paid separately by Medicare. This equipment must meet certain criteria to be covered. Medicare usually pays 80% of the Medicare-approved amount for certain pieces of medical equipment, such as a wheelchair or walker. If your home health agency doesn't supply durable medical equipment directly, the home health agency staff will usually arrange for a home equipment supplier to bring the items you need to your home.
Below are some examples of what Medicare doesn't pay for:
- 24-hour-a-day care at home.
- Meals delivered to your home.
- Homemaker services like shopping, cleaning, and laundry when this is the only care you need, and when these services aren't related to your plan of care.
- Personal care given by home health aides like bathing, dressing, and using the bathroom when this is the only care you need.
- Home Health and Alzheimer's Disease