How Do I Qualify for Home Care Under Medicare? 

Over the years, the home health care service industry has continued to grow as people are getting older and living longer in the United States. Today, many seniors choose to get their long-term medical care at home instead of in a hospital or nursing home. And, having access to short-term health care at home is also vital for a faster recovery from illness, injury, or surgery as patients transition from hospital care to their normal lives. 

Home health care services provide the elderly, disabled, or those who are recovering with assistance and support with medical needs and activities of daily living so they can age in place or get well in the comfort of their own home, closer to family members and friends. 

How do you qualify for home health care services through Medicare? 

Original Medicare Parts A (hospital insurance) and B (medical insurance) cover certain home health care services for those who meet the following qualifications:

  • You must be currently under the care of a physician who also prepares your plan of care and reviews it regularly. 
  • You must have a one-on-one meeting with the physician who plans your care either before you start home health care or within 90 days of starting it. 
  • You must first be certified as homebound by your physician. According to Medicare, being homebound means that you can’t leave home without the assistance of medical equipment or a person. 
  • Your physician certifies that you need intermittent skilled nursing care, physical therapy, occupational therapy, and/or speech-language pathology sessions. 
  • You must be under the care of a Medicare-affiliated doctor or health care provider. 
  • Your home health care services must be provided by a home health care agency that is Medicare-certified. 

After meeting the above-mentioned conditions, Medicare begins your coverage for as long as you need part-time or intermittent skilled home health care services. 

Original Medicare Parts A and B cover the following services you get at home from your agency if they are medically necessary :

  • Part-time or intermittent care from skilled nurses and home health aides
  • Physical therapy sessions
  • Occupational therapy sessions
  • Speech-language pathology sessions
  • Social services regarding medical issues
  • The rental or purchase of durable medical equipment for your use at home
  • Medical supplies you use in your home
  • Osteoporosis injections for women

Even if you qualify for home health care services, Medicare won’t pay for 24-hour care, delivered meals, home-keeping services that aren’t associated with your care plan, or custodial care (if it’s the only type of care you need). Custodial care includes activities of daily life such as bathing, going to the bathroom, hygiene, and other personal care.

Original Medicare Part A pays for 100 percent of the home health care services it covers. Original Medicare Part B, which covers durable medical equipment and medical supplies, pays 80 percent of the final approved cost. You pay the remaining 20 percent after meeting your annual Part B deductible. 

If you have a Medicare Advantage (MA) plan, your provider must cover home health care services if you are eligible under the same criteria as listed above. However, depending on the type of Medicare Advantage plan you have, you may need to use a home health care agency that is included in your plan’s network of providers. You may have additional coverage that includes other services not included in Original Medicare’s coverage. 

If you aren’t sure what restrictions or additional benefits your MA plan includes, call your provider for more information before signing up for home health care.

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