Medicare & Insurance

To qualify for Medicare home health coverage, you must meet all four of the following conditions:

  • Your doctor must determine that you need medical care in your home and prepare a plan for your care at home.
  • The care you need must include intermittent (not full time) skilled nursing care, or physical therapy or speech language pathology services.
  • You must be homebound. This means you normally are unable to leave your home. If you do leave your home, it is with considerable and taxing effort. Absences from home must be infrequent, or of short duration, or to get medical care. You can still be considered homebound if you occasionally go to the barber or beauty shop or for a walk around the block or a short drive.
  • The home health agency serving you must be approved by the Medicare program.

Medicare Services Covered

  • Skilled nursing care either on an intermittent or part-time basis. Skilled nursing includes services and care that can only be performed safely and effectively by a licensed nurse.
  • Home health aide services either on an intermittent or part-time basis. Home health aide services include assistance with personal care such as bathing, using the toilet, or dressing. These types of services do not require the skills of a licensed nurse.
  • Physical therapy as often and for as long as it is medically necessary and reasonable. Physical therapy includes exercise to restore movement and strength to an injured arm or leg, and training in getting into and out of a wheelchair or bathtub.
  • Speech language pathology as often and for as long as it is medically necessary and reasonable. This type of therapy includes exercises to restore speech.
  • Occupational therapy as often and for as long as it is medically necessary and reasonable, even if you no longer need other skilled care. Occupational therapy helps you to achieve independence in daily living by learning new techniques for eating, dressing and performing other routine tasks.
  • Medical social services to assess the social and emotional factors related to your illness, counseling based on this assessment, and searches for available community resources.
  • Medical supplies like wound dressings.
  • Medical equipment. Medicare pays 80 percent of the approved ammount. An example of medical equipment would be a wheel chair or walker.

Medicare Services NOT Covered

  • 24-hour care at home.
  • Self-administered prescription drugs.
  • Meals delivered to the home.
  • Homemaker services such as shopping, cleaning and laundry.
  • Personal care provided by home health aides, such as bathing, toileting, or providing help in getting dressed when this is the only care you need. Medicare classifies this as “custodial care” because it could be provided safely and reasonably by people without professional skills and training. Medicare does not pay for “custodial care” unless you are also getting skilled care such as nursing or therapy and the custodial care is related to the treatment of your illness or injury.

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