Home Health Care
Check Medicare Eligibility
Medicare pays the costs of home health care for more than a third of the people who receive it. But there are limits on the amount of care that is covered — and to get any type of help with paying, the provider, the patient, and the care must all satisfy Medicare requirements.
Who Is Eligible?
Medicare is a federal health insurance program for people age 65 and older, some disabled people under 65, adults who receive Social Security payments, and those with end-stage renal disease.
Medicare coverage has two parts:
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Part A hospital insurance pays for most inpatient hospital care, some inpatient skilled nursing home care, some home health care, and hospice care.
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Part B pays for doctors’ services, outpatient hospital care, outpatient physical and speech therapy, some home health care, ambulance services, and some medical equipment and supplies. Those who don’t automatically qualify for Medicare can get its coverage by paying a premium.
For home health care services to be covered by Medicare, they must be performed by a Medicare-certified provider, and the patient must be homebound — meaning that leaving home takes considerable effort; be under a doctor’s care; and need skilled nursing care, or occupational, physical, or speech therapy “intermittently” — generally defined as less than eight hours a day and 28 hours per week.
Also, the home health care services provided must be: under a doctor’s supervision; performed as part of a home health care plan written specifically for that patient; and considered “medically reasonable and necessary” according to Medicare guidelines.
To find out more about eligibility, use the Medicare Eligibility and Enrollment Date Calculator.
What Is Covered?
Medicare pays a set amount of money for 60 days of an “episode of care.” Coverage includes part-time or intermittent:
- Skilled nursing care;
- Home health aide services for personal care, such as dressing and bathing, for patients who are also receiving skilled nursing care;
- Physical, speech, and occupational therapy; and
- Medical social services, such as counseling to find helpful community resources.
It also pays the cost of some medical supplies, such as wound dressings and a portion of some medical equipment, such as a wheelchair or walker.
What Is Not Covered?
Medicare does not pay for some of the care and services commonly considered to be part of home care, such as:
- 24-hour care at home;
- Home-delivered meals and homemaker services such as shopping, cleaning, and laundry; or
- Personal care provided by home health aides, such as help with bathing, using the toilet, or getting dressed if those are the only kinds of care required.
How To Apply
Those who already receive Social Security benefits are automatically enrolled in Medicare Part A and Part B the month they turn 65.
If you are at least 61 years and 8 months old and want to start benefits within the next four months, you can apply online for both Social Security and Medicare.
To apply for Medicare alone, call the Social Security Administration at 800-772-1213 or 800-325-0778 (TTY) or contact your local Social Security office.
Other Medicare-approved Plans
A number of plans, approved by Medicare but run by private companies, now also offer health and prescription drug coverage. For example, Medicare Advantage Plans generally provide Part A and B coverage, but charge different amounts for certain services — and may offer extra coverage for an extra cost. Other plans, including Medicare Cost Plans and Demonstration or Pilot Programs provide coverage for Parts A and B, with some also covering prescription drug costs.
While offered to increase the number of coverage options available to consumers, there are still confusing kinks in timing, coverage, and cost for these plans. For specific questions, contact the main Medicare office at 800-633-4227 or 877-486-2048 (TTY).
For more information on Medicare coverage of home health care, visit the Medicare Web site.
For more information on Medicare coverage and its costs, including free individual counseling, contact the local office of the Health Insurance Counseling and Advocacy Program (HICAP).
Medigap Coverage
Medigap insurance, or Medicare supplemental insurance, is designed to cover the “gaps” between what Medicare does and does not pay. In California, 12 standard Medigap plans are sold by private insurance companies, regulated by state and federal law, and must be clearly designated as Medicare supplements and identified by the letters A through J. For home health care, the most common gaps that may need and get this coverage include aide services that are provided on more than a part-time or intermittent basis or when there is no skilled care component.
For guidance on buying Medigap policies and an explanation of rights under them, see "Choosing a Medigap Policy — A Guide to Health Insurance for People with Medicare (PDF)."
Dual Coverage with Medi-Cal
Some people who qualify for Medicare benefits and have low income and asset levels may also qualify for full Medi-Cal coverage. For such people, known as “dual eligibles” or “Medi-Medis,” Medicare will first pay for the benefits it covers — and Medi-Cal will provide secondary coverage. And for those with dual eligibility, Medi-Cal may also cover deductibles and copayments for Medicare Part A and pay for Part B premiums.
