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Medicare Coverage and Eligibility | The Legacy at Home

At The Legacy at Home, one of the most common things we field questions about is Medicare eligibility, costs, and benefits. That’s why we compiled this information from Medicare.gov, to help current and future patients understand their eligibility, benefits and qualifications in regard to Medicare and home health care.

Who Is Eligible?

If you meet certain eligibility requirements and home health care services are considered reasonable and necessary to treat an illness or injury, Medicare may pay for you to receive various health care services in your home. This is known as the Medicare home health benefit.

To utilize your home health benefit, there are several conditions which you must meet. First, you must be under the care of a doctor, and you must be receiving services as part of a plan of care outlined and regularly reviewed by a doctor.

Second, you must have a doctor certify that you are in need of one or more of the following:

  • Intermittent skilled nursing care
  • Physical therapy
  • Speech-language pathology services
  • Continued occupational therapy

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 (i.e., leaving home isn’t medically recommended because of your condition, you cannot do so without assistance, or leaving home takes a considerable and taxing effort). You may still leave for medical treatment or short, infrequent non-medical outings, such as a religious service. You can still receive home health care if you attend adult day care, and you would have access to the services in your home.

Eligibility is also based on the amount of services you need

If you meet the conditions outlined above, Medicare will pay for your home health services for as long as you are eligible and your doctor certifies you need them. However, if you require 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 for 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, you could receive coverage for the following services if they’re reasonable and medically necessary for the treatment of your illness or injury:

  1. Skilled nursing care (when it meets the requirements outlined above).

Skilled nursing services are provided by either a registered nurse (RN) or a licensed practical nurse (LPN). If a LPN administers services, your care will be supervised by a RN. Home health nurses provide direct care and teach you and your caregivers. They also manage, observe, and evaluate your care. Examples of skilled nursing include: giving IV drugs, shots, or tube feedings; changing dressings; and teaching about prescription drugs or diabetes. Any service that could be done safely by a non-medical person (or by yourself) without the supervision of a nurse, isn’t skilled nursing care.

Home health aide services may be covered on a part-time or intermittent basis if needed as support services for skilled nursing care. Home health aide services must be part of the care for your illness or injury. Medicare doesn’t cover home health aide services unless you also have skilled care such as nursing or other physical therapy, occupational therapy, or speech-language pathology services from the home health agency.

  1. Physical therapy, occupational therapy, and speech-language pathology services, with certain specific requirements:
  • The therapy services must be a specific, safe, and effective treatment for your condition.
  • The therapy services must be complex or your condition must require services performed safely and effectively only by qualified therapists.
  • The amount, frequency, and duration of the services must be reasonable.
  • One of the three following conditions must exist:
    • It’s expected that your condition will improve in a reasonable and generally-predictable period of time.
    • Your condition requires a skilled therapist to safely and effectively establish a maintenance program.
    • Your condition requires a skilled therapist to safely and effectively perform maintenance therapy.
  1. Medical social services are covered when given under the direction of a doctor to help you with social and emotional concerns related to your illness. This might include counseling or assistance to find resources in your community.
  2. Medical supplies. Supplies, like wound dressings, are covered when they are ordered as part of your care.

Durable medical equipment, when ordered by a doctor, is paid separately by Medicare. This equipment must meet certain criteria. 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 to your home.

Before your home health care begins, the home health agency should tell you how much of your bill Medicare will pay. The agency should also tell you if any items or services aren’t covered by Medicare, and how much you will have to pay for them. This should be explained by both talking with you and in writing.

The home health agency is responsible for meeting all your medical, nursing, rehabilitative, social, and discharge planning needs, as reflected in your home health plan of care. This includes skilled therapy services for a condition that may not be the primary reason for getting home health services. Home health agencies are required to perform a comprehensive assessment of each of your care needs when you become a client, and must communicate those needs to the doctor responsible for the plan of care. After that, home health agencies are required to routinely assess your needs.

What isn’t covered?

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.

What you have to pay

You may be billed for medical services and supplies that Medicare doesn’t pay for when you agree to pay out of pocket for them. The home health agency should give you a notice called the Home Health Advance Beneficiary Notice (HHABN) before providing services and supplies that Medicare doesn’t cover. You will also have to pay 20% of the Medicare-approved amount for Medicare-covered medical equipment such as wheelchairs, walkers, and oxygen equipment.

How Medicare pays for home health care

Original Medicare (as opposed to a Medicare health plan), pays your Medicare-certified home health agency one payment for the covered services you receive during a 60-day period. This 60-day period is called an “episode of care,” and payment is based on your condition and care needs.

Getting treatment from a home health agency that’s Medicare-certified can greatly reduce your out-of-pocket costs. A Medicare-certified home health agency (such as The Legacy at Home) agrees to be paid by Medicare and accept only the amount Medicare approves for their services.

Medicare’s home health benefit only pays for services provided by the home health agency. Other medical services, such as visits to your doctor, are generally still covered by your other Medicare benefits.

Additional Resources:

For more information about Medicare and home health care, you can call and speak to one of our experts who can help outline and explain your benefits at 972-244-7700. You can also go to our website (https://thelegacyseniorcommunities.org/legacyathome/) and view the different service options and therapies offered by The Legacy at Home.

If you receive Medicare benefits through a Medicare health plan (not Original Medicare) be sure to check your plan’s membership materials and refer to the plan for details about how it provides your Medicare-covered home health benefits.

You can also call 1-800-MEDICARE (1-800-633-4227) if you have questions about your Medicare benefits. TTY users should call 1-877-486-2048.


Medicare and Home Health Care. (n.d.). Retrieved March 03, 2017, from https://www.medicare.gov/Pubs/pdf/10969.pdf