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There are a lot of reasons that someone might need home health care. Have you recently had surgery and are regaining mobility in your recovery? Do you need an assistive device to safely leave your home? Is an ongoing medical condition getting worse, and you could use a little more help and reassurance around the house? Then you just might qualify for home health care. But to find out if you meet all of the criteria for Medicare-covered care, there’s more to learn.
What Qualifies as Home Health Care?
Home health services are care that licensed medical professionals provide. The most common home healthcare services are doctor care, skilled nursing care, and physical, occupational, and speech therapy.
What needs to be covered is essential to family caregivers because this is usually what we care for. For example, non-skilled help at home with laundry, house cleaning, shopping, meal delivery, or personal transportation is not covered. Both are personal care with activities of daily living (like bathing, dressing, or using the bathroom) when it is the only care assistance needed.
Is the help at-home care services you need to be covered? Your doctor and home health care agency can help detail what qualifies.
Why Care About Home Health Care?
Home health care is usually less expensive, more convenient, and equally effective as care in a hospital or skilled nursing facility. However, there’s no substitute for the comfort of a favorite couch, the nuzzle of a sweet pet, or rehab in the house with the view from a favorite corner.
A significant benefit of home health care and assistance is that people who want to stay home and maintain their health independently get that ability.
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Criteria to Qualify for Home Health Care
Ultimately, a doctor decides if someone meets the criteria. Talk with a doctor if there is a new diagnosis or if you notice a decline in overall health.
Understanding the requirements as a caregiver prepares you to talk about support options and manage expectations.
People who are eligible for home health care need to meet specific criteria:
- A doctor creates a care plan and routinely checks on progress with the team.
- A doctor explicitly states a need for either intermittent skilled nursing care or therapy services (physical, occupational, speech) from a licensed professional.
- A doctor defines someone as 'homebound,' meaning that they require help to leave home even for a short period. Help, in this case, is a person or a thing like a cane, rollator, wheelchair, or transport chair.
Who Is Automatically Covered?
According to Medicare's official site, anyone with Medicare Part A and Part B OR just Part B coverage will likely have home health care covered.
Medicare Part A covers the following:
- The first 100 days of home health care if at least three consecutive days at a hospital inpatient care OR stay at a Medicare-covered skilled nursing facility.
- Part A coverage requires home health care services to start within 14 days of being released from a hospital or skilled nursing facility.
You’re Qualified! What to Do Next?
Your doctor is responsible for 'prescribing' reasonable and necessary services and the cadence of care. They design a plan and should know which services will or won’t be covered by Medicare.
Following this, your doctor submits orders to a Medicare-certified home health agency. (You can also find Medicare-certified home health services near you with the locator tool at medicare.gov.) Sometimes, your healthcare or insurance provider has a list of pre-approved home health agencies you can choose from.
Once a care plan begins, the doctor will monitor progress at least every 60 days to ensure reasonable goals are met and care is adjusted as needed.
Good to Know
Medicare will cover additional services when someone qualifies for home health benefits.
A home health aide helps with personal tasks like bathing, dressing, or going to the bathroom if necessary because of illness or injury. Medicare covers these services only when getting prescribed at-home skilled nursing or therapy.
Medical social services, such as social or emotional counseling, concerns related to illness or injury if receiving prescribed skilled care. It also covers help in finding community resources if you need them.
Standard Home Healthcare Services
A wide range of services falls under “home health care.” Here are some of the most common services covered by Medicare:
Skilled Nursing Services:
Skilled nursing services include dressing wounds, managing medications, administering IVs, and other health-related services licensed professionals must perform.
Physical Therapy (PT):
PT might be required to recover from an injury or illness that impacts mobility. Physical therapists help people regain balance and rebuild muscle strength, coordination, and joint flexibility.
This rehab takes consistency over time, working towards an attainable, reasonable goal. Some additional services that a PT may provide are:
- Pain-reducing techniques
- Recommendations for assistive devices and home modifications to improve safety
- Family or caregiver training to reinforce and enhance treatment benefits
Occupational Therapy (OT):
OT is recommended for people who need to relearn how to perform basic activities of everyday living, like getting around, bathing, or dressing. Some occupational therapy goals are to develop, recover, improve, and maintain the skills needed for daily living and working.
“Occupational therapy practitioners possess the critical skills needed to address fall prevention with older adults.” - According to the AOTA.
Speech-Language Therapy (ST):
ST services help individuals with speech impairments regain communication skills.
Speech pathologists focus on more than just the act of speaking. They help improve hearing, communication, and swallowing difficulties in patients with a heart attack, stroke, head injury, hearing loss, or difficulty speaking.
Patient Bill-Of-Rights and Home Health Care
What's great about these support options is that some fundamental rights are included in the prescribed care plan when caring at home.
These personal rights include being told in advance what care is prescribed, when the care plan changes, and that property and the person are treated respectfully. In addition, there is a right to file a complaint about the quality of home health care if there are any issues.
Learning how to qualify for home health care can be confusing — but connecting your circle and organizing help doesn’t have to be.
When you and your loved ones download the CircleOf app, you can let everyone know if your care plan changes, what you’re working on, or if you need help with upcoming appointments or errands. Share the care and connect through CircleOf.
Build A Family Care Team Here
If you’re a family caregiver, CircleOf is the app for you. You can set up a care team with family and friends, and maintain regular communication, so everyone is on the same page. Download CircleOf today to build your circle of care.
Article Definitions
Durable Medical Equipment (DME)
Medically necessary equipment that a Medicare-enrolled doctor or other health care provider writes an order for, for use in your home. You can either buy or rent these support items. A partial list is available at the medicare.gov site here.
Medically Necessary Equipment
Health care services or supplies needed to diagnose or treat an illness, injury, condition, disease, or its symptoms and that meet accepted standards of medicine.
Intermittent Nursing Care
Medicare defines intermittent nursing care as the skilled nursing care you need or get that is "less 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.”
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