How To Qualify For Home Health Care Under Medicare

Home health nursing care and therapy services are so important to older adults recovering from hospitalizations or managing chronic conditions. However, Medicare eligibility rules can be confusing, leaving many seniors unsure whether they’re qualified for home health care or how to initiate the services they need. 

We offer practical information about home senior care so that you have your medical needs met at home or help your elderly loved ones access these essential services. 

What counts as home health care under Medicare?

Home care is tightly defined under Medicare rules. 

Medicare’s definition of home health care

Medicare rules define “home health services” as skilled, medically necessary care that is provided at home. Qualifying services covered under this rule include:

• Nursing
• Physical therapy
• Occupational therapy
• Speech therapy
• Medical social work
• Home health aide support (in some cases)

Typically, Medicare does not cover custodial care services such as meal preparation and household chores. Support with activities like bathing and using the bathroom will be covered only if they are connected to eligible skilled medical services. 

The role of a Medicare-certified home health agency

If you are eligible for home health care under your Medicare plan, it must be provided by a Medicare-certified agency. When arranging care, ask the agency whether it is Medicare-certified. You can also confirm their status online.

The 5 key requirements to qualify for home health care

You or your elderly loved one may be eligible for home health care under Medicare if all five of these requirements are met. 

1. You must be under the care of a doctor

Specific medical situations may lead to home health referrals, such as recovery from surgery or a new diagnosis. A decline in mobility could also make you eligible for home health care. To show that you qualify, you must undergo a care assessment by a physician. The doctor will evaluate your medical condition and provide a plan of care. 

2. You must need skilled nursing or therapy services

There is a major difference between skilled medical services and home health aide support. Examples of skilled nursing or therapy services include the following:

• Wound care after a fall
• Physical therapy after a joint replacement
• Medication management for chronic conditions 

Medicare does not cover home health aides as a standalone service. If you only need help with cooking, bathing, or cleaning, those needs are not covered under basic Medicare plans. 

3. You must be homebound

The Medicare.gov definition of homebound is broad. You are considered homebound if:

• You have difficulty leaving your home without help (you might need a cane, a walker, a wheelchair, assistance from another person, or special transportation) 
• Your provider recommends staying at home because of your medical condition
• You’re typically unable to leave your home due to the amount of effort required 

You are still allowed to leave home for short, infrequent, or medically necessary purposes. For example, you can make arrangements to go grocery shopping or attend follow-up appointments with your healthcare provider.

4. A doctor must certify that home health services are necessary

You need a physician’s order for skilled care at home. The order must be documented in your care plan, and it should explain why the care is medically necessary. If your doctor requests home health services simply because they are more convenient for you, the request will likely be denied. 

5. You must receive care from a Medicare-certified home health agency 

Here’s where many families run into trouble. First, you need to find an agency that is Medicare-certified. Once you find one, you’ll need to verify that it has enough staff to accept you as a patient. Seniors commonly experience:

• Delays because agencies aren’t accepting new patients
• Confusion about which agencies are Medicare-certified
• Difficulty coordinating between the physician order and the agency’s services

A care advocate can streamline the process and ensure that you choose an approved provider with the capacity to onboard you as a patient. 

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What services are covered by Medicare home health?

Typically, Medicare covers the following home health services. 

Skilled services

Medicare covers skilled care when medically necessary.

Nursing care:

• Wound care
• Injections
• Disease and medication management
• Monitoring of unstable conditions 

Therapy services:

• Physical therapy for mobility, fall prevention, and post-surgery recovery
• Occupational therapy for daily activities and safety
• Speech therapy for swallowing or communication challenges 

Medical social work:

• Support with care coordination
• Assistance connecting to community or behavioral health resources

Suppose that a patient was released from the hospital after a recent admission for heart failure, but they don’t yet have the strength to handle their own medical needs. They may be eligible for skilled in-home nursing care and physical therapy until they regain enough endurance to perform activities of daily living (ADLs). 

Home health aide support

Medicare may cover aide services when paired with skilled care. Aides may help with:

• Bathing
• Dressing
• Personal hygiene

They do not provide routine housekeeping or long-term ADL support. 

Services Medicare does NOT cover 

Medicare will not pay for:

• 24/7 nursing services
• Full-time personal care
• Transportation
• Meal preparation or grocery shopping
• Companionship or homemaker services 

Many seniors mistakenly believe that home health aides will handle household tasks. Knowing what your Medicare plan will and will not cover helps you set realistic expectations. 

How the home health care process works step-by-step

Do you need home health care? Here’s how to qualify for services under Medicare. 

Step 1: Talk to your doctor

The first step is to have a clear, honest conversation with your doctor about what you’re struggling with at home. Many seniors minimize their symptoms or challenges because they don’t want to feel like a burden. However, Medicare is set up precisely to help people in your situation.

Voice your concerns to your provider. Let them know that you would like to have a skilled nursing professional come to your home to provide care. Tell them what symptoms you’re experiencing and what daily tasks have become difficult, and ask whether you qualify for home health services under Medicare. 

Step 2: Get a Medicare eligibility evaluation

Once your doctor submits an order, a Medicare-certified home health agency will evaluate your eligibility. They will consider the following: 

• The medical need for skilled care
• Your functional ability
• Your homebound status

The clinician will ask questions about your medications, pain levels, and ability to perform ADLs. They will also observe your mobility levels. They will look for hazards such as poor lighting or loose rugs that could cause you to fall. 

Step 3: The doctor issues a plan of care 

If you meet Medicare’s criteria, your doctor will create a formal plan of care. This plan outlines what services you will receive. Some common examples are medication management, physical therapy, and regular monitoring of vital signs. It typically includes goals like improving strength, healing from a wound, or regaining mobility. 

The doctor will specify how often you will receive home visits, such as once, twice, or three times per week. The type and frequency of support you receive will depend on your condition. 

Step 4: Start of care visit

Your first official visit will include a comprehensive assessment and education session. This will likely be your longest visit. The clinician will review your medications, identify any safety risks, and discuss your symptoms in detail. They may perform a focused or generalized assessment, such as examining your wound site or taking vitals. 

You’ll also receive information about your care plan, including:

• How often the nurse will visit
• What therapy exercises you’ll complete between sessions
• How to look for signs or symptoms that require immediate attention

The goal is to get everyone on the same page regarding the purpose, scope, and frequency of care. 

Step 5: Ongoing visits and recertification 

Home health visits will continue based on your doctor’s care plan. The agency will thoroughly document your progress and continued need for skilled care during the certification period. 

A typical plan lasts for up to 60 days. If you are improving but still require skilled services, the doctor may recertify you for another 60 days. In their recertification, the doctor must outline why services are still medically necessary. Reasons might include slow-healing wounds, declining strength, or a continued risk of hospitalization. 

Common roadblocks seniors face when trying to qualify 

When trying to qualify for home health care under Medicare, you may run into one or more of these challenges. 

Misunderstandings about the “homebound” rule

According to Amanda Ledwich,  Lead Patient Advocate at Understood Care, misunderstanding the homebound status is one of the most common roadblocks to accessing Medicare home health care. 

“Homebound” does not mean you can never leave your house. You can still:

• Go to doctor appointments 
• Get your hair done up to once per month
• Go grocery shopping
• Attend a wedding or funeral

Even when you are considered homebound by Medicare, you can leave your house for necessary services or occasional special events. However, if you are not at home during a scheduled visit, your eligibility will be at risk. This is a challenging detail, which is why many seniors seek advocacy or support. 

Missing documentation or incomplete doctor orders

One of the most common delays occurs when a physician’s order is incomplete or missing key details. For example, a referral without a qualifying diagnosis could delay home care for days or weeks. Agencies cannot begin providing services until those issues are resolved. 

Fortunately, an advocacy organization can work with you to ensure your documentation is completed correctly the first time so that you get care when you need it. 

Difficulty coordinating between doctor, agency, and insurance

Many seniors find themselves stuck between three entities that don’t always communicate well: their doctor, a home health agency, and their insurance provider. 

Your doctor might assume that you’ve started receiving care, while the agency is still waiting for the right paperwork. Medicare is notorious for requesting additional information. It’s frustrating for everyone, but especially for you, the patient.

Advocates often see cases where a referral was sent to an agency with a long waiting list. The patient is stuck without care, even if everything was done through the proper channels. 

Challenges after hospital discharge

Hospital discharges often happen quickly. Patients may go home without knowing that home health care is an option, and the instructions they receive may be confusing or overly technical. 

Families frequently discover days later that their loved one was eligible for at-home help with wound care, medication management, and early physical therapy. Going without these services can increase the risk of readmission to the hospital. 

How Understood Care helps you navigate home health care

At Understood Care, our advocates are experts in working within the U.S. healthcare system to get you the support you need. Here’s how our team members can help.

Support with understanding Medicare rules

Understood Care advocates explain Medicare’s home health rules in simple, friendly language so that you aren’t overwhelmed. We break down what “homebound” truly means and how it applies to your case, and we’ll help you understand your eligibility so that you can make full use of your Medicare benefits. 

We want to stand behind your entire family during this time of need, which is why we also deliver caregiver support. 

Help coordinating appointments and referrals

Our advocates assist with the behind-the-scenes work that often causes delays. We gather medical records, contact your doctor to request complete orders, and confirm that a home health agency is Medicare-certified. We also help families understand which agencies have availability and can meet their needs. 

Help managing paperwork, coverage, and claims

Understood Care’s advocates take on the administrative burdens that often overwhelm seniors and their families. If something is denied or delayed, we identify the next steps and work to resolve the problem. This support can be essential for seniors who don’t feel comfortable dealing with complex paperwork or bureaucratic roadblocks. 

When home health isn’t enough — how advocates fill the gaps

Even if you are eligible for Medicare’s home health benefits, they may not adequately meet all of your needs. If you or your elderly loved one requires additional help, our advocates bridge the gap. We can connect you with resources to assist with:

• Transportation
• Medication management 
• Housing support
• Meal programs
• Caregiver support networks 

Explore Understood Home Care services and learn how our advocates can help you and your loved ones access care when it matters most. 

Partner with Understood Care

Now that you know how to qualify for home health services under Medicare, the next step is to determine whether you or your elderly loved one is eligible. The answer depends on these factors:

• Medical necessity
• Homebound status
• Physician oversight

Far too many seniors struggle needlessly, not because they are ineligible but because they get bogged down in the complex Medicare system. At Understood Care, we provide friendly, clear, human support to help seniors get Medicare-covered services that improve their quality of life. 

Do you need an advocate to stand up for you or your loved one? Get started with Understood Care today. 

Related Reading

• Home Care - Learn More
• Home modification benefit denied as “home improvement”: how to appeal or re-request
• SSBCI home modifications benefit, ramps, grab bars, bathroom safety, what qualifies” (home safety intent)
• Compare Medicare Supplement Plans: A Smart Guide for Seniors

FAQs

What conditions must be met before Medicare pays for home health care?

You must:

• Be under a doctor’s care
• Need skilled nursing or therapy services
• Be homebound
• Have a doctor certify medical necessity
• Use a Medicare-certified home health agency

These requirements are nonnegotiable. 

Does Medicare pay for in-home care?

Medicare pays for skilled in-home medical care, but not long-term custodial care. Temporary home health aide services may be covered if you are approved for skilled care. 

What qualifies a person for home health care? 

You may be eligible for home health care if you require skilled care, have difficulty leaving home, have a documented medical need, and receive services from a certified agency. 

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