Your Medicare Coverage
Is my test, item, or service covered?
Home health services
How often is it covered?
- Part-time or intermittent skilled nursing care
- Part-time or intermittent home health aide care
- Physical therapy
- Occupational therapy
- Speech-language pathology services
- Medical social services
Usually, a home health care agency coordinates the services your doctor orders for you.
Medicare doesn't pay for:
All people with Part A and/or Part B who meet all of these conditions are covered:
- You must be under the care of a doctor, and you must be getting services under a plan of care created and reviewed regularly by a doctor.
- You must need, and a doctor must certify that you need, one or more of these:
- Intermittent skilled nursing care (other than drawing blood)
- Physical therapy, speech-language pathology, or continued occupational therapy services. These services are covered only when the services are specific, safe and an effective treatment for your condition. The amount, frequency and time period of the services needs to be reasonable, and they need to be complex or only qualified therapists can do them safely and effectively. To be eligible, either: 1) your condition must be expected to improve in a reasonable and generally predictable period of time, or 2) you need a skilled therapist to safely and effectively make a maintenance program for your condition, or 3) you need a skilled therapist to safely and effectively do maintenance therapy for your condition.The home health agency caring for you is approved by Medicare (Medicare certified).
- You must be homebound, and a doctor must certify that you're homebound.
You're not eligible for the home health benefit if you need more than part-time or "intermittent" skilled nursing care.
You may leave home for medical treatment or short, infrequent absences for non-medical reasons, like attending religious services. You can still get home health care if you attend adult day care.
Home health services may also include medical supplies for use at home, durable medical equipment, or injectable osteoporosis drugs.
Your costs in Original Medicare
Before you start getting your home health care, the home health agency should tell you how much Medicare will pay. The agency should also tell you if any items or services they give you aren't covered by Medicare, and how much you'll have to pay for them. This should be explained by both talking with you and in writing. The home health agency should give you a notice called the "Advance Beneficiary Notice of Noncoverage" (ABN) before giving you services and supplies that Medicare doesn't cover.
To find out how much your test, item, or service will cost, talk to your doctor or health care provider. The specific amount you’ll owe may depend on several things, like:
- Other insurance you may have
- How much your doctor charges
- Whether your doctor accepts assignment
- The type of facility
- Where you get your test, item, or service
Your doctor or other health care provider may recommend you get services more often than Medicare covers. Or, they may recommend services that Medicare doesn’t cover. If this happens, you may have to pay some or all of the costs. Ask questions so you understand why your doctor is recommending certain services and whether Medicare will pay for them.
If you get services from a home health agency in Florida, Illinois, Massachusetts, Michigan, or Texas, you may be affected by a Medicare demonstration program. Under this demonstration, your home health agency, or you, may submit a request for pre-claim review of coverage for home health services to Medicare. This helps you and the home health agency know earlier in the process if Medicare is likely to cover the services. Medicare will review the information and cover the services if the services are medically necessary and meet Medicare requirements.
Your Medicare home health benefits aren't changing and your access to home health services shouldn’t be delayed by the pre-claim review process. For more information, call us at 1-800-MEDICARE.