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5 Requirements to Qualify for Medicare Home Health Care

Dana Klosner-Wehner
April 23, 2018

This type of care must be requested by a doctor and fulfilled by a Medicare-certified home health agency.

You are doing everything you can for your aging parents, but sometimes it comes to the point where that is not enough. After a hospitalization, or to simply maintain or slow the decline of their health, Mom or Dad may need skilled therapists and nurses.

This new twist in caring for Mom and Dad raises many questions. How will you afford these professionals? What about Medicare? Who qualifies for Medicare Home Health Care benefits?  

“Medicare pays for skilled services, such as nursing and therapy in the home, when there is a skilled need and the patient is homebound,” says the administrator of the Gurwin Certified Home Health Agency, Jeanmarie Kineiko, RN, BSN, in New York. In order to qualify for benefits, the following five requirements must be met, according to the Medicare Learning Network’s (MLN) pamphlet, “Medicare & Home Health Care.”

1. You’re under the care of a doctor, and you’re getting services under a plan of care established and reviewed regularly by a doctor.

2. You need, and a doctor certifies that you need, one or more of these:

  • Intermittent skilled nursing care (other than drawing blood)
  • Physical therapy
  • Speech-language pathology services
  • Continued occupational therapy

3. The home health agency caring for you is approved by Medicare.

4. You’re homebound, and a doctor certifies that you’re homebound. To be homebound means: You have trouble leaving your home without help (such as a cane, wheelchair, walker, crutches, special transportation or help from another person) because of an illness or injury, or leaving your home isn’t recommended because of your condition.

5. As part of your certification of eligibility, a doctor, or other health care professional that works with a doctor, must document that they’ve had a face-to-face encounter with you within required time frames and that the encounter was related to the reason you need home health care.

“Medicare covers 100% for services when there is a skilled health-care need following an acute episode such as hospitalization or change in health status as long as the patient is homebound,” Kineiko says. “Income is not a factor when home care services are provided due to a skilled need under Medicare.”

All Medicare-certified home health agencies (CHHAs) accept Medicare benefits, Kineiko says. Home health agencies are certified to make sure they meet certain federal health and safety requirements, according to MLN’s pamphlet “Choosing a Home Health Agency.”

“Your choice should be honored by your doctor, hospital discharge planner, or other referring agency. You have a say in which agency you use, but your choices may be limited by agency availability, or by your insurance coverage,” the pamphlet states. “If you have a Medicare Advantage Plan (like an HMO or PPO) or other Medicare health plan, it may require that you get home health services from agencies they contract with.”

You can compare home health agencies in your area by the types of service they offer and the quality of care they provide on Medicare.gov/homehealthcompare.

Medicare also covers continuous health care but on a different level. It only covers a percentage of the cost. Unfortunately, home aides that help with housework, bathing, dressing and meal preparations are not covered by Medicare.

You also may be comforted by the fact that your parents have rights as far as their health care is concerned. These include having their property treated with respect; to be told, in advance what care they’ll be getting and when their plan of care is going to change; to participate in their care planning and treatment. They also have the right to file a complaint about the quality of their home health care.

For more information about Medicare go to Medicare.gov. For more information about how home health care is covered look in the “Medicare & You” handbook. To view or print this booklet go to medicare.gov/publications, or call 1-800-MEDICARE HIDDEN) for questions about benefits.

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