Medicare Coverage & Qualifiers

Medicare covers a limited amount of home health care services. This provides an alternative to entering a nursing home unnecessarily. It does not cover custodial care that can be provided by the person himself or a family member. Custodial care is not covered when it is the only care that is needed. It may be covered when it is needed in combination with skilled nursing care for a short-term ailment or recovery.

Four Criteria to meet Medicare qualifications

1.     The patients’ doctor must decide that medical care at home is necessary and then make a plan for the home care that is needed.

2.     Intermittent skilled nursing care or skilled care must be needed.

3.     The home care agency providing care must be Medicare certified

4.     The patient must be homebound or unable to leave home safely without help. However, leaving home for short periods of time for a medical reason such as going to a doctor’s appointment or for a nonmedical reason such as going to church does not disqualify someone for Medicare home health services.

When these four Medicare criteria are met, Medicare will cover the following services:

  • Skilled nursing care on a part-time intermittent basis. Skilled nursing care is care that can only be performed safely by a licensed nurse. This may include procedures such as wound care management, administration of intravenous (IV) medication, injections, tube feeding, and oxygen to help with breathing,
  • Skilled care not only includes nursing, but it includes rehabilitation therapies such as physical therapy, occupational therapy, and speech-language therapy for as long as the physician in charge states the need for it. Any care that can safely be provided by a non-medical person without the supervision of nurse is not considered skilled care.
  • Home health aide services are provided on a part-time intermittent basis if the home health aide services are part of the care plan due to the illness or injury. Home health aide services are not covered if they are the only care needed. Home health aide services may include bathing, using the bathroom, dressing, or other personal care. These services are not performed by a licensed nurse.
  • Medical social services are provided when they relate to the specific illness that Medicare home health care covers. This might include counseling or help in finding community resources.
  • Certain medical supplies like wound dressings.
  • Durable medical equipment such as a wheelchair or walker.

Currently, Medicare does not cover any of the following:

  • Home care needed 24 hours per day.
  • Home delivered meals.
  • Homemaker/companion services such as shopping, cleaning, and laundry.
  • Personal care given by home health aides such as bathing, dressing, toileting when this is the only care that is provided.