How to Qualify for Home Health Care Under Medicare

Do you know that over 62 million Americans are enrolled in Medicare? For seniors and individuals with disabilities, Medicare is often their primary lifeline to healthcare. 

However, accessing your Medicare benefits involves navigating multiple steps, such as qualifying, enrolling, and understanding your specific coverage. But the process isn’t as challenging as you might think, especially if you have the right guidance.

As part of Nurse Next Door McLean’s ongoing commitment to helping seniors remain safe, independent, and comfortable as they age in place, here we present information about how to qualify for home health care coverage under Medicare. 

Call Nurse Next Door McLean today at (703) 774-9421 for compassionate in-home care

Understanding Medicare Home Health Care Coverage 

Before diving into the requirements, it helps to understand what “home health care” means in the context of Medicare. 

Under Medicare, home health care refers to skilled, medically-necessary services provided in your home by a certified home health agency. The services are ordered by your doctor and delivered by licensed medical professionals. 

This is very different from non-skilled home care. 

Home Health Care versus Non-Skilled In-Home Care 

Many families who need both types of care may confuse the two, but Medicare draws a firm line. 

Covered home health care includes services by a skilled nurse or licensed therapist.

On the other hand, Medicare does not cover non-skilled in-home care services, such as companionship, meal preparation, or light housekeeping, transportation, errands, and personal care, such as bathing, grooming, and dressing.

In other words, Medicare generally only covers skilled home health care, not long-term personal care.

Personal or custodial care is generally not covered, unless it is also provided in conjunction with skilled nursing or therapy services. 

It is also important to note that Medicare does not cover 24/7 round-the-clock custodial care. Under Medicare guidelines, home health care must be intermittent, medically necessary, and provided under a doctor’s direction. 

The Basic Requirements: How to Qualify for Home Health Care Under Medicare

Medicare has three core requirements for anyone trying to qualify for home health care services. When families understand these basic requirements, the process becomes far less challenging. 

1. You Must Be Under the Care of a Physician Listed in PECOS 

To qualify, your doctor must: 

• Oversee your treatment plan. 
• Be enrolled in Medicare’s PECOS (Provider Enrollment, Chain, and Ownership System). 
• Approve and certify your need for home health services. 
• Another key requirement is the face-to-face encounter with a Physician. An encounter with a Non-Physician Practitioner will not qualify you for Medicare. Additionally, the encounter must be related to your need for home health care and must take place within 30 days after or 90 days before the beginning of your care. 

Your doctor plays a central role in determining your eligibility, ordering necessary services and supplies, and periodically recertifying your care. 

2. You Must Require Skilled Services 

Medicare home health coverage requires a need for skilled professional medical services, such as those provided by a nurse and/or a physical, occupational, or speech therapist. However, the skilled need has to be necessary and reasonable. The skilled service should be required for the assessment or treatment of a particular skilled need. Besides this, the client must have the potential for improvement or need it for the skilled management of an unstable health condition. If you have a stable chronic condition that can be managed without professional intervention, Medicare won’t cover skilled nursing.

This is a crucial part of how to qualify for home health care under Medicare, and it can include services for both temporary and chronic conditions. 

3. You Must Be Considered Homebound 

“Homebound” status does not mean you can never leave your house. Instead, Medicare defines homebound individuals as those for whom leaving home: 

• Takes considerable effort, or 
• Requires the help of another person, or 
• Necessitates the use of an assistive device such as a walker, wheelchair, or scooter. 

Understanding Medicare’s Intermittent Care Requirement 

To qualify, the services must be: 

• Intermittent, not continuous,  or 
• Part-time, meaning less than 8 hours daily and as many as 28 hours weekly. In some cases, Medicare weekly coverage may even extend to 35 hours. 

Medicare only pays for skilled medical care, not long-term custodial care. 

Certification and Recertification 

Your doctor: 

• Determines your eligibility and need for home health care 
• Confirms your homebound status 
• Verifies that you need skilled professional services 

This certification must be renewed every 60 days for home health services to continue. 

Differences Between Medicare and Medicaid

What Medicare Covers Once You Qualify 

Once you are successfully enrolled, Medicare Part A or Part B covers a comprehensive list of skilled professional services delivered in your home, including but not limited to: 

Skilled Nursing Care (Intermittent) 

• Medication management 
• Monitoring of chronic illnesses 
• Assessment of unstable or serious health conditions 

Wound Care 

• Surgical wounds 
• Pressure sores 

Intravenous or Nutrition Therapy 

• Tube feeding 
• IV medications or fluids 

Monitoring of Serious Illnesses

Including, but not limited to:

• Diabetes 
• Congestive heart failure 
• Cancer 
• COPD 
• Post-hospitalization recovery 

Therapy Services 

• Physical therapy 
• Occupational therapy 
• Speech-language pathology 

Your therapy services will only be covered if your condition is expected to improve within a certain period. Those who have reached a plateau and are just receiving maintenance therapy won’t be covered by Medicare.

Home Health Aide Services (Part-Time) 

Home health aide support can be availed if it is medically related to the skilled service. For example, if you’re receiving physical therapy to recover from a broken hip, the home health aide can assist with bathing as you’re not able to bathe because of the injury. They can provide assistance with tasks like:  

• Mobility assistance 
• Bathing and grooming 
• Feeding 
• Changing bed linens

You can receive personal care from a home health aide, but it’s only covered by Medicare as a supportive service to your skilled needs. Long-term custodial care that doesn’t involve any skilled need won’t be covered, even when provided by a home health care agency.

Patient and Family Caregiver Education

Medicare coverage also includes training and education for patients and their family caregivers, empowering you to participate in your own wellness with confidence and competence. This also keeps skilled and family caregivers on the same page, ensuring continuity of care.

Cost: If you have Original Medicare (Parts A & B) and fulfil all of the criteria, you won’t face any copay or deductible for the home health services. Home health aide services, therapy, and skilled nursing services are free of charge. But you may have to pay 20% coinsurance for Durable Medical Equipment (DME).

Steps to Qualify

Qualifying for home health care under Medicare starts with talking to your doctor, who will evaluate your needs and supply the necessary documentation.

If you meet all the eligibility requirements, you can then schedule an in-home care assessment from a Medicare-certified agency. The Medicare-certified home health agency has the responsibility of creating the client-specific care plan in collaboration with your physician. They also ensure that all requirements of eligibility have been met prior to admitting you.

Getting help from experienced professionals, like doctors and reputable home health agencies in Virginia, helps you avoid common mistakes that delay your qualifying for home health care under Medicare.

How Nurse Next Door McLean Can Help

Nurse Next Door McLean is your most-trusted local resource when it comes to premium home health care in Northern Virginia. We can guide you on how to qualify for home health care. If you have Medicare and you don’t know about your coverage, we can provide guidance. If you have questions, call Nurse Next Door McLean at (703) 774-9421.