Medicare and home health care — what qualifies and what doesn't

This article is for educational purposes only and does not constitute medical, legal, or financial advice. Every family situation is different, and you should consult with appropriate professionals about your specific circumstances.

When my aunt had a stroke, the hospital discharge planner sat down with my uncle and me and explained the options. She could go to a nursing home. She could go to a skilled nursing facility for rehabilitation. Or she could go home with Medicare-covered home health care.

My uncle wanted her home. She wanted to be home. We all agreed that made sense. The discharge planner said Medicare would cover a nurse to visit several times a week, plus a physical therapist to help her relearn walking, plus an occupational therapist to help her manage daily tasks. "How long?" my uncle asked. The discharge planner said, "As long as she needs skilled care. Once she stabilizes, it stops."

That "once she stabilizes" part is the key to understanding home health care. Medicare covers it temporarily, not indefinitely. Medicare covers the skilled care—the nursing judgment, the therapy, the medical management—that helps your parent recover from an acute event. Once your parent is stable, once they've recovered enough to manage their condition, the coverage stops.

That distinction between medical care and ongoing assistance determines whether your parent will pay for home help or whether Medicare pays.

What Medicare Considers Home Health Care

Home health care, in Medicare's definition, is skilled care provided in your parent's home. Skilled care means a healthcare professional is providing a medical service that requires professional judgment, assessment, or intervention.

A home health nurse assessing your parent's wound and changing a complex dressing is skilled care. A nurse monitoring your parent's blood pressure and heart failure symptoms to prevent another hospitalization is skilled care. A physical therapist teaching your parent to walk again after a stroke is skilled care. An occupational therapist retraining your parent to dress and bathe after a joint replacement is skilled care. A speech therapist helping your parent recover swallowing ability after a stroke is skilled care.

These services require professional assessment, knowledge, and judgment. They're medically necessary. They have a defined goal of restoration or stabilization. Medicare covers them at home, even though they could only be covered in a facility under other circumstances.

Home health care is temporary, not ongoing. The key word is temporary. Medicare doesn't cover home health care for indefinite or maintenance purposes. Your parent can't have a nurse visiting once a week forever, checking on their diabetes, because diabetes is managed and stable. Medicare covers the intensive skilled care while your parent is recovering from an acute event. Once your parent reaches the plateau where they're stable and not making progress toward independence, the coverage stops.

Home health care requires a doctor's order. Your parent can't call and request home health services. Their doctor must order it. The doctor must certify that home health care is medically necessary and that your parent is unable to leave home without significant assistance. These orders typically come from a hospital discharge, but they can also come from a primary care doctor when your parent is recovering from a serious illness or surgery.

The Homebound Requirement: Stricter Than You Think

Medicare has a specific definition of homebound, and it's stricter than most people expect.

Your parent is homebound if they cannot leave the home without considerable assistance, or if leaving the home is medically inadvisable. This means your parent can't easily walk out the door on their own. They need help. They need equipment. They're limited in their ability to go outside.

But this doesn't mean your parent has to stay in the house 24/7. Your parent can leave home for medical appointments. They can leave with help. They can leave occasionally for important activities. These occasional outings don't disqualify them from home health care.

The homebound requirement is Medicare's way of distinguishing between home health care and other services. The point is that your parent is too weak, too impaired, or too unstable to go to an outpatient facility for care. The care comes to them at home because they can't safely go to a medical office.

This becomes important when Medicare reviews the home health case. If your parent is going to the grocery store, running errands, and doing yard work, Medicare might question whether they're truly homebound. But occasional medical appointments or occasional trips with help don't disqualify them.

What Medicare Covers (And Doesn't) at Home

Medicare covers skilled nursing visits. A nurse can come to your parent's home to assess their condition, manage wounds, teach medication management, monitor for complications, and coordinate care. These visits are covered at no cost to your parent, beyond their regular Medicare copay structure.

Medicare covers physical therapy, occupational therapy, and speech therapy. These services help your parent recover function after a stroke, joint replacement, fall, or other acute event. Your parent learns how to walk again, dress again, or swallow again. These services have a specific goal of functional restoration or stabilization.

Aide services are covered only if your parent is also receiving skilled nursing or therapy. This is important. A bath aide who simply helps your parent bathe is not covered on their own. The aide can come to help with bathing, but only if a nurse is also visiting to provide skilled care. This prevents Medicare from paying for custodial care disguised as home health.

Help with medications is covered only as part of the nurse's visit. The nurse can assess your parent's ability to manage medications safely and provide education. But a person simply coming to your parent's home to hand them their pills is not a covered home health service.

Cleaning, cooking, and general household help are not covered. This is the boundary between medical care and homemaking. Medicare stops at medical care. Your parent might desperately need someone to clean the house or do the laundry, but Medicare doesn't pay for it. If your parent can't manage these tasks alone and has no family to help, these become out-of-pocket expenses.

Personal care,help with bathing, dressing, toilet use,is covered only if skilled nursing or therapy is also being provided. Alone, it's custodial care. Combined with skilled care, the aide can help as part of the overall home health package.

The Duration Question: How Long Does It Last

Home health care coverage is duration-limited in two ways: the specific length of benefit after an acute event, and the duration until your parent stabilizes.

After a hospital stay or major surgery, Medicare typically covers home health care for several weeks to several months, depending on your parent's recovery. If your parent had hip surgery, three months of home health therapy might be typical. If your parent had a stroke, the duration might be longer. But the coverage is not open-ended.

The real limit is stabilization. Once your parent's condition is stable,they've recovered what they're going to recover, they're doing as well as they likely will, they're not making functional progress,the coverage stops. Your parent might improve to the point where they can walk with a walker but not walk normally. Once they reach that functional level and it's stable, the skilled care ends.

This is where families often get surprised. They think, "Medicare is covering the home health care, so it will continue until my parent is completely better." But Medicare stops when your parent is stable enough to manage their condition, which might not be completely recovered.

Transition planning becomes essential. Before the coverage ends, you need to know what happens next. Will your parent need ongoing help? Can family provide it? Is private pay in-home care needed? Can your parent manage alone with grab bars and equipment? These questions need answering before the nurse makes the last visit.

When Home Health Care Stops But Your Parent Still Needs Help

This is the cliff that catches families off guard. The physical therapist comes for the last time. The nurse says, "You're doing great, you're stable, you don't need skilled care anymore." Your parent is thrilled. You're thinking, "Wait, they still can't dress themselves. What happens now?"

What happens is you start paying. Home health care stops because Medicare's obligation to cover skilled care ends. But your parent might still need help with bathing, dressing, meal preparation, or other daily activities. That help becomes private pay.

An aide who simply helps with personal care, without medical oversight, is not a home health aide. It's private pay. Your parent or family pays the aide directly, or you hire an agency that manages the aide. The costs are substantial. In many areas, home care aides cost $20 to $30 per hour, which adds up to $400 to $600 per week for daily help.

Some families manage this through family members providing care. Some families hire aides. Some families move their parent to an assisted living facility because the costs of home care exceed the cost of the facility. But the transition from Medicare-covered to private pay is sharp.

Planning for this transition begins before home health care ends. Talk to the physical therapist or nurse. Ask specifically, "When you think skilled care will end, what will my parent still need help with?" Get honest answers. Then figure out how to pay for it.

Getting Home Health Care Approved and Paid

The process begins with a doctor. Your parent needs to be in contact with their doctor,usually a primary care doctor or a specialist managing a recent illness or surgery. The doctor needs to believe that home health care is medically necessary and that your parent is homebound.

The doctor places an order for home health care. Medicare requires a specific order. The order must specify the type of services needed (nursing, physical therapy, occupational therapy, speech therapy) and the frequency and duration.

A home health agency then evaluates your parent. The agency's nurse assesses whether your parent meets Medicare criteria for home health care. The agency determines if your parent is truly homebound and if the services are medically necessary.

If the agency and your parent's doctor agree, the care is authorized. Medicare covers 100 percent of approved home health services after your parent's Part B deductible is met. There are no copays for home health services themselves, though your parent still pays for medications, medical equipment, and other out-of-pocket costs.

If coverage is denied, your parent has the right to appeal. The appeal process takes time, but it exists. If your parent or your parent's doctor believes Medicare wrongly denied coverage, you can request an appeal and make the case for why the services are medically necessary.

The Reality of Staying Home

Home health care allows many people to recover in familiar surroundings, which matters for their mental health and motivation to rehabilitate. Your parent can be home while getting the skilled care they need to recover.

But home health care is not full-time care. It's hourly visits from professionals. Nursing visits might be three times per week. Physical therapy might be twice per week. No one is there overnight. Your parent needs to be safe at home, which sometimes means family nearby or significant home modifications.

Home health care works best when your parent is recovering from something specific,surgery, stroke, serious illness,and they will genuinely improve with therapy. It works worst when your parent has chronic ongoing disabilities that will never resolve. For ongoing disabilities, home health care provides management, but once the acute phase ends, the coverage ends.

Understanding what home health care covers allows you to plan appropriately. You know it's temporary. You know it requires a doctor's order. You know it ends when your parent stabilizes. You can plan for what comes after, instead of discovering the gaps when the last therapist walks out the door.

How To Help Your Elders is an educational resource. We do not provide medical, legal, or financial advice. The information in this article is general in nature and may not apply to your specific situation. If you are concerned about a loved one's cognitive health or safety, consult with their healthcare provider or contact your local Area Agency on Aging for guidance and support.