Medicare will pay for in-home health care services and, in certain instances, may pay for in-home care services that are not medically necessary. As an alternative to obtaining treatment in a hospital or skilled nursing facility, one of the key goals of Medicare’s coverage of home health care is to provide elderly patients with short-term specialized services that may be performed in the familiar surroundings of their own homes.

There is a significant difference between personal care services that are not medically essential and home health care services that are required due to a medical condition. To determine who is qualified for in-home services that are covered by Medicare, it is essential to have a solid understanding of the distinction between these two categories of care.

Who is eligible to receive Medicare-covered home care services?

In order to be eligible for Medicare, a senior citizen must obtain health insurance via Medicare Part A (hospital insurance) and/or Medicare Part B (medical insurance) and satisfy the requirements outlined below by

Patients who are being treated by a physician are the only ones who may qualify for this benefit. A care plan that includes services that are considered to be medically required for the diagnosis, treatment or ongoing management of a health condition must be prescribed by the attending physician.

A physician’s note attesting to the recipient’s inability to leave their house is required for eligibility. This indicates that leaving the house involves a significant amount of work and exertion on the part of the individual due to their need for a mobility device (such as a cane, wheelchair, or walker), specialized transportation, or the help of another individual. A person may still be eligible for assistance even if they are able to leave their home for medical treatments, adult day care, and brief, occasional trips that are not related to medical needs, such as attending religious services or getting together with relatives.

A certification of medical necessity from an approved physician is required for beneficiaries to be eligible for at least one of the following services:

Intermittent skilled nursing care

Services of a therapist with expertise

The services must be delivered by a home healthcare agency that has been approved by Medicare.

What kinds of in-home health care are included in Medicare’s coverage?

Medicare coverage for home health care covers two broad types of services: skilled nursing services and skilled therapy services. Both of these categories are considered skilled care.

A competent health care practitioner, such as a registered nurse (RN) or a licensed practical nurse (LPN), is required to provide skilled nursing services (LPN).

The following are some examples of these services:

Keeping track of a patient’s vital signs as well as their general health

Care of wounds resulting from a surgical incision or a pressure ulcer

the administration of medications or nutrition treatment by intravenous route


Alterations to the Catheter

Education for both patients and caregivers

The provision of skilled therapy services is required to be carried out either directly by a licensed therapist or indirectly under their supervision. These services are required if they are to bring about an improvement in the patient’s condition within a time frame that is both realistic and relatively predictable.

The following categories of services are included in therapy:

  • The goal of physical therapy is to improve a patient’s range of motion, strength, and balance so that they may perform their daily activities to their full potential.
  • Occupational therapy, which helps patients recover the capacity to participate in activities of daily life on their own without assistance, is one kind of rehabilitation (ADL). This may require modifying regular activities or the environment around them in order to increase functionality and accessibility.
  • Patients may recover the capacity to talk and communicate via speech-language therapy, which also helps them overcome issues with swallowing (dysphagia).
  • It is essential to keep in mind that the aforementioned services will only be reimbursed if it is determined that they are appropriate and efficient treatments or maintenance approaches for the condition of the patient.

Would Medicare cover the cost of home health care delivered by a member of the patient’s own family?

No, Medicare will only pay for home health care that is medically required, has been ordered by a doctor, and is administered by an organization that has been approved to offer home health care. On the other hand, Medicaid may provide options for paying a family member who provides in-home care for a loved one.

Read: How to Get Paid to Care for Aged Parents or Other Family Members

Does Medicare pay for dementia patients to get home health care?

In accordance with the standards outlined above, Medicare will, in fact, pay for intermittent medically essential home health care services, provided that the patient meets the criteria. On the other hand, it is essential to keep in mind that Medicare does not provide coverage for the long-term personal care and monitoring that an elderly person with dementia would ultimately need in order to be able to continue living at home securely. In most cases, the payment for these kinds of nonmedical home care services comes out of the patient’s own pocket or comes from some other source of coverage.

Have you read: How Much Does It Cost to Provide Dementia Care at Home?

When it comes to home health care, how long will Medicare pay for it?

Care provided to beneficiaries in their homes on a “part-time” or “intermittent” basis is covered by Medicare. In this context, “less than seven days a week” or “less than eight hours per day for a period of three weeks or less” refers to services that are required for a shorter amount of time. As it is expected that the patient would no longer need this treatment after sixty days, the patient’s primary care physician will need to recertify the patient’s plan of care.

The Medicare criteria will decide how often and for how long a senior gets care. When a patient’s demands go beyond those that may be met by intermittent treatment, Medicare is no longer an option for financing. Medicare sees services for home health care as a strategy to postpone or delay placement in an assisted living community or skilled nursing facility. It does not consider them as a full replacement for these types of facilities.

Does Medicare pay for treatment provided in the patient’s home?

If there is just one service that has to be provided, Medicare will not pay for non-medical in-home care. Personal home care services, which include assistance with activities of daily living, as well as homemaker services, which include things like light housekeeping, laundry, and meal preparation, will only be covered if they are included as part of the home health services that are outlined in a patient’s care plan. Medicare does not provide coverage for round-the-clock in-home care of any type, nor does it pay for food delivery services.

Does Medicare Advantage pay for treatment provided in the patient’s home?

There is coverage for in-home medical care provided through Medicare Advantage plans. Private health insurance firms that are accepted by Medicare are the ones that provide these plan options. Coverage that is equivalent to that offered by Medicare Parts A and B must be provided by advantage plans as a minimum requirement. On the other hand, they could impose certain extra requirements and expenses. For instance, the majority of benefit plans impose obligations on older citizens to use the health care providers that are part of the plan’s network.

To be eligible for coverage of home health care under a Medicare advantage plan, an individual may need to fulfil one or more of the following requirements:

Before obtaining treatment, you are required to obtain a reference from a physician.

Use a home health care agency that is part of the network that is provided by the plan.

Copayments must be made.

How much does it cost to get home health care that is covered by Medicare?

For seniors who are eligible and have original Medicare coverage (Part A and/or Part B), there is no out-of-pocket cost associated with receiving home health care services that have been prescribed by a physician and are carried out by a home health agency that has been awarded Medicare certification. Nevertheless, if a patient receives additional treatments that are not included in the approved care plan, those services will not be reimbursed and the patient will be responsible for paying for them out of pocket.

Before beginning treatment, the home health agency must provide the patient with either an itemized receipt or a plan of care that details the aspects of the care that are covered by Medicare as well as those that are not. Also, the organization has to provide the patient with a formal “Advance Beneficiary Notice” (ABN) that outlines any treatments and long-term medical equipment that Medicare will not pay for, in addition to any expenditures that are the patient’s responsibility to pay.

Help families to navigate the Medicare system and home care options

Medicare may be a useful resource for helping families afford some of the expenses associated with in-home care in some circumstances; however, there are a number of eligibility limits and service limitations. When it comes to the question of how to pay for in-home care, families, fortunately, have a wide variety of choices available to them.

It might be difficult to find an appropriate home care service that meets the requirements of your loved one as well as their financial constraints. But, our Care Consultants are here to assist in making your search more manageable. In addition, the AgingCare forum provides the chance to interact with other family carers who can provide support, guidance, and answers to questions.


Call now for a free consultation

Are you looking for compassionate and reliable home care services in Orange, Osceola, Brevard, or Seminole counties? Look no further than our professional team at Embracing Home Care! Our highly trained caregivers provide personalized care for seniors and individuals with disabilities, ensuring that they can continue to live independently in the comfort of their own homes. With a variety of services including personal care, transportation, meal preparation, and companionship, we strive to improve the quality of life for our clients and provide peace of mind for their families. Contact us today at 321-758-2036 to learn more about our affordable and flexible home care options and to schedule a consultation with one of our care coordinators. Let us help you or your loved one live life to the fullest!  We serve Central Florida cities like Orlando, Apopka, Ocoee, Winter Garden, Sanford, Altamonte Springs, Casselberry, Palm Bay, Melbourne, Titusville, Kissimmee, St.  Cloud, Celebration, Lake Mary, Oviedo, Longwood, Winter Springs, Cocoa Beach and more.

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