What Medicare Does and Does Not Cover at Home

This is the single most consequential misunderstanding in home care, and it is almost always discovered at the worst moment: several weeks after a hospital discharge, when the covered service ends and the family realizes the help their mother actually depends on was never the covered part.

Rules change and individual circumstances vary, so confirm anything specific with Medicare directly or with the agency involved. What follows is the shape of it, which is what most families are missing.

The distinction Medicare is built on

Medicare pays for skilled care. It does not, as a rule, pay for custodial care.

Skilled care is treatment requiring a licensed clinician: nursing, physical therapy, occupational therapy, speech therapy. It treats a condition and it is expected to end.

Custodial care is help with the activities of daily living: washing, dressing, meals, mobility, supervision. It does not require a clinician and it may go on for years.

That second category is what most people mean by home care, and it is the category Medicare generally does not fund.

What Medicare home health can include

Where somebody qualifies, the home health benefit can cover intermittent skilled nursing, physical and occupational therapy, speech-language pathology, medical social services, and some medical supplies.

It can also include a home health aide for personal care, but with an important condition: the aide is generally only covered while the person is also receiving skilled care. When the skilled service ends, the aide ends with it.

That condition is the mechanism behind the cliff families fall off, and it is worth understanding before it happens rather than afterwards.

The conditions attached

Broadly, qualifying requires a doctor certifying that home health is needed, a plan of care that is reviewed, care delivered by a Medicare-certified agency, and the person being considered homebound.

“Homebound” does not mean bedbound or never leaving. It generally means leaving home requires considerable effort, or help, and that absences are infrequent or short. People rule themselves out unnecessarily on this point, assuming that attending church once every two weeks disqualifies them. Ask rather than assuming.

The care must also be intermittent rather than continuous. Medicare home health is visits, not shifts.

What it does not cover

Stated plainly, because this is the list that matters:

• Around-the-clock care at home.
• Homemaker services such as cleaning and laundry, where that is the only help needed.
• Personal care alone. Help with bathing and dressing, where no skilled service is involved.
• Meals delivered to the home.
• Long-term custodial care, whether at home or in a facility.

In other words: the ongoing daily support that keeps somebody living independently is, for most people, not a Medicare benefit. Our guide to the difference between home care and home health care covers which service is which.

Medicare Advantage may differ

Medicare Advantage plans must cover everything original Medicare covers, and some offer additional benefits which in recent years have sometimes included limited in-home support, respite, or help around the house.

These vary enormously between plans and between years. If somebody is on an Advantage plan, it is worth reading the current benefits document rather than assuming it matches original Medicare, and worth checking again at each annual enrollment.

Ask the plan directly, in writing, what in-home support is included this year. Do not rely on last year’s answer, and do not rely on a general statement about what Medicare covers.

Planning around the cliff

If somebody is coming home from the hospital with home health arranged, do this early:

Establish what has been ordered and for roughly how many weeks. Ask specifically what happens when it ends. Work out which of the daily tasks will still need doing at that point, because those are the ones nobody has funded. Then look at how that gets covered: privately, through Medicaid if eligible, through veterans’ benefits, or by family.

Doing this in week one rather than week six is the difference between a planned transition and a scramble. Our piece on starting home care after a hospital stay covers the rest of that first two weeks.

If you are denied or the service is stopped

You have appeal rights, and they are worth using. Home health services are sometimes ended on the basis that somebody is not improving, and improvement is not the correct standard: maintaining a condition or slowing decline can also justify skilled care.

If a service is being terminated and you disagree, ask for the decision in writing and ask about the expedited appeal process. Families who push back on this are frequently successful, and most never try.

Where the money actually comes from for the rest

For long-term daily support, the realistic sources are Medicaid through Community HealthChoices for those who qualify, veterans’ benefits where there is service history, long-term care insurance, and private payment.

Our guides to Pennsylvania Medicaid waivers and budgeting for home care cover those routes in more detail.

Questions that get a straight answer at discharge

Ask these before anybody leaves the ward, and write the answers down:

• Is what has been arranged skilled care or personal care? Use those exact words, because they are the ones in the paperwork.
• Which agency, starting when, how many visits a week, for how many weeks?
• Is a home health aide included, and does that stop when the therapy stops?
• Who is covering the mornings, the evenings and the weekends that nobody has mentioned?
• What is the plan for the day after this ends?

That last question is the one that changes outcomes, and it is almost never volunteered. Discharge planning is measured on getting somebody home safely, not on what happens six weeks later.