A 90-year-old woman needed home care after a hospital and SNF stay. Her family worked to set up the care with a knowledgeable, compassionate care coordinator. Nonetheless, the coordinator definitively informed the family that Medicare simply does not cover home health aide care. This is not true. While obtaining Medicare-covered home health aides is increasingly difficult, this care is fully part of the Medicare home health benefit.
Medicare law and regulations clearly authorize coverage for home health aides to provide personal hands-on care for people who meet other criteria, including being homebound and need skilled nursing and/or therapy. To help stakeholders understand what is covered under the law, we reiterate here the legal criteria for Medicare-covered home health care – including for home health aides.
Home Health Care Can Be Covered By Medicare If It Meets the Following Criteria:
- The patient must see a physician or other authorized health care provider. The physician/provider must write a brief narrative describing the patient’s clinical condition and how the patient’s condition supports homebound status and the need for skilled home health services.
- A physician/authorized provider has signed or will sign a plan of care
- The patient is homebound. This standard is met if leaving home requires a considerable and taxing effort which may be shown by the patient needing personal assistance, or the help of a wheelchair or crutches, or other supportive device. Occasional but infrequent “walks around the block” and outings are allowable. Attendance at an adult day center or religious services is not an automatic bar to meeting the homebound requirement.
- The patient needs skilled nursing care on an intermittent basis (at least once every 60 days), or physical or speech-language pathology. (Occupational therapy can continue Medicare home health care but not begin coverage.)
- The care must be provided by, or under arrangements with, a Medicare-certified provider.
Medicare Coverable Home Health Services
If the triggering conditions described above are met, the beneficiary is eligible for Medicare coverage of home health services. Generally, there is no deductible or coinsurance. (Check Medicare Advantage plans – some MA plans may include cost-sharing.)
Home health services include:
- Part-time or intermittent nursing care provided by or under the supervision of a registered professional nurse;
- Physical, occupational, or speech therapy;
- Part-time or intermittent home health aide services;
- Medical social services under the direction of a physician.
Other Important Points:
- Medicare coverage should not be denied simply because the patient’s condition is “chronic,” “stable,” or unlikely to improve. “Restorative potential” is not necessary. Medicare coverage is available to maintain an individual’s condition or slow deterioration.
- There is no legal limit to the duration of the Medicare home health benefit. Medicare coverage is available for necessary home care so long as coverage criteria are met – even if it extends over a long period of time.
- Resist arbitrary caps on coverage imposed by the Medicare contractor or insurer. For example, do not accept provider assertions that aide services in excess of one visit per day/week are not covered, or that daily nursing visits can never be covered.
- The doctor and other health care providers are the patient’s most important allies. If it appears Medicare coverage will be denied, ask them to provide information to help demonstrate that the standards above are met.
- Prior to the discontinuance of Medicare covered services the home health agency must issue a written notice of non-coverage. If you disagree with the discharge, pursue an appeal as soon possible, as directed in the notice.
1. Review the Medicare home health qualifying criteria in the Center’s Home Health Quick Screen above. If you meet these criteria follow the advocacy steps below.
2. Contact the individual’s physician and other providers, inform them about what is happening, and ask them to support the need for the home health services. The physician (or other authorized provider) should be the person who decides whether home health services are necessary and whether they should be reduced or terminated.
- If the physician/authorized provider is able to help, request a written statement explaining the on-going need for the services and that the medical circumstances leading to the order for home health services are still present. Ask the physician/authorized provider not to sign a discharge order for home health services if s/he continues to think the services are medically appropriate.
3. If the home health care is to be inappropriately discontinued, follow the steps outlined in the Center for Medicare Advocacy’s home health expedited appeal Self Help Packet.
4. Ask the home health agency to hold a meeting with the patient and family prior to any termination or reduction in services to discuss the appropriateness of the proposed action and the continued need for care.
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*(But often is not.) These are the criteria per Medicare law, regulations, and policy – but the criteria are often misinterpreted or ignored. Thus, Medicare coverage and access to care, especially by health aides, are frequently inaccessible.
July 24, 2025 – J. Stein