Home Health Care vs Home Care: What Medicare Actually Covers

Home health care is medical care at home: part-time visits from nurses or therapists, ordered by a doctor and given by a Medicare-certified agency. Home care is non-medical help with daily life, like bathing, meals, errands and company. Medicare covers home health for people who are homebound and need skilled care, with nothing owed for the visits themselves. It does not pay for home care when that's the only help someone needs, so families usually arrange and pay for that part themselves, or through Medicaid, the VA or long-term care insurance.

Many families end up with both at once. Here's who does what, who pays, and what to write down.

The short version: side by side

The names don't help. "Home health aide" is a job title in both worlds, and some agencies do both. When you call, ask which side you're talking to.

Who qualifies for Medicare home health

Medicare.gov's home health services page and its booklet Medicare & Home Health Care set out the conditions, and the federal rule behind them is 42 CFR 409.42. All of these have to be true:

1. Your parent is under the care of a doctor or allowed provider (like a nurse practitioner or physician assistant) who sets up and regularly reviews the plan of care.
2. They need skilled care on a part-time or intermittent basis: skilled nursing (a visit just to draw blood doesn't count), physical therapy, speech-language pathology, or continued occupational therapy.
3. They're homebound. More on that below, because it's the condition families most often misjudge.
4. The provider has seen them face to face for the reason they need home health. Under 42 CFR 424.22, that visit has to fall no more than 90 days before home health starts or within 30 days after, and the provider documents the date.
5. A Medicare-certified agency provides the care.

One quirk: occupational therapy can't start home health on its own. Medicare.gov says it must first be ordered along with nursing, physical or speech therapy; after that it can continue alone.

"Homebound" doesn't mean bedbound

The booklet describes homebound as having trouble leaving home without help (a cane, walker, wheelchair, crutches, special transportation or another person), or leaving isn't recommended because of an illness or injury, and leaving normally takes a major effort.

Your parent can still leave. The booklet allows medical appointments and short, infrequent outings like "an occasional trip to the barber, a walk around the block," or a family funeral. Adult day care and religious services don't disqualify them either. So a mother who goes to church on Sunday may still be homebound; one who drives herself to the grocery store twice a week probably isn't. CMS's policy manual adds that frailty from advanced age, on its own, doesn't make someone homebound.

No hospital stay required

Unlike rehab in a skilled nursing facility, with its 3-day inpatient rule, home health doesn't need a hospital stay first. A parent at home with a worsening wound or new trouble walking can be referred by their regular doctor. If your parent is coming home from an operation, our guide to caring for a parent after surgery covers the first weeks.

The hospital stay only changes which part of Medicare pays. Chapter 7 of CMS's Medicare Benefit Policy Manual says for someone with both Part A and Part B, Part A covers up to 100 visits when home health starts within 14 days of a hospital stay of at least 3 days in a row (or a covered skilled nursing stay). Part B pays for the rest, and for people who come "from the community" with no qualifying stay. Either way, your parent owes nothing for covered visits.

What Medicare covers at home

Covered home health services include:

• Skilled nursing: wound care for pressure sores or a surgical wound, IV or nutrition therapy, injections, monitoring a serious illness, and teaching your parent and family how to manage medicines or diabetes care
• Physical therapy, occupational therapy and speech-language pathology
• Medical social services, like counseling or help finding community resources, when your parent is also getting skilled care
• Home health aide visits for help walking, bathing, grooming or feeding, but only when your parent is also getting skilled nursing or therapy
• Medical supplies like wound dressings, when ordered

Durable medical equipment such as a walker or wheelchair is billed separately: after the Part B deductible, your parent pays 20% of the Medicare-approved amount.

How much "part-time or intermittent" is

Medicare.gov says skilled nursing and home health aide services combined can usually run up to 8 hours a day and 28 hours a week, or up to 35 hours a week for a short time if the provider decides it's necessary. Someone expected to need full-time skilled nursing over a long period usually won't qualify.

Those are ceilings. Staff visit as often as the provider orders, so read the order.

It isn't automatically short-term

Home health is often described as short-term care after a hospital stay, but Medicare.gov says someone who qualifies can get unlimited visits, and the Center for Medicare Advocacy says there's no legal time limit while the coverage rules are met. The plan of care is reviewed at least every 60 days.

What Medicare won't pay for

Medicare.gov and the booklet both rule out:

• 24-hour-a-day care at home
• Meals delivered to the home
• Homemaker services like shopping, cleaning and laundry (Medicare.gov adds: unrelated to the care plan)
• Custodial or personal care, like help bathing, dressing or using the bathroom, when that's the only care your parent needs

That last line is the hinge. A home health aide can help your father shower while a nurse comes for his wound. When the wound heals and the nurse stops, the aide stops too, even if he still can't shower safely alone. That's usually when families discover home care.

Medicare.gov's long-term care page adds that Medicare and most health insurance, including Medigap, don't pay for non-medical long-term care, at home or anywhere else.

The notices to watch for

The booklet describes three written notices from a home health agency. Keep every one.

The booklet says the reviewer generally responds within 3 days of the notice's effective date and will talk to your parent's doctor, so ask the doctor to back the appeal.

"Not improving" isn't a reason to stop

If you hear that your parent has "plateaued" and therapy has to end, know about Jimmo v. Sebelius. CMS's Jimmo settlement page says the 2013 settlement clarified that coverage of skilled nursing and therapy in home health (and skilled nursing facilities and outpatient therapy) "does not turn on the presence or absence of a beneficiary's potential for improvement, but rather on the beneficiary's need for skilled care." Skilled care to maintain your parent's condition or slow decline can be covered.

The Center for Medicare Advocacy, lead counsel in the case, says it still hears from people denied care because they aren't improving.

So the useful question isn't "is she getting better?" but "does she still need a nurse's or therapist's skill to do this safely?" If yes, ask the doctor to write that down.

How Medicare Advantage is different

The Medicare & You 2027 handbook says Medicare Advantage plans provide almost all the medically necessary services Original Medicare covers, but they may require prior authorization and may limit your parent to providers in their network. For home health specifically, the booklet says a plan may require your parent to use agencies it contracts with. The Center for Medicare Advocacy notes some plans charge cost-sharing for home health, where Original Medicare charges none.

Before the first visit, call the number on your parent's plan card. Ask which agencies are in network, whether visits are approved and for how long, and what your parent owes per visit. Note the date, the person's name and any reference number.

Extra benefits are, in the handbook's words, generally limited, so check the plan's Evidence of Coverage, not an ad. Our list of Medicare documents to keep for a parent shows which papers say what the plan covers.

Paying for home care: where families look

Since Medicare won't cover help that's only personal care or housekeeping, families piece home care together. All of these vary by state.

Medicaid home and community-based services. For a parent with limited income and assets, Medicaid may pay for help at home. Medicaid.gov's page on 1915(c) waivers says nearly all states and DC run them, with standard services including homemaker, personal care, adult day health and respite. The catch: your parent must need an institutional level of care, and states cap how many people a waiver serves, so ask about a wait. Before any money changes hands, read up on the Medicaid look-back period.

PACE. Medicare.gov's PACE page describes the Program of All-inclusive Care for the Elderly, offered in some states for people 55 or older who live in a PACE service area, need a nursing home level of care as certified by the state, and can live safely in the community with PACE's help.

The VA. For an enrolled veteran, the VA's Homemaker and Home Health Aide program can send an aide from a VA-contracted agency to help with daily activities, if your parent meets the clinical criteria and the service is available locally. A copay may apply depending on service-connected disability status. Start with a VA social worker.

Long-term care insurance. The Medicare & You handbook names it as a way to pay for non-medical care. If your parent bought a policy years ago, find it and read how a home care claim starts.

The Area Agency on Aging. The Eldercare Locator (1-800-677-1116) connects you to your parent's local agency, which knows what help exists nearby. Our guide to respite care for caregivers covers it further.

Family and private pay. For many families, this is most of it. Paying a relative or hiring an aide directly has tax and Medicaid angles; our post on siblings sharing caregiving points to the IRS and AARP guidance.

Finding a Medicare-certified home health agency

Medicare.gov says the provider should give you a list of agencies serving your area and must disclose any financial interest in them. You have a say in which agency you use, though availability or your parent's plan may limit the choice. To check agencies yourself:

1. Search Care Compare by ZIP code for home health services. CMS's home health star ratings page explains the two kinds of stars: Quality of Patient Care, from agency assessments and Medicare claims, and Patient Survey, from a survey of patients. An agency with fewer than 40 completed surveys over the year-long reporting period gets no survey stars, so a missing rating isn't a bad one.
2. Ask your State Survey Agency for the survey report. The booklet says this agency inspects and certifies home health agencies and can give you the report on any agency you're considering.
3. Ask the booklet's checklist questions: Can it give the care and hours the doctor ordered, starting when needed? Is staff available nights and weekends for emergencies? Has it explained what your parent would pay?

Two booklet rules that surprise people: Medicare pays only one home health agency at a time, and your parent can switch agencies any time, with a new referral from the doctor and a heads-up to both agencies.

What to keep in the binder

With two kinds of help coming to the house, the binder is where everyone looks first. Put a copy of the schedule on the fridge too.

For home health:

• Agency name, main number, after-hours and weekend number, and the name of the nurse or therapist in charge
• A copy of the plan of care, which lists the services, who gives them, how often, equipment and expected results
• The ordering provider's name and number, and the date of the face-to-face visit
• Visit schedule, with who is coming on which day
• Every notice: ABN, HHCCN, NOMNC, and any Medicare Advantage approval letter
• The state home health hotline number, which the agency should give you at the start
• Your parent's medication list, updated after each visit if anything changed

For home care:

• Agency or aide name, phone, and who to call if they can't come
• Days and hours, and what the aide does and doesn't do
• Aide instructions: how your parent likes help in the shower, what they eat, what calms them, where the spare key is
• Who pays, and where the agreement is kept
• An "if something's wrong" line: 911 first for an emergency, then which family member

The booklet's fraud signs include visits that were billed but never happened. Compare the visit schedule with your parent's Medicare Summary Notice now and then.

A sibling stepping in needs all of this too; our caregiver backup plan covers the handoff. If the agency won't discuss your parent's care with you, see the HIPAA authorization for a parent.

Frequently asked questions

Does Medicare pay for home care for the elderly?

Not for non-medical home care alone. It pays for home health when your parent is homebound and needs part-time skilled nursing or therapy, which can include some aide help with bathing. Personal care as the only need, housekeeping, meal delivery and 24-hour care aren't covered.

How long will Medicare pay for home health care?

There's no set limit. Medicare.gov says someone who qualifies can get unlimited visits, as long as they stay homebound and need intermittent skilled care. The plan of care is reviewed at least every 60 days.

Does my parent need to be in the hospital first?

No. Their regular doctor or allowed provider can order home health after seeing them. A recent hospital stay only changes whether Part A or Part B pays.

Can my parent get home health and private home care at the same time?

Yes. The home health agency handles the skilled visits Medicare covers; family or a private aide covers the rest. Keep one shared schedule.

Keep it in one place

Home health brings orders and notices; home care adds instructions and phone numbers. You can organize all of it with this guide and a three-ring binder. Or Emergency Binder Now can do the organizing from about 25 minutes of guided questions, with your parent's doctors, insurance, medications and contacts in one printable binder and a list of what's still missing. You can see a sample binder first.

This article is general information, not medical, legal or financial advice. Medicare rules, Medicare Advantage plans and Medicaid programs change and vary by plan and state. For your parent's situation, ask their doctor, their plan, 1-800-MEDICARE or your local State Health Insurance Assistance Program.