Home Health
Medicare Home Health Eligibility: The Homebound Rule and What Skilled Care Means
Medicare home health needs you to be homebound and to need skilled care. See what homebound allows, what skilled care means, and what you pay.
Key takeaways
- You must be homebound. Leaving home must take great effort and happen rarely, for short times.
- You must need skilled care, such as skilled nursing or therapy, on a part-time basis.
- A doctor must order the care and set up a plan of care, and must check that plan over time.
- Covered home health services cost $0 (Ledger A13).
- Durable medical equipment costs 20% of the Medicare-approved amount, and the Part B deductible applies (Ledger A13).
- Part B coinsurance is in most cases 20% of the Medicare-approved amount after the deductible (Ledger A16).
A patient comes home from the hospital. A nurse at the desk says Medicare home health can help, but only if the patient is homebound. That word stops many families cold. They picture a person who can never leave the house at all. The rule means something more precise than that. This guide sets out the homebound rule, the skilled care rule, and the costs, in clear terms. Our Home Health section holds more guides on care at home.
What homebound means
Homebound means leaving home is hard for you. Your health makes it a major effort to go out. Most of your time is spent at home because of that effort. You may need the help of a person, a cane, a walker, or a wheelchair to leave at all.
Homebound does not mean you can never leave. Trips for medical care do not break the rule. A trip to a doctor, a clinic, or a hospital for treatment fits the rule. Short trips for other needs can fit too, if they are rare and short. A trip to a place of worship or a rare family event can fit, as long as such trips stay rare and take real effort.
What breaks the rule is a pattern of easy, frequent trips out for normal life. If you can leave home often and with ease, Medicare will not see you as homebound. The agency that visits you will ask about your trips and note them in your record. Answer with care, and keep the facts straight.
What skilled care means
Skilled care is care that a nurse or a therapist must give, or must teach you to give. It is more than help with daily tasks. A home health aide who helps you bathe is a great help, but that help alone is not skilled care.
Skilled care can include:
The care must be part-time. Visits come on set days, for a set span of weeks. Home health is not round-the-clock care at home. If you need a person with you at all hours, that need points to a different kind of plan.
- Wound care for a cut, a sore, or a surgical wound.
- Teaching you how to give your own shots or care for a tube or a drain.
- Checks of a new drug and how it affects you.
- Physical therapy to help you walk, climb steps, or regain strength.
- Speech therapy or work therapy set by a care plan.
The doctor's role
A doctor, or a clinician the rules allow, must order home health for you. That clinician must have seen you face to face for the health problem that drives the care. The visit can be a short time before or after the care starts, within the span the rules set.
The doctor sets a plan of care with the home health agency. The plan names the visits, the care to be given, and the goals. The doctor signs the plan and reviews it at set times. If your needs change, the plan can change too.
The agency must be a Medicare-approved home health agency. Our guide on home health after a hospital stay walks through how a hospital discharge leads to these steps. Our Care Compare guide shows how to check an agency's quality scores before you choose one.
Care that rides along with skilled care
Once you qualify for skilled care, some other help can ride along. A home health aide can help with bathing, dressing, and meals for a short time, as part of the plan. A social worker visit can help you find support at home. These services add to skilled care. They do not replace it.
If skilled care ends, the aide help under home health ends too. That is a key point for families to grasp early. A plan built on aide hours alone will not last once the skilled need is met. Ask the agency at the start what will happen when skilled care ends, so the shift does not come as a shock.
What you pay
Covered home health services cost $0 (Ledger A13). You do not pay a copay for each nurse or therapy visit that the plan covers.
Durable medical equipment is billed in a different way. For equipment such as a hospital bed or a walker that the plan supplies, you pay 20% of the Medicare-approved amount, and the Part B deductible applies (Ledger A13). That split is part of the Part B pattern: in most cases you pay 20% of the Medicare-approved amount after the deductible, when the provider accepts assignment (Ledger A16).
Meals, private duty nursing, and drugs you take by mouth are not part of home health payment. If you need those, ask how they will be billed before you agree to them. Surprise bills at home hurt just as much as bills from a hospital stay.
Who pays for what
- Medicare pays for covered home health services for a person who is homebound and needs part-time skilled care under a doctor's plan. The patient share for those services is $0 (Ledger A13).
- The patient pays 20% of the Medicare-approved amount for durable medical equipment, after the Part B deductible (Ledger A13, Ledger A16).
- Original Medicare does not pay for long-term help with daily tasks when that is the only care you need.
- A Medicare Advantage plan must cover home health too, but it can use its own rules and networks, and it may ask for approval first.
- Medicaid can pay for home care help for people who qualify under their state rules. Private pay covers care no program covers.
Sample situation
David is 79 and comes home after hip surgery. He uses a walker and cannot leave home without his son's help. A trip out takes him a long time to recover from. His doctor orders home health. A nurse visits to care for his wound and check his drugs. A therapist visits to teach him safe steps with the walker and to build his strength. David is homebound and needs part-time skilled care, so covered services cost him $0 (Ledger A13). The agency arranges a walker for him as equipment, and David pays 20% of the Medicare-approved amount for it after his deductible (Ledger A13). He still goes to his follow-up visit at the clinic, and that trip does not break his homebound status.
Steps to get care started
- Ask the hospital or your doctor to refer you to a Medicare-approved home health agency.
- Confirm the face-to-face visit with your doctor is set and noted.
- Ask the agency to state, in writing, which visits are skilled care and which are aide help.
- Ask what equipment you will get and what your 20% share will be (Ledger A13).
- Keep a list of your trips out of the home and the reason for each one.
- Ask what happens to aide help when skilled care ends, and plan for that date.