TL;DR: Medicare may cover home health care if you are homebound and need skilled medical services ordered by a healthcare provider. Medicare also covers hospice care for eligible patients with a terminal illness. Most covered home health services have no copay under Original Medicare, and Luna Vista Home Healthcare & Hospice is a Medicare-certified provider that can help determine eligibility.
Medicare may cover home health care if you are homebound and need skilled nursing or therapy services, and it may cover hospice care if you have a terminal illness and meet Medicare’s eligibility requirements.
Coverage depends on factors such as your medical needs, physician documentation, and whether services are provided through a Medicare-certified agency.
Understanding Medicare home care benefits can help you make informed decisions for yourself or a loved one. This guide explains what Medicare covers, how to qualify for home health care, what hospice benefits include, and which services Medicare does not pay for.
If you have questions about eligibility or coverage, learn more about home health care in Albuquerque or contact Luna Vista to discuss your situation.
What Medicare Covers for Home Health Care
In short: Medicare Parts A and B cover skilled nursing, therapy, and related home health services when eligibility requirements are met. Most covered services have no copay under Original Medicare, although durable medical equipment may require coinsurance.
Does Medicare cover home health care? In many cases, yes. Medicare home health coverage may help pay for skilled medical services provided in the home when a patient meets Medicare’s eligibility requirements.
According to Medicare, Part A may cover home health care after a qualifying hospital or skilled nursing facility stay. Medicare Part B may cover medically necessary home health services when patients meet coverage requirements, even if they have not recently been hospitalized. Coverage details are available through Medicare’s official Home Health Services page.
Medicare home care benefits may include a range of skilled medical services designed to help patients recover from illness, injury, or surgery at home. Covered services may include:
- Part-time or intermittent skilled nursing care
- Physical therapy
- Occupational therapy
- Speech-language pathology services
- Home health aide services when skilled care is also being provided
- Medical social services
- Certain medical supplies used during treatment
- Durable medical equipment (DME), such as walkers or wheelchairs
Under Original Medicare, most covered home health services do not require a copay. Durable medical equipment is treated differently. After meeting the Medicare Part B deductible, patients typically pay 20% of the Medicare-approved amount for covered equipment.
People enrolled in Medicare Advantage plans also receive home health benefits because these plans must cover all services included under Original Medicare. Costs, provider networks, referral requirements, and prior authorization rules may vary by plan. Reviewing your plan documents can help you understand any additional requirements before services begin.
Care must be provided by a Medicare-certified home health agency. Luna Vista Home Healthcare & Hospice is Medicare and Medicaid certified and provides skilled nursing and therapy services throughout the Albuquerque metro area.
For additional guidance about Medicare home health coverage, the National Council on Aging provides a helpful overview.
How to Qualify for Medicare Home Health Care
In short: To qualify for Medicare home health care, you generally must be homebound, need skilled care, receive services under a physician-directed plan of care, and obtain care through a Medicare-certified agency.
Understanding how to qualify for home health care under Medicare starts with Medicare’s definition of eligibility. Medicare uses several specific criteria to determine whether home health services are covered, and all requirements must be met for coverage to apply.
First, you must be considered homebound. This does not mean you can never leave your home. Instead, leaving home must require considerable and taxing effort, assistance from another person, or the use of assistive equipment such as a walker, wheelchair, or cane. According to Medicare, brief and infrequent absences for medical appointments, religious services, or adult day care programs generally do not affect homebound status.
Second, you must need intermittent skilled services such as:
- Skilled nursing care
- Physical therapy
- Speech-language pathology
- Continued occupational therapy
Medicare home health coverage generally requires a medical need for skilled nursing or therapy services. Assistance with personal care alone does not typically qualify a patient for the home health benefit.
Third, a physician or authorized healthcare provider must establish a plan of care that outlines the services you need. The provider must regularly review and recertify the plan at least every 60 days.
Fourth, Medicare requires a face-to-face encounter with a physician or qualified healthcare provider within 90 days before home health services begin or within 30 days after care starts. This requirement helps confirm that home health services are medically necessary.
Finally, services must be delivered through a Medicare-certified agency. Medicare generally covers home health services only when they are provided through a Medicare-certified agency that meets federal requirements.
If you would like a broader explanation of eligibility and services, read Luna Vista’s article about what home health care is and who benefits.
If you are unsure whether you or a loved one qualifies, contact Luna Vista or call 505-440-8316 to discuss your situation.
Understanding Medicare Hospice Coverage
In short: Medicare Part A may cover hospice care for patients with a terminal illness and a life expectancy of six months or less, with little to no out-of-pocket cost for most covered services.
Home health care and hospice care serve different purposes. Home health care focuses on recovery, rehabilitation, and maintaining independence. Hospice care focuses on comfort, symptom management, and quality of life for patients with terminal illnesses.
Medicare hospice coverage is available through Medicare Part A when a hospice physician and the patient’s attending physician certify that the patient has a terminal illness with a life expectancy of six months or less if the illness follows its expected course. The patient must also choose palliative, comfort-focused care rather than treatment intended to cure the terminal illness.
Medicare hospice benefits are divided into two initial 90-day benefit periods followed by unlimited 60-day benefit periods. Coverage may continue as long as eligibility requirements are met. Patients also have the right to revoke hospice and return to standard Medicare coverage if circumstances change.
Covered hospice services may include:
- Physician services
- Skilled nursing care
- Medical equipment and supplies
- Prescription medications for symptom management and pain relief
- Home health aide and homemaker services
- Grief and bereavement counseling
- Short-term inpatient respite care
- Crisis care when medically necessary
Most hospice services have little or no out-of-pocket cost. Medicare may charge up to a $5 copay for certain prescription drugs used for symptom control and up to 5% coinsurance for inpatient respite care. For families evaluating hospice payment options, understanding these costs can help with care planning.
Hospice services are most often provided in a patient’s home but may also be provided in assisted living communities, nursing facilities, hospitals, or inpatient hospice facilities when medically necessary.
More information is available through Medicare’s Hospice Care resource.
Luna Vista Home Healthcare & Hospice provides hospice support throughout Albuquerque, Rio Rancho, Corrales, Placitas, Bernalillo, Bosque Farms, Los Lunas, and surrounding communities.
What Medicare Does Not Cover
In short: Medicare does not cover around-the-clock home care, custodial-only services, meal delivery, or housekeeping services when no skilled medical care is involved.
Understanding the limits of Medicare home care benefits is just as important as understanding what is covered.
Medicare generally does not cover:
- 24-hour-a-day care at home
- Custodial care when bathing, dressing, or toileting assistance is the only service needed
- Meal delivery programs (Meals on Wheels and similar services are separate programs)
- Housekeeping, shopping, and laundry services when no skilled care is required
- Prescription drugs under the home health benefit (these are typically covered through Medicare Part D)
For hospice patients, Medicare generally does not cover treatments intended to cure the terminal illness once hospice care has been elected.
Some services not covered by Medicare may be available through Medicaid programs, including New Mexico Home and Community-Based Services (HCBS) waiver programs. Eligibility requirements vary, so families should consult their local Medicaid office or discuss available options with a healthcare provider.
For questions about covered services or eligibility, visit Luna Vista’s home health care services in Albuquerque.
Frequently Asked Questions
How much does Medicare pay for home health care per hour?
Medicare does not pay for home health care by the hour. Medicare home care benefits are based on medical necessity and the physician-approved plan of care. Most covered home health services have no patient copay. Medicare reimburses certified agencies according to CMS payment systems rather than hourly billing rates.
How long will Medicare pay for home health care?
There is no fixed time limit for Medicare home health coverage. Medicare may continue paying for covered services as long as you remain eligible, need skilled care, and have a physician who recertifies your plan of care every 60 days. Coverage ends when the patient no longer meets the homebound requirement or no longer needs skilled care.
How do you qualify for home health care under Medicare?
To qualify for home health care under Medicare, you generally must be homebound, require skilled nursing or therapy services, receive care under a physician-approved plan, and obtain services through a Medicare-certified agency. See the qualification section above for a more detailed explanation of each requirement.
Will Medicare pay for home health care for dementia patients?
Yes, Medicare may cover home health care for dementia patients who meet standard eligibility requirements. The patient must be homebound and require skilled nursing or therapy services. Medicare does not cover custodial care alone. In some situations, Medicare may allow up to 35 hours of intermittent care per week, but conditions must be met.
Does Medicare Advantage cover home health care?
Yes. Medicare Advantage plans are required to cover all services covered under Original Medicare, including home health care. Costs, network restrictions, referral requirements, and prior authorization rules may vary. Review your plan documents carefully or contact Luna Vista for assistance verifying coverage.
What is the difference between home health care and hospice care?
Home health care focuses on recovery, rehabilitation, and maintaining independence through skilled medical services. Hospice care focuses on comfort, symptom management, and quality of life for patients with terminal illnesses. Patients receiving home health care may continue curative treatment, while hospice care requires choosing comfort-focused care instead. Both services may be covered by Medicare.
If you have questions about Medicare coverage, eligibility requirements, or home health and hospice services in Albuquerque, contact Luna Vista or call 505-440-8316 to discuss your situation.
