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Patient Eligibility

Eligibility is an important step in the home health process, and your patients may have questions about the requirements they need in order to qualify. As a quick reference guide we've included the Medicare eligibility requirements for home health. This may help your patients gain a better understanding.

Eligibility Requirements

Medicare covers eligible home health services like these:

Usually, a home health care agency coordinates the services your physician orders for you. Medicare does not pay for the following services, which are often provided through Private Duty companies:

  • 24-hour-a-day care at home
  • Meals delivered to your home
  • Homemaker services (like shopping, cleaning, and laundry), when this is the only care you need
  • Custodial or personal care (like bathing, dressing, or using the bathroom), when this is the only care you need

Who’s Eligible?

All people with Medicare (either Part A and/or Part B) who meet all of these conditions are covered:

  • You must be under the care of a doctor, and you must be getting services under a plan of care created and reviewed regularly by a doctor.
  • You must need, and a doctor must certify that you need, one or more of these: 
    • Intermittent skilled nursing care (other than drawing blood)
    • Physical therapy, speech language pathology, or occupational therapy. These services are covered only when the complexity of the service is such that it can be performed safely and/or effectively only by or under the general supervision of a skilled therapist and the treatment is specific, safe and an effective treatment for the your illness or injury. To be eligible, the skilled services must also be: (1) reasonable and necessary to the treatment of your illness or injury or (2) restoration of your illness or injury or (3) maintenance of function affected by your condition
  • You must be confined to the home (homebound), and a doctor must certify that you are homebound

You're not eligible for the home health benefit if you need more than part-time or "intermittent" skilled nursing care. You may leave home for medical treatment or short, infrequent absences for non-medical reasons, like attending religious services. You can still get home health care if you attend adult day care.

Source: Medicare.gov; CMS.gov

*Information as of April 9, 2020

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