Does Medicare Cover Home Health Care? What Texans Should Know

After a fall, a surgery, or a hard stretch with a chronic illness, getting care at home can make a big difference. That's especially true in Texas, where many people live an hour or more from the nearest hospital. Medicare does cover home health care, and covered services cost you nothing. But the rules are narrower than most families expect.

What Medicare home health care covers

Both Part A and Part B cover home health services. If you qualify, covered care can include:

• Part-time or intermittent skilled nursing, such as wound care, injections, IV or nutrition therapy, and monitoring a serious or unstable condition
• Physical therapy, occupational therapy, and speech-language therapy when you meet certain conditions
• Medical social services
• Part-time home health aide care, like help with bathing or walking, but only if you're also getting skilled nursing or therapy at the same time
• Medical supplies for use at home and durable medical equipment

If you qualify, there's no set limit on the number of visits.

Who qualifies

You generally need to meet all of these:

1. You're homebound. Leaving home takes a lot of effort, and you need help to do it (like a walker, wheelchair, special transportation, or another person), or your doctor advises against it.
2. You need part-time or intermittent skilled care, like nursing or therapy.
3. A doctor or other provider sees you in person, confirms you need home health care, and orders it.
4. A Medicare-certified home health agency provides the care.

Being homebound doesn't mean you can never leave. Medicare allows trips for medical treatment and short, infrequent outings, like going to church. You can also still qualify if you attend adult day care.

"Part-time or intermittent" has a specific meaning. In most cases, Medicare says you may get skilled nursing and home health aide services up to 8 hours a day combined, and up to 28 hours a week. For a short time, your provider may decide you need more, up to 35 hours a week.

What Medicare won't pay for

This is the gap that surprises many Texas families. Medicare doesn't pay for:

• 24-hour-a-day care at home
• Home-delivered meals
• Homemaker services, like shopping and cleaning, that aren't part of your care plan
• Personal care, like bathing, dressing, or using the bathroom, when that's the only care you need

That kind of help is called custodial or long-term care, and Medicare generally doesn't cover it. If a loved one needs daily help, call your local Area Agency on Aging or HICAP to ask about other options. If income is limited, Texas Medicaid may also help; our guide to Medicare and Medicaid in Texas explains how the two work together.

What you'll pay, and the notices to watch for

Covered home health services cost $0. Covered medical equipment, like a walker or hospital bed, generally costs 20% of the Medicare-approved amount after the Part B deductible. Our guide to Part B medical equipment explains how that works.

Before care starts, the agency should tell you what Medicare will pay. If an item or service won't be covered, the agency should tell you, in writing, and give you a notice called an Advance Beneficiary Notice (ABN) before providing it. Read it before you sign.

If you're in a Medicare Advantage plan, your plan may have its own network of home health agencies and approval rules. Check with your plan before care begins.

Finding an agency in Texas

Your doctor should give you a list of agencies that serve your area, and tell you if they have a financial interest in any of them. You can also compare Medicare-certified agencies by ZIP code, including quality ratings, on Medicare.gov's Care Compare tool.

In Texas, home health agencies are overseen by Texas Health and Human Services, which calls them Home and Community Support Services Agencies (HCSSAs). In rural counties, fewer agencies may serve your area, so ask early which ones travel to your ZIP code.

Home health vs. other Medicare care

Home health is one of several ways Medicare covers care after an illness. If you need more care than a few hours a day, a short stay in a skilled nursing facility may fit better; see our guide to the 3-day rule for skilled nursing. For someone with a terminal illness, Medicare hospice can also be provided at home.

Free, unbiased help

For questions about your rights, an agency that's cutting off care, or what Medicare will pay, call HICAP at 1-800-252-9240 or 1-800-MEDICARE (1-800-633-4227). Both are free, and 1-800-MEDICARE offers help in Spanish.