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How Does Medicare Coverage for Home Health Care Differ by State?
Date Updated: December 13, 2024
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Medicare coverage for home health care doesn’t differ by state when Part A or Part B — collectively known as original Medicare — fund services. The government insurance program operates uniformly nationwide, with identical eligibility requirements, service provision and coverage. However, home health coverage under Part C varies among providers.
Original Medicare Coverage of Home Health Care
Nationwide, individuals qualify for original Medicare if they meet any of the following criteria:
- They or their spouse have earned enough credits through payroll taxes or paid premiums, and are 65 or older, or
- They receive Social Security Disability Insurance
- Have an ALS diagnosis
- Have end-stage kidney failure
Waiting limits apply for those receiving SSDI, except for people with ALS or end-stage renal failure. For home health services coverage, a physician must prescribe services, agencies must have Medicare certification and individuals must meet the following additional criteria:
- Be homebound, as certified by a doctor
- Have a medical need for home health care, as certified by a doctor
Medicare Advantage Coverage of Home Health Care
Medicare Advantage plans, also known as Part C plans, offer private insurance coverage through Medicare-approved providers. Individuals pay monthly premiums for bundled coverage. To qualify, people must remain enrolled in Parts A and B of standard Medicare, meaning basic eligibility requirements remain the same.
Because Part C plans must offer at least the same coverage as original Medicare, Part C providers can’t impose stricter eligibility criteria for home health care. However, individuals may need provider permission before services start. Additionally, people can only use home health care providers within their insurer’s service network.
Medicare-Covered Home Health Care Services
Medicare pays for various clinical and therapeutic services in a person’s home. Care teams include diverse medical professionals. Original Medicare covers:
- Skilled nursing care
- Physical therapy
- Speech therapy
- Occupational therapy (for those initially receiving skilled nursing, physiotherapy or speech therapy)
- Personal care support (for those also receiving skilled care)
- Medical social services
Medicare Advantage covers at least the same home health care services as original Medicare. However, many plans include benefits beyond those covered by Parts A and B. For example, providers may include extra nonmedical home care services or waive the requirement to qualify for skilled nursing or another rehabilitation therapy before becoming eligible for occupational therapy. Moreover, while Medicare covers durable medical equipment, it pays for limited home adaptations. However, Medicare Advantage plans may fund home modifications, safety devices, and medical supplies and equipment. Individuals should check exact coverage with their insurers.