Who Qualifies for Home Health Care Services?
Team Carepolicy.usKey Summary
- Medicare sets the national baseline.
- To qualify you must be home-bound, need intermittent skilled care, complete a doctor’s face-to-face exam, and use a Medicare-certified Home Health Agency (HHA).
- Meet all four and Medicare covers nursing, therapy, and limited aide hours at $0 out-of-pocket, plus 80% of durable-medical-equipment costs.
- Medicaid can extend the help. Every state pays for basic home-health;
- optional Home- & Community-Based Services (HCBS) waivers add long-term custodial hours.
- California (Medi-Cal): No asset test as of 2024;
- income (≤ 138% FPL) is the main hurdle. The IHSS program funds non-skilled personal care.
- Texas: Programs such as Primary Home Care and STAR+PLUS serve residents who meet “medical-necessity” nursing-facility criteria.
- Other payers—VA, long-term-care (LTC) insurance, workers’ comp, private health plans—fill the gaps but each imposes its own clinical and financial rules.
- Private-pay costs: The 2024 national median runs about $34 per hour for a home-health aide.
- Provider reimbursement: Medicare pays HHAs a bundled 30-day rate (Prospective Payment System) rather than by the hour. Navigating these payment systems can be challenging, but CarePolicy.US offers insights into how agencies get paid and stay profitable.
1. Medicare: the federal baseline
The following table:
| Requirement | Medicare rule (2025) |
|---|---|
| Face-to-face exam | MD/NP/PA visit within 90 days before or 30 days after start of care |
| Home-bound status | Leaving home is a major effort or requires help/device |
| Intermittent skilled need | Fewer than 7 days/week and less than 8 hours/day for up to 21 days (extendable) |
| Certified provider | Care must be delivered by a Medicare-certified HHA |
Tip: Medicare never covers 24-hour or “custodial-only” care (bathing, meal prep, housekeeping) unless it is paired with a skilled clinical service.
2. Who qualifies near California?
Medicare beneficiaries who satisfy the four federal tests above.
Medi-Cal recipients within the 138% FPL income cap (no asset limit) can receive the same skilled visits and add IHSS hours for bathing, dressing, and other activities of daily living (ADLs). For those looking to start a home care agency in California, understanding these nuances is vital, and CarePolicy.US offers a guide to starting your agency.
Agencies must hold a California Department of Public Health (CDPH) Home Health license;
aides are fingerprint-cleared and listed on the state registry.
3. Who qualifies near Texas?
Medicare beneficiaries (federal rules apply).
Texas Medicaid: you must pass both the income/asset screen and the “medical-necessity” test (i.e., you’d otherwise need nursing-facility care).
Eligible Texans may receive up to 50 hours/week of attendant services through Primary Home Care or broader support under the STAR+PLUS HCBS waiver. Starting an agency in Texas? CarePolicy.US provides a comprehensive guide for Texas home health agencies.
Providers must be licensed as Home & Community Support Services Agencies (HCSSAs). CarePolicy.US offers specific policy and procedure manuals for HCSSAs in Texas.
4. What home-health services are covered?
The following table:
| Covered by Medicare | Usually excluded (unless via Medicaid HCBS or private pay) |
|---|---|
| "Skilled nursing (wound care, IV, injections)" | 24-hour attendant care |
| "Physical, occupational & speech therapy" | Meal preparation & grocery shopping |
| Home-health aide (only if skilled care is active) | "Routine housekeeping, laundry" |
| Medical social work | Long-term custodial ADL care |
| Medical supplies & 80 % of DME cost | "Transportation, companion services" |
5. How to see if Mom (or Dad) qualifies
- Book a face-to-face visit with her primary doctor.
- Request “home-health orders.” The doctor must certify home-bound status and an intermittent skilled need.
- Choose a Medicare-certified agency.
- Compare quality ratings on Medicare’s Care Compare site or ask CarePolicy.US for vetted options. Our expertise can help you find trusted providers.
- Welcome the first RN visit. The nurse completes an OASIS assessment and builds a 30-day Plan of Care.
- Recertify every 60 days. As long as the physician updates the Plan of Care and eligibility criteria persist, services can continue.
6. Medicaid applications—California vs. Texas
The following table:
| Step | California (Medi-Cal) | Texas (Medicaid) |
|---|---|---|
| Financial eligibility | Income ≤ 138 % FPL; no asset test | "Income ≤ SSI level or 138 % FPL; assets ≤ $2,000" |
| Medical test | Same as Medicare for skilled care | Must meet nursing-facility level of care |
| Choose provider | CDPH-licensed HHA or IHSS vendor | HCSSA with current Medicaid contract |
| Authorization | County DSS + physician order | State nurse review + managed-care approval |
Navigating these state-specific Medicaid applications can be complex. CarePolicy.US offers consultation services to guide agencies through these processes.
7. How long—and how much—does Medicare pay?
The following table:
| Parameter | Medicare policy |
|---|---|
| Episode length | "30-day “periods of care,” renewable indefinitely while criteria are met" |
| Daily visit limits | "Skilled nursing & aide services < 8 hrs/day, usually < 28 hrs/week (up to 35 hrs short-term)" |
| Beneficiary cost | $0 for visits; 20 % coinsurance on DME (after Part B deductible) |
| Agency payment | One bundled Prospective Payment System (PPS) rate per 30-day episode; CMS projects a modest rate increase for CY 2025 |
8. Which insurance plans will pay?
The following table:
| Payer | Pays for | Key limitations |
|---|---|---|
| Original Medicare / Medicare Advantage | Skilled intermittent nursing & therapy | Must be home-bound & meet clinical criteria |
| Medicaid HCBS waivers | Skilled + custodial ADL care | "State caps, waiting lists" |
| Long-term-care (LTC) insurance | Daily dollar amount for personal care | Must fail ≥ 2 ADLs or meet cognitive trigger |
| VA Aid & Attendance | Skilled & custodial support for qualified vets | Service thresholds; income/asset rules |
| Workers’ Comp / Auto PIP | Injury-related home-health & aide services | Must link to covered accident |
| Private health insurance | Post-acute skilled visits | Rarely covers custodial ADL help |
9. Choosing a Home Health Agency
- Check licensure & CMS star ratings.
- Aim for ≥ 3 stars in both Quality of Patient Care and Patient Experience.
- Ask staffing questions. Weekend coverage?
- Average aide turnover? On-call RN availability?
- Demand cost transparency. Agencies must explain what Medicare/Medicaid will cover and issue an Advance Beneficiary Notice for any non-covered service.
- Review the state survey report. Look for zero “Immediate Jeopardy” citations and a solid Quality Improvement Plan. CarePolicy.US can help you understand these reports and ensure your agency meets the highest standards.
10. Starting—or running—your own agency
This is where CarePolicy.US truly shines, offering comprehensive support for new and existing agencies.
- Secure the state license (e.g., New Jersey Health-Care Service Firm). CarePolicy.US provides essential guides for navigating state-specific licensing.
- Hire an RN clinical director and comply with CMS Conditions of Participation (42 CFR 484). Our policy and procedure manuals are designed to meet these rigorous standards.
- Implement OASIS data collection, QAPI, infection-control, emergency-preparedness, and HIPAA programs. CarePolicy.US offers resources covering all these critical operational areas.
- Diversify your payer mix—Medicare, Medicaid waivers, VA contracts, LTC insurance—to manage cash flow.
- Track quality metrics: hospital readmission rate, patient-satisfaction score, and HHCAHPS survey results.
- CarePolicy.US can draft custom policies, prepare your survey binder, and guide you from application to first accreditation. Explore our customized policy solutions and licensing consultation services.
Frequently Asked Questions
Who can receive a “home-care package” of personal-care hours?
"Medicaid HCBS (IHSS in CA, PHC or STAR+PLUS in TX) or LTC insurance policies bundle custodial hours."
Why is it sometimes hard to access home-health?
"Strict home-bound rules, staffing shortages, and prior-authorization barriers in some Medicare Advantage plans."
What is the most common home-health service?
Post-hospital wound care and hip/knee replacement physical therapy.
Personal-care vs. home-health—what’s the difference?
Personal-care = custodial help with ADLs; home-health = skilled clinical services delivered by nurses/therapists. CarePolicy.US provides policy manuals for both non-medical personal care and skilled home health agencies.
How much is private in-home care?
National median is ~$34/hour for a home-health aide (Data often tracked by sources like Genworth). For precise local rates, further research is advised.
Will any plan pay for 24-hour care?
"Medicare never covers it; some Medicaid waivers and high-end LTC policies may, depending on state and contract."
How do agencies find patients?
"Hospital discharge planners, physician referrals, insurer networks, community outreach, and digital marketing."
What should I expect from a Medicare-paid home-health aide?
"Help with bathing, dressing, ambulation, light meal prep—only while skilled nursing or therapy is also active."
How do I ensure quality service for my parent?
"Review CMS star ratings, read the latest state survey, and confirm RN supervisory visits every 60 days."
Why choose home-based care for older adults?
"Maintains independence, cuts rehospitalization risk, and costs roughly half of skilled-nursing-facility care."
Ready to move forward?
Whether you’re a family caregiver in California, a Texas agency owner, or a multistate operator, CarePolicy.US can streamline licensure, policy writing, and payer enrollment. Our state-specific templates and customization services ensure you have exactly what you need.
Book a free 30-minute consultation today and avoid costly missteps—so you can focus on delivering exceptional care. Let our team of experts support your journey in the home care industry.