Home Health in Assisted Living: Does Medicare Cover It?

Quick answer: Yes. Medicare home health in assisted living is covered when a resident is homebound, needs intermittent skilled nursing or therapy, and a doctor or allowed practitioner orders care under a plan of care after a face-to-face visit. Medicare treats an assisted living apartment or board and care room as the resident’s home. Home health does not replace the facility’s personal care, and it cannot be used in a skilled nursing facility.

Many families assume that once a parent moves into assisted living, Medicare home health is no longer available. In fact, home health in assisted living is common. Nurses and therapists visit residents in their apartments or rooms to provide skilled care after a hospital stay, a fall, a new diagnosis, or a decline. This guide explains who qualifies, what home health covers, how it differs from caregiving, how to arrange it, and how it fits with assisted living and board and care.

What is Medicare home health?

Medicare home health provides skilled, short-term care at home, delivered by a Medicare-certified home health agency. Services can include:

• Skilled nursing, such as wound care, injections, medication teaching, and monitoring
• Physical therapy
• Occupational therapy
• Speech-language therapy
• Medical social services
• Home health aide visits, when the patient also receives skilled care

Our guide to home health care in San Diego explains these services in more detail.

Can Medicare home health visit assisted living or board and care?

Yes. Medicare considers a resident’s assisted living apartment or board and care room to be their home. Medicare-certified home health agencies can provide covered services there. The one major exception is a skilled nursing facility, where home health is not covered because skilled care is already provided. See assisted living in San Diego and board and care homes in San Diego.

Who qualifies for Medicare home health?

• Homebound: leaving home requires considerable and taxing effort, often with help or a device, and absences are infrequent or short, such as medical appointments, religious services or adult day care.
• Skilled need: the resident needs intermittent skilled nursing or therapy.
• Doctor’s order: a doctor or allowed practitioner orders care and oversees a plan of care.
• Face-to-face encounter: a qualifying visit related to the reason for home health, within the required timeframe.
• Medicare-certified agency: care is provided by an approved agency.

Many assisted living residents meet the homebound standard, especially after a hospitalization.

What does Medicare home health cost?

For eligible beneficiaries under Original Medicare, covered home health services usually cost nothing. Durable medical equipment may have 20% coinsurance after the Part B deductible. Medicare Advantage plans cover home health but may require prior authorization and in-network agencies.

How is home health different from home care?

• Home health is skilled, medical, short-term care ordered by a doctor and often covered by Medicare.
• Home care is non-medical help with daily activities, such as bathing, dressing and companionship, usually paid privately. See in-home care in San Diego.

In assisted living and board and care, the facility provides personal care. Home health adds skilled services the facility cannot provide.

When is home health in assisted living most helpful?

• After a hospital or rehab discharge
• After a fall, to rebuild strength and balance. See physical therapy in assisted living.
• For wound care or new medications needing teaching
• For a decline in mobility or swallowing
• To manage heart failure, COPD, or diabetes

Home health can also help prevent hospital readmissions by catching problems early.

How do you arrange home health in assisted living?

1. Ask your parent’s doctor or the hospital discharge planner for a home health referral.
2. Choose a Medicare-certified agency that serves the facility’s area and, for Medicare Advantage, is in network.
3. Tell the care home, so staff can coordinate visits.
4. Expect an initial assessment visit and a plan of care.
5. Ask the agency and care home how they will communicate.

How does home health relate to hospice?

Home health focuses on recovery and improvement. Hospice focuses on comfort for people with a terminal illness. Both can be provided in assisted living and board and care, but generally not at the same time for the same condition. See hospice care in San Diego and our palliative care definition.

Who does what: home health staff vs. care home staff

Home health in assisted living works best when everyone knows their role. A simple way to think about it:

• The care home provides 24-hour supervision, meals, help with bathing, dressing and toileting, medication assistance, housekeeping and daily monitoring. This is what the monthly rate pays for.
• The home health nurse provides skilled nursing visits: wound care, injections, assessing heart failure or COPD, teaching new medications, and reporting changes to the doctor.
• The home health therapists work on walking, balance, transfers, strength, swallowing and daily skills, and often teach caregivers safer ways to help.
• The home health aide, when ordered, may help with bathing during the episode of care, but does not replace the care home’s daily help.
• The doctor signs the orders and plan of care, and adjusts treatment based on the agency’s reports.

The best results come when the care home and the agency talk. Ask the nurse to leave a brief note or call the home after each visit, and ask the care home to tell the agency right away about falls, new confusion, or changes in eating.

How does home health work in a board and care home vs. large assisted living?

Medicare treats both as your parent’s home, so the coverage rules are the same. The experience is a little different.

In a large assisted living community, several agencies may visit different residents, and the community may have a preferred agency or even one on site. Coordination usually runs through the wellness director or nurse.

In a board and care home in San Diego, with about 6 residents and the same few caregivers every day, coordination is often simpler. The caregiver who helps your parent every morning can show the physical therapist exactly how transfers go, and can practice the therapist’s exercises between visits. Many board and care homes in San Diego work with the same home health agencies regularly. Our family guide to board and care homes explains how these small homes handle health coordination.

How long does home health last, and when does it end?

Medicare home health does not require a prior hospital stay, and there is no set limit on how long it can continue as long as your parent stays eligible. In practice, care is ordered in certification periods of up to 60 days. The doctor can recertify if skilled care is still needed.

Home health usually ends when:

• Therapy or nursing goals are met, such as walking safely with a walker or a wound healing
• Your parent is no longer homebound
• The remaining needs are custodial only, such as help with bathing or dressing
• Your parent chooses hospice instead for the same condition

The agency must give written notice before Medicare-covered services end, and you can ask for a fast appeal if you disagree. A new episode can begin later if your parent has another hospitalization, fall or decline.

How do you choose a home health agency?

Medicare patients have the right to choose their home health agency, though Medicare Advantage plans may limit you to in-network agencies. When choosing:

• Use Medicare’s Care Compare tool on Medicare.gov to compare agencies serving your parent’s ZIP code.
• Ask the care home which agencies it already works with and which it trusts.
• Ask how soon the agency can start after a referral, especially after a hospital discharge.
• Ask whether therapists and nurses are consistent, or whether your parent will see many different staff.
• Ask how the agency communicates with families and with the care home.

A hypothetical example: home health after a hospital stay

For example, imagine a family in Chula Vista whose father, 84, lives in one of the 6-bed board and care homes in Chula Vista. He is hospitalized for pneumonia and comes back weaker, unsteady on his feet and short of breath. The hospital discharge planner sends a home health referral before he leaves.

Within a couple of days, a nurse visits to check his breathing and medications, and a physical therapist starts twice-weekly visits. The therapist shows his caregivers how to help him stand safely and which exercises to repeat daily. A few weeks later he is walking to the dinner table again, the agency discharges him, and the care home continues his daily care. Every case differs, but this is how home health in assisted living and board and care is meant to work: skilled care layered on top of daily care.

Common myths about home health in assisted living

• “Medicare won’t pay because she lives in a facility.” Medicare treats an assisted living apartment or board and care room as home. Skilled nursing facilities are the exception.
• “He has to be in bed all day to be homebound.” No. Leaving home must take considerable effort, but short trips for medical care, religious services or adult day care are allowed.
• “Home health means a caregiver every day.” No. Visits are intermittent and skilled. Daily help comes from the care home.
• “Once it ends, it can’t restart.” It can, after a new hospitalization, fall or decline, with a new doctor’s order.
• “Home health replaces the need for a care home.” Rarely. For a parent who needs daily hands-on help, home health works best alongside assisted living in San Diego or a residential senior care home.

How Elder Answers helps

Elder Answers provides free senior care placement throughout San Diego County. Our advisors personally visit assisted living communities and board and care homes and can point you to homes that coordinate well with home health, hospice and mobile doctors. Our help is free for families because the care home pays us after move-in, and the rate you pay does not change. Contact Elder Answers to find a home that fits your parent’s health needs.

Frequently Asked Questions

Can Medicare home health come to assisted living?

Yes. Medicare treats an assisted living apartment as the resident’s home. The same applies to residents of licensed board and care homes, since that is where they live.

Can home health visit a board and care home?

Yes, if the resident meets Medicare home health eligibility. Many residential senior care homes in San Diego work with home health agencies regularly and can help coordinate visits.

Who qualifies for home health in assisted living?

Residents who are homebound, need intermittent skilled care, and have a doctor’s order and plan of care. The doctor must certify eligibility, usually after a face-to-face visit related to the reason for care.

Does Medicare pay for home health in assisted living?

Yes, for eligible residents. Original Medicare usually covers it at no cost. Medicare Advantage plans also cover home health but may require in-network agencies and prior approval.

Is home health the same as home care?

No. Home health is skilled and medical; home care is non-medical help with daily activities. Home health visits are short and time-limited, while the care home provides daily hands-on help. Learn more in our guide to home health care.

Can home health be provided in a nursing home?

Not in a skilled nursing facility, where skilled care is already provided. Residents of assisted living or board and care homes are not in a SNF, so they can still receive Medicare home health if eligible.

Does my parent need a hospital stay before Medicare home health starts?

No. Original Medicare does not require a prior hospital stay for home health. Your parent needs to be homebound, need intermittent skilled care, and have a doctor’s order after a qualifying face-to-face visit.

How long can home health continue in assisted living?

Care is ordered in periods of up to 60 days, and the doctor can recertify if skilled care is still needed. There is no fixed limit on the number of periods while your parent remains eligible. Home health ends when goals are met or needs become custodial only.

Can we choose which home health agency visits the care home?

Yes, with Original Medicare you can choose any Medicare-certified agency that serves the area. Medicare Advantage plans may require an in-network agency. Ask the assisted living community or board and care home which agencies already work well with its staff.

Conclusion: home health in assisted living

Home health in assisted living is covered by Medicare for eligible residents who are homebound, need intermittent skilled care, and have a doctor’s order. It adds nursing and therapy to the personal care the facility provides, and is especially helpful after a hospital stay or fall. Ask the doctor for a referral and coordinate with the care home. A free senior care assessment can help you find a home that works well with home health partners.