Understanding Medicare’s Home Health Care Coverage
Medicare’s home health care benefits cover medically necessary, part-time, temporary skilled nursing services to address health conditions or injuries. Covered services may include physical, occupational, or speech therapy, and some medical social services.
Home health care differs from home care services. Home health care involves clinical, skilled services such as therapies, wound care, IV administration etc. Home care generally refers to non-medical help with daily living activities such as assistance with bathing and dressing, ambulation, food preparation, medication reminders, and light house keeping. Medicare does not cover the latter.
Skilled care is provided by individuals specifically licensed to perform those services, such as nurses or therapists. By contrast, “non-skilled” care is provided by home health aides or CNAs (Certified Nursing Assistants). Understanding the difference helps determine what services are covered by Medicare and what will require payment from another source, such as long-term care insurance or private payment.
How to Qualify for Home Health Care Under Medicare
In order for Medicare to cover home health care, an individual must meet all of the following eligibility conditions:
- Be under a doctor’s care and have a regularly reviewed care plan. It has to be reviewed every 60 days to maintain coverage of in-home care.
- Need skilled nursing care to address a qualifying condition.
- Be homebound. Leaving the home for services must be impossible or cause significant difficulty due to illness or injury.
- Work with a Medicare-certified home health agency to provide in-home care services.
- Have a face-to-face visit with a doctor related to the specific health need within 90 days before or 30 days after the start of services.
If all the above criteria are met, services will usually be covered either under Medicare Part A or Medicare Part B. Medicare Part A generally covers services if they are following a qualifying hospital stay of at least 3 consecutive days or a stay in a Medicare skilled nursing facility. Medicare Part B covers most other cases of qualifying home health care.
Common conditions that qualify a patient for home health care may include:
- Rehab after stroke
- Surgical recovery
- Severe mobility limitations such as from advanced arthritis
- Infection needing IV antibiotic administration at home
How Long Can You Be on Home Health Care?
Medicare provides episodic home health care coverage in 60-day certification periods. Each period requires a doctor to certify that the patient still meets the eligibility requirements for the coverage. This does not limit care to 60 days, but requires that patient needs be reassessed every 60 days as a basis for ongoing coverage of the cost of care. This in-home care can generally continue as long as the patient continues to meet eligibility requirements and progress or maintenance of function as a result of the care can be documented.
What Is the 21-Day Rule for Medicare?
Medicare’s 21-day rule applies to patients who need intermittent skilled nursing care. To qualify for home health care, services must be needed fewer than 7 days per week and for no more than 21 days unless a likely end date can be predicted. This ensures care is short-term and medically necessary, differentiating between custodial care (which is not covered by Medicare) and temporary recovery support, which is Medicare’s aim as it relates to in-home care services. If therapy is the primary need, the 21-day rule does not apply, but coverage is based on ongoing need and progress.
What Home Health Services Does Medicare Cover?
Medicare covers home health services including skilled nursing care, physical, occupational, and speech therapy, and medical social services. Certain supplies such as wound dressings may also be covered. Qualifying medical equipment may also be covered in some cases. Services must be intermittent and medically necessary to be covered. Full-time or long-term care is not covered. Medicare does not cover 24/7 care, or care involving assistance with activities of daily living.
Does Medicare Pay for Home Health Care After Hospitalization?
Medicare may cover home health care if the patient was hospitalized for 3 consecutive inpatient days and needs skilled nursing care at home upon discharge. Discharge planning is key in receiving coverage for home health care. Hospital staff must assess the patient’s needs and coordinate with a medicare-approved home health agency before discharge. The patient must meet all eligibility requirements to ensure coverage: being under a doctor’s care, being truly homebound, and needing intermittent skilled services as opposed to around-the-clock care.
How Many Hours of Home Health Care Does Medicare Cover?
Medicare’s coverage of home health care is visit-based instead of hourly. There are no Medicare guidelines for home health visit time. Payment is for each visit with a qualified nurse or therapist regardless of visit length. On average, skilled care visits are 30 to 60 minutes depending on the patient’s needs. Private insurance may offer more flexible coverage, sometimes covering hourly or extended visits, especially following surgery. Coverage varies significantly from one private insurance policy to another.
When Does Medicare Stop Paying for Home Health Care?
Medicare will stop paying for home health care when the patient no longer meets eligibility requirements, such as no longer being homebound, not needing the skilled care, or failing to show continued progress. If the patient’s needs progress to being custodial rather than medical, coverage may also end.
Recertification with a doctor is required every 60 days to determine if coverage can continue. The doctor must confirm homebound status and ongoing medical need. Individuals are able to submit a fast appeal through MAC (Medicare Administrative Contractor) if Medicare denies coverage.
Exceptions: When Medicare Covers Home Health Aides
Medicare may pay for a home health aide to provide personal care such as bathing, dressing, or toileting, when the care is provided as part of a temporary skilled nursing care plan. To qualify, the care must be temporary and short-term and the patient must be receiving skilled nursing care in conjunction with the other services.
Medicare-covered aides work under the supervision of a nurse or therapist and cannot be hired independently. Private-pay aides are able to provide long-term or custodial care, but they cannot be paid by Medicare.
Alternative Options If Medicare Coverage Ends
Depending on the state, Medicaid may cover extended home care for individuals with low income and minimal assets. Some states also offer Home and Community-Based Services Waivers, which fund longer term care in the home instead of in a facility.
Private insurance varies. Some plans cover short-term skilled home care, while long-term care insurance specifically covers custodial services like bathing or meal help, which are not services covered by Medicare.
Local and state-funded programs, such as Area Agencies on Aging, may offer home health support, caregiver assistance, or respite services. Availability of these services depends on location, age, income, and health needs, so contacting local agencies is essential.
FAQs About Medicare’s Home Health Care Coverage
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How many weeks does Medicare pay for home health care?
Coverage is not provided in terms of weeks. It is based on ongoing eligibility (home bound, under the care of a doctor, documented progress) which must be recertified by a doctor every 60 days. Care can continue over weeks or months if eligibility continues. - How long can you be on home health care under Medicare?
There is no set period of time for home health care coverage under Medicare. As long as eligibility requirements (home bound, under the care of a doctor, documented progress) are re-established every 60 days by a physician, care will continue to be covered.
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Does Medicare cover home health care for seniors long-term?
Medicare does not cover long-term home health care. Medicare home health coverage is limited to temporary skilled care needed to aid in recovery and does not include general aid with daily life. Long-term, in-home custodial care is usually paid for privately, though long term care insurance is designed to cover those services. In some cases Medicaid may be able to cover long-term home health care as well depending on state of residence and personal eligibility.
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How Long Will Medicare Pay for Home Health Care?
Medicare typically covers intermittent home health services for up to 21 days, including skilled nursing or therapy. Extensions beyond this timeframe are possible if your physician certifies ongoing need under intermittent care rules.
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