Does Medicare Pay for Overnight Care at Home?

Medicare supports the health needs of millions across the country. It is a federal health insurance program for people aged 65 or older, certain younger people with disabilities, and people with End-Stage Renal Disease. Understanding how Medicare operates, especially for home services, can be complex. This article clarifies Medicare’s coverage for home health services, focusing on overnight care.

What Medicare Covers for Home Health Care

Medicare Part A and Part B cover specific home health services for eligible individuals. These services are generally for short-term needs following an illness or injury, or to improve or maintain a health condition. Covered care must be ordered by a doctor and provided by a Medicare-certified home health agency.

Medicare typically covers intermittent skilled nursing care, including wound care, injections, or monitoring serious illnesses. Physical therapy, occupational therapy, and speech-language pathology services are also covered when medically necessary to restore function or prevent decline. Medical social services that address social and emotional factors related to an illness are included. Part-time or intermittent home health aide services, such as assistance with walking or bathing, are covered if provided alongside one of the skilled services.

What Medicare Does Not Cover for Home Care

While Medicare covers many home health services, it has specific limitations, particularly regarding long-term and overnight care. Medicare generally does not cover 24-hour-a-day care at home, which includes continuous supervision or assistance throughout the night. It also does not cover personal care services, known as custodial care, if these are the only services an individual needs.

Custodial care involves help with daily living activities such as bathing, dressing, eating, or using the bathroom, when there is no associated medical need for skilled care. Homemaker services, like cleaning, laundry, or meal preparation, are also not covered unless directly tied to a covered skilled service in the care plan. Therefore, overnight care for general assistance or supervision, without a direct link to intermittent skilled medical needs, typically falls outside of Medicare’s coverage.

Eligibility for Medicare Home Health Benefits

To qualify for Medicare home health benefits, individuals must meet specific criteria. An individual must be under the care of a doctor, who must certify a need for home health care. This certification often follows a face-to-face evaluation by the healthcare provider to assess medical necessity.

A person must also be considered “homebound,” meaning it is difficult to leave home without assistance, such as using a mobility aid or requiring help from another person. While homebound, individuals can still leave for medical appointments, religious services, or to attend licensed adult day care without jeopardizing their eligibility. The required care must be intermittent skilled nursing care, physical therapy, speech-language pathology services, or continued occupational therapy.

How to Get Medicare-Covered Home Care

The process for obtaining Medicare-covered home care begins with a doctor’s order or referral. The physician, or another authorized healthcare provider, must establish and regularly review a care plan detailing the specific home health services needed. This plan ensures care aligns with medical necessity guidelines.

After receiving a doctor’s order, individuals can select a Medicare-certified home health agency. Resources like Medicare’s Care Compare tool, available on Medicare.gov, allow individuals to find and compare agencies based on quality and services offered in their area. The chosen agency will then conduct an initial assessment to determine care needs and develop a comprehensive plan of care. The home health agency is required to inform the beneficiary about what Medicare will cover and any potential out-of-pocket costs before services begin.