How Long Will Medicare Pay for Home Health Care?
Understand the intricacies of Medicare's home health care. Gain clarity on the scope of benefits and the conditions for receiving support at home.
Medicare covers home health care services, allowing individuals to receive medical attention at home. This benefit supports recovery from illness or injury and manages chronic conditions, often as an alternative to hospital or skilled nursing facility care.
Eligibility Criteria for Coverage
To qualify for Medicare home health care, an individual must meet several requirements. A primary condition is being “homebound,” meaning it is a considerable and taxing effort to leave home, and a physician certifies this status. While homebound, a person may still leave for medical appointments, religious services, or to attend a licensed adult day care center without jeopardizing eligibility. Occasional, short, and infrequent non-medical absences, such as a trip to the barber or a special family event, are also permitted.
The individual must also require intermittent skilled nursing care or skilled therapy services. Skilled nursing care refers to services that can only be performed safely and correctly by a licensed nurse, such as wound care, injections, or monitoring of unstable conditions. Skilled therapy includes physical therapy, occupational therapy, and speech-language pathology services, which aim to restore function, improve mobility, or regain communication abilities. These services must be medically necessary and ordered by a physician as part of a comprehensive plan of care.
A physician or allowed practitioner, such as a nurse practitioner or physician assistant, must develop and regularly review the plan of care. This plan outlines the specific medical needs, services, and expected outcomes. A face-to-face encounter with a doctor must occur either 90 days before or within 30 days after the start of home health care, certifying the need for these services. All home health services must be provided by a Medicare-certified home health agency.
Covered Home Health Services
Once eligibility is established, Medicare covers a range of home health services. Skilled nursing care is a core component, encompassing tasks like wound dressing changes, administration of injections, intravenous therapy, and observation and assessment of the patient’s condition.
Skilled therapy services are also covered, including physical therapy to help with mobility and strength, occupational therapy to regain independence in daily activities, and speech-language pathology services for communication and swallowing difficulties. These therapies must be reasonable and necessary for treating the illness or injury. Medical social services, which assist with social and emotional concerns related to the illness, are covered when ordered by a doctor.
Home health aide services are covered only if the individual is also receiving skilled nursing care or therapy services. These aides provide personal care such as bathing, dressing, and assistance with mobility. Medicare does not cover 24-hour-a-day care, meal delivery, or homemaker services like shopping or cleaning if they are unrelated to the care plan. Personal care is not covered if it is the only care needed.
Understanding Coverage Duration and Limits
Medicare’s home health coverage is designed for intermittent care, not for full-time or long-term custodial care. An initial certification period for home health services typically lasts 60 days.
For continued coverage beyond the initial 60 days, a physician must re-certify the patient’s ongoing need for home health services. This re-certification process involves reviewing the patient’s medical history, current condition, and the effectiveness of the treatment plan. There is no fixed limit to the number of 60-day episodes Medicare will cover, provided the individual continues to meet all eligibility criteria, including homebound status and the need for intermittent skilled care.
Intermittent care generally means skilled nursing care and home health aide services are provided for fewer than seven days a week or less than eight hours a day. Combined skilled nursing and home health aide services are typically limited to a maximum of 28 hours per week. In some circumstances, if a doctor determines it is necessary, this can be extended for a short time up to 35 hours per week, especially if the need is predictable and finite. Therapy services, such as physical, occupational, and speech therapy, do not have the same part-time or intermittent restrictions as skilled nursing and home health aide services, allowing for more flexibility in their duration.
Costs Associated with Medicare Home Health Care
For approved home health care services, Medicare generally covers 100% of the costs. Beneficiaries typically pay no deductible or coinsurance for these services, provided all eligibility criteria are met. The home health agency bills Medicare directly for the covered services.
An exception to this full coverage applies to durable medical equipment (DME), such as wheelchairs, walkers, or oxygen equipment. For DME, the beneficiary is usually responsible for 20% of the Medicare-approved amount. Before services begin, the home health agency is required to inform the beneficiary in writing about what Medicare will cover and any potential out-of-pocket costs for non-covered items or services.