How Long Will Medicare Pay for Home Health Care?
If you need medical care at home, Original Medicare may pay for home health care services. These services typically include skilled nursing care, physical therapy, and occupational therapy. However, your doctor needs to certify that home health care is a medical necessity and that you or your loved one is homebound.
If approved, Medicare will cover 60 days of home health care. This can then be renewed for 30 days at a time. Typically, Medicare will cover home health care for as long as you need it. However, home health care is defined as intermittent care. If you or your loved one needs more comprehensive care, then it might not be covered by Original Medicare.
Knowing how Medicare covers home health care can help you plan better and ensure you or your loved one can get the care you need.
Key Takeaways:
To be eligible for Medicare’s home health care services, you or your loved one must be unable to leave home without help. A doctor or other health care professional will assess your needs and order this care.
Initially, home health care coverage lasts for 60 days. If it is still required, it can be renewed for 30 days at a time.
Coverage length is impacted by need. This coverage is intended to be short-term, meaning less than 8 hours per day and under 28 hours per week.
How long will Medicare cover home health care?
If you’re approved for home health care, your initial coverage will last 60 days. If you still require help, your doctor can renew your coverage for 30 days at a time.
Medicare coverage for home health care is intended to be for part-time or intermittent care. In most cases, home health care is restricted to less than 8 hours a day, for fewer than 7 days per week, and under 28 total hours per week.
However, if your doctor deems it necessary, you may be able to get extended assistance. If extended coverage is granted, you may be able to get care for less than 8 hours a day, but up to a total of 35 hours per week. Individuals who require more care may wish to look into long-term care options.
What are Medicare’s criteria for providing in-home nursing care?
To qualify for in-home nursing care covered by Medicare, you need to require part-time or intermittent care. If you need more comprehensive care, you won’t qualify for Medicare home health care at the level you need. You also need to be considered “homebound,” or unable to leave your home. This means:
You’re unable to leave your home without help from a person or medical device, like a wheelchair, walker, or cane.
Your doctor recommends that you stay home due to a medical condition.
You typically don’t leave your home because it would be a major effort.
You will still qualify for coverage if you leave for medical treatment, religious services, or adult daycare. You can also leave your home for short periods to attend special events like funerals or graduations.
Factors that affect Medicare home health care duration
Knowing the facts about home health care coverage can help you plan ahead.
Medical necessity documentation
Medical necessity means a doctor or other medical professional determines that you need home healthcare services. For example, if you injured your leg and have trouble leaving the home without assistance, then they might document that you need to receive physical therapy at home.
Skilled nursing vs. custodial care distinctions
The type of care you need also determines your eligibility for home health care. Typically, Medicare does not cover custodial care. Custodial care includes help with activities of daily living, such as dressing, preparing meals, and bathing.
This care may be provided by a home health aide. However, Medicare does pay for custodial care if you are receiving skilled nursing care or other therapies and it’s included as part of the care. Examples of skilled nursing care and other therapies include:
Wound care
Monitoring of health conditions and patient and caregiver education
Intravenous (IV) or nutrition therapy
Injections
Physical therapy
Occupational therapy
Speech-language pathology
Medical social services
Recovery progress
If you’re receiving home health care, the home health agency and your doctor will monitor your progress. If you reach your goals and no longer need support, then coverage will stop.
Likewise, if you stop progressing, then coverage may change or stop. However, people with chronic conditions who need home health care will continue receiving coverage.
Doctor certification
To receive home health care covered, your doctor must say that you are homebound and need skilled nursing care, physical therapy, speech therapy, or occupational therapy. Your doctor needs to certify that you are under their ongoing care.
To provide this documentation, your doctor will meet with you face-to-face and sign a clinical note. If you’re discharged from a care facility and require home health care, your doctor can sign a discharge summary.
How to extend Medicare home health coverage
After an initial 60-day period of home health care, you’ll be re-evaluated to determine if care is still needed. Your doctor will check if you still qualify as homebound and need skilled nursing care or approved therapies. If you still require home health care, it can be extended for 30 days.
You are required to have an evaluation every 30 days to get an extension.
If your Medicare home health coverage was not approved and you feel that you still need support, there are a few options. When your coverage ends, you’ll receive a Home Health Advance Beneficiary Notice (HHABN). This will explain why your coverage ended and provide you with information about the next steps.
The first is to request reconsideration. This means that Medicare will review your medical files and your doctor’s recommendation to determine if care can continue. This needs to be filed within 60 days of receiving the official decision.
If you don’t agree with a denial after reconsideration, the next step is to have a hearing with an administrative law judge. This hearing can be completed online, in person, or over the phone. During this hearing, the judge will review the evidence about your medical condition and ask you questions. They may also call on medical experts to testify.
If you don’t agree with the administrative law judge’s decision, then you can file an appeal with the Appeals Council. This council will review your request. They can either approve or deny it, or return it to a judge for a more in-depth review.
The final step in the appeals process is filing a federal court action with the US District Court. It’s important to note that you do not need to go through all of these steps if you agree with the decision. You only need to progress to the next step if you continue to disagree with the decision.
There are also resources available to help you navigate this process. Each state has a State Health Insurance Assistance Program (SHIP). You can visit their website to find your local office. The Center for Medicare Advocacy is another resource that can provide support.
Bottom line
The initial period for Medicare home health care is 60 days. But, this can be extended for 30 days at a time. To get an extension, you must still be homebound. A doctor must also deem skilled nursing care, physical therapy, occupational therapy, speech therapy, or medical social services as medically necessary for your condition.
Progress is another important factor for extending home health care services. Coverage may change if you require more care or are not progressing towards your goals. However, coverage still applies if you have a chronic health issue that requires home health care to manage your condition.
Stay in touch with your doctor or health care professional. They must certify your home health care for Medicare to approve it. They’ll also develop a care plan and monitor your progress.