How long does Medicare pay for overnight care at home?

According to the Centers for Medicare & Medicaid Services, Medicare's home health benefit is strictly for intermittent care, not round-the-clock or overnight shifts. This means the critical question, "How long does Medicare pay for overnight care at home?" is a nuanced one, with the simple answer being that it does not cover continuous, 24-hour-a-day care.

Quick Summary

Medicare does not cover full-time or overnight care at home. It covers medically necessary, part-time, or intermittent skilled services, with duration dependent on ongoing medical necessity and recertification by a physician.

Key Points

• No Overnight Coverage: Medicare does not pay for full-time, 24/7 care, which includes overnight care at home.

• Intermittent Skilled Care: Medicare covers part-time or intermittent skilled services like nursing or therapy, up to 28-35 hours per week, not continuous shifts.

• No Custodial Care Alone: Overnight care is often considered custodial, which Medicare does not cover unless provided alongside approved skilled services.

• Requires Recertification: Continued coverage for intermittent care requires a doctor's recertification every 60 days, as long as you meet the homebound criteria.

• Alternative Funding Needed: For overnight care, you must use alternative funding sources such as a Medicare Advantage plan (if it includes supplemental benefits), Medicaid, or private pay.

Understanding Medicare's Home Health Benefit

Medicare's rules for home health care are specific and designed to cover short-term, medically necessary services for individuals who are considered homebound. The key to understanding your coverage for care at home lies in two important definitions: "intermittent care" and "custodial care".

Intermittent vs. Continuous Care

• Intermittent care: This is the type of skilled care that Medicare covers. It is defined as care provided for less than 8 hours a day and no more than 28 to 35 hours per week. This is intended to help a patient recover from an illness or injury. For a beneficiary to be eligible, a doctor must certify they require medically necessary part-time or intermittent skilled nursing care, physical therapy, speech-language pathology, or occupational therapy.
• Continuous care: This is the type of full-time, 24/7 care that Medicare explicitly states it does not cover. This includes services like having a home health aide present overnight to monitor a patient or assist with routine tasks. Since overnight care almost always falls into this continuous category, it is not a covered service.

The Custodial Care Exclusion

Medicare does not pay for custodial care, which is non-skilled personal care like help with bathing, dressing, eating, or using the bathroom. While a home health aide can provide this type of assistance, Medicare will only cover it if it is provided alongside skilled services (like nursing or therapy). The moment a patient only requires custodial care, Medicare coverage ends. Overnight care is nearly always considered custodial care, especially when the patient does not require skilled medical services during the overnight hours.

Eligibility Requirements and Recertification

To receive any home health care, including intermittent skilled care, a patient must meet specific eligibility requirements.

1. Homebound Status: A doctor must certify that the patient is homebound. This means leaving home requires a considerable and major effort due to an illness or injury.
2. Medical Necessity: The services must be ordered by a doctor as medically necessary.
3. Physician-Approved Care Plan: The patient must be under a plan of care established and reviewed regularly by a doctor.
4. Medicare-Certified Agency: Care must be provided by a Medicare-certified home health agency.

The 60-Day Recertification Period

Coverage for intermittent home health services is provided in 60-day periods. After each period, the patient's doctor must review the plan and recertify that the services are still medically necessary. As long as the patient continues to meet the eligibility requirements, this 60-day recertification can be repeated without limit. However, this does not extend coverage to non-covered services like overnight, continuous care.

Medicare Home Health Coverage at a Glance

Feature	Intermittent Skilled Home Care	Overnight/Continuous Care
Coverage Status	Covered by Medicare Part A and/or Part B.	Not covered by Original Medicare.
Services Covered	Skilled nursing, physical therapy, occupational therapy, and speech-language pathology.	Generally considered custodial care, which is not covered.
Duration	Unlimited 60-day periods, as long as patient remains eligible and doctor recertifies medical necessity.	No coverage for full-time or continuous care.
Hours per Week	Typically up to 28-35 hours per week.	Requires 24/7 care, which is not covered.
Purpose	Recovery from an illness or injury, or managing a condition.	Long-term personal assistance and supervision.
Cost	100% covered for approved home health services (DME may have copay).	Out-of-pocket, unless using a Medicare Advantage plan that covers it.

Alternative Options for Overnight Care

Since Original Medicare does not cover overnight care, individuals needing this level of assistance must explore other options. These can include:

• Medicare Advantage (Part C) Plans: Some privately-run Medicare Advantage plans may offer additional benefits that include non-medical home care services, such as assistance with daily activities, for a limited time or in specific situations. It is crucial to check with the specific plan provider for details.
• Medicaid: State-specific Medicaid programs may cover some long-term care services at home for low-income individuals. Coverage varies significantly by state.
• Long-Term Care Insurance: Private long-term care insurance policies can cover extended periods of home care, including overnight assistance.
• Private Pay: Paying for care out-of-pocket provides the most flexibility in terms of choosing providers and services.
• Veterans' Benefits: Eligible veterans may receive benefits to help cover the cost of in-home care.

Conclusion

While Medicare is a vital resource for home-based medical care, it is not a solution for continuous, 24-hour care, including overnight shifts. The coverage is strictly limited to intermittent skilled nursing and therapy, provided on a part-time basis for as long as a patient remains homebound and requires medically necessary services. Understanding these distinctions is the first step toward securing the right type of care. For those needing round-the-clock or overnight assistance, alternative funding sources like Medicare Advantage, Medicaid, or long-term care insurance are necessary to fill the gap left by Original Medicare's limitations.

Navigating Your Home Health Care Journey

It is essential to have open and frequent communication with your doctor and home health agency to ensure you continue to meet the eligibility requirements for medically necessary care. Keeping clear records and understanding your care plan will help you manage your home health journey effectively. For concerns or questions regarding coverage, contacting Medicare directly or seeking guidance from a State Health Insurance Assistance Program (SHIP) can provide clarity.

How to Appeal a Coverage Decision

If your home health agency informs you that your coverage is ending and you disagree, you have the right to appeal the decision. You can request an expedited appeal through your Quality Improvement Organization (QIO) within 72 hours of receiving the discharge notice to ensure services continue during the review process. An appeal provides an opportunity to present your case and challenge a denial of services.

Frequently Asked Questions

Will Medicare cover a home health aide to stay overnight?

No, Original Medicare does not pay for a home health aide to stay overnight. It only covers intermittent, part-time skilled care, and overnight shifts are considered continuous, non-covered care.

What is the maximum number of hours of home care Medicare covers per day?

Medicare typically covers skilled services for fewer than 8 hours a day, for a maximum of 28 to 35 hours per week. This is based on medical necessity, not for continuous or overnight shifts.

Does being 'homebound' limit my ability to leave home at all?

No, being homebound does not mean you can never leave. You can leave home for medical appointments or short, infrequent non-medical absences, such as attending religious services.

Can a Medicare Advantage plan cover overnight care?

Some Medicare Advantage (Part C) plans may offer supplemental benefits that include non-medical home care services, potentially covering some overnight needs. Coverage and rules vary, so it is important to check with your specific plan provider.

What is the difference between intermittent skilled care and custodial care?

Intermittent skilled care is a medical service provided by a professional, like a nurse giving an injection. Custodial care is non-skilled personal care, like help with bathing or dressing, and is not covered by Medicare unless provided alongside skilled services.

How do I pay for overnight home care if Medicare won't cover it?

Options for paying for overnight home care include private pay, long-term care insurance, certain supplemental benefits from Medicare Advantage plans, or state Medicaid programs.

How often does a doctor need to recertify home care for Medicare to continue coverage?

A doctor must review and recertify the need for home health care every 60 days for coverage to continue. There is no limit to the number of recertifications as long as the patient remains eligible.