Medicare’s Policy on In-Home Nursing Care
When it comes to providing medical care at home, Medicare follows a strict policy that distinguishes between different levels and durations of service. The primary factor is whether the care is 'skilled' and 'intermittent' versus 'full-time' or 'custodial.'
Intermittent vs. Continuous Skilled Nursing Care
Medicare may cover skilled nursing care, but only if it is part-time or intermittent. This means the care is needed less than seven days a week or less than eight hours a day for a maximum period of up to 21 days. In some cases, this can be extended if a doctor can predict when the patient's need for daily skilled nursing care will end. Examples of covered skilled care include:
- Wound care for surgical wounds or pressure sores.
- Giving injections or intravenous (IV) therapy.
- Tube feedings.
- Monitoring a serious illness or unstable health condition.
- Teaching the patient and caregiver about disease management.
Medicare does not cover nursing care that is needed on a full-time, round-the-clock basis. This type of continuous care is considered long-term and is generally not covered by the program.
The Homebound Requirement
To qualify for any Medicare-covered home health services, a doctor must certify that the patient is 'homebound'. This means leaving home is a major effort for the patient, requiring the help of another person or the use of a device like a cane, wheelchair, or walker. A patient can still be considered homebound if they leave for medical appointments or short, infrequent non-medical reasons.
The Doctor's Orders and Care Plan
Before Medicare will cover home health services, a patient must be under a doctor's care, and the doctor must establish and regularly review a plan of care. The doctor's orders are essential for certifying the medical necessity of the services. Additionally, all care must be provided by a Medicare-certified home health agency.
Understanding Custodial Care vs. Skilled Care
One of the most important distinctions in Medicare home health coverage is between skilled care and custodial care.
- Custodial care includes non-medical help with activities of daily living (ADLs), such as bathing, dressing, eating, and using the bathroom. It also includes general housekeeping, meal preparation, or errands. Medicare will not pay for these services if they are the only care a person needs.
- Skilled care requires the expertise of a licensed healthcare professional, such as a Registered Nurse or Physical Therapist. Medicare may cover home health aide services (custodial-type care) on a part-time or intermittent basis, but only if the patient is also receiving skilled nursing or therapy services.
Coverage Comparison: Home Health Care vs. Skilled Nursing Facility (SNF) Care
To better understand the nuances of Medicare coverage, it's helpful to compare home health care with skilled nursing facility care.
| Feature | Medicare Home Health Care | Medicare Skilled Nursing Facility (SNF) Care |
|---|---|---|
| Duration of Care | Part-time or intermittent (less than 7 days/week, or less than 8 hours/day for up to 21 days). | Up to 100 days of coverage per benefit period for rehabilitation. |
| Patient Location | The patient's home. | An inpatient facility that is Medicare-certified. |
| Eligibility Requirement | Must be homebound, under a doctor's care, and need intermittent skilled services. | Must have a qualifying 3-day inpatient hospital stay and need daily skilled services. |
| Services Covered | Skilled nursing, physical therapy, occupational therapy, and home health aide services (if also receiving skilled care). | Semi-private room, meals, skilled nursing care, therapies, medications, and medical supplies. |
| Services Not Covered | 24-hour care, homemaker services, and custodial care if only care needed. | Custodial care beyond 100 days. |
| Patient Cost | $0 for approved home health services. 20% coinsurance for durable medical equipment. | Days 1-20: $0. Days 21-100: Daily coinsurance payment. |
Other Options for Long-Term Care
Since Medicare's home health benefit is temporary and doesn't cover full-time nursing, other options are needed for long-term or extensive care needs. Medicaid is a federal and state program that may cover long-term custodial care in a nursing home or through Home and Community-Based Services (HCBS) for eligible low-income individuals. Eligibility varies by state and is based on income and personal resources. Private long-term care insurance is another option designed to cover the costs of extensive in-home or facility-based care.
Conclusion
While Medicare provides valuable coverage for short-term, intermittent skilled nursing care at home following an illness or injury, it does not cover full-time nursing care. The distinction between skilled, intermittent care and long-term, custodial care is the core of Medicare's policy. Families needing continuous, 24/7 care must seek alternative funding sources, such as Medicaid for those with limited income, or private long-term care insurance.
