A Common Question with a Confusing Answer
Does Medicare pay for 24 hour care at home? That’s a question one of our clients asked the 1-800-Medicare line recently, a question that comes up a lot, thanks in part to confusing regulations.
The person who answered that 1-800 call said, “Yes, as long as there is a doctor’s order.” While well-meaning, that answer is wrong and far too simplistic.
Does Medicare Cover 24 Hour Care? In short, the answer is no, not at home, and yes, in a skilled nursing facility, as long as certain parameters are met. Most of the time when people read about their Medicare benefits and see 100 days of skilled nursing or 100 days of home health, they don’t understand that those are simply potential maximums without the explanation of the rules.
24 Hour Care in a Skilled Nursing Facility
Medicare will cover 24 Hour care in a skilled nursing facility as long as the patient had a preceding 3-day hospital stay. (Medicare Advantage Plans may waive that 3 day rule). The care to be provided in the skilled nursing facility needs to be medically necessary and reasonable. If it is, Medicare also covers basic room and board and meals, along with activities of daily living such as bathing, dressing and transferring, for a specified and limited amount of time.
Does the hospital stay have to be right before the skilled nursing stay?
The patient doesn’t necessarily have to go straight from the hospital to skilled nursing facility. They may opt for home at first and realize they need more care.
Just because the patient didn’t chose the skilled nursing facility option does not mean that they can’t choose that option later. This Medicare page specifies how to quality for a skilled nursing facility (SNF) stay and who pays for it. One line says, “You must enter the SNF within a short time (generally 30 days) of leaving the hospital.”
Put simply, a patient might get Medicare to fully fund a 20 day stay in a skilled nursing facility, as long as they have a skilled need and the care is reasonable and necessary. What about the 100 days of skilled nursing mentioned above? That comes with lots of caveats.
How to qualify for a Medicare funded stay in a skilled nursing facility
To stay in a skilled nursing facility at Medicare’s expense, the patient must have a “skilled need.” The skilled need can be the need for a nurse, physical therapist, occupational therapist or speech therapist, dietary counseling, or all of the above.
Someone who has a “custodial need”, for example, someone who has memory loss and needs help with bathing, dressing, and safety monitoring, will most likely not qualify for a Medicare funded stay, but would have to pay out of pocket, or with long term care insurance. The custodial care would likely be more appropriate in assisted living or memory care, or with caregivers at home.
Even if the person qualifies for a Medicare funded stay, and has a skilled need, there are time limits. For example, in the first 20 days of stay at a skilled nursing facility, if the patient has met the intended goals and no longer has a skilled need, then Medicare will no longer pay, despite days being left. The patient may opt to stay and just pay out of pocket in that case.
The patient does have the right to challenge or appeal a discharge from a skilled nursing facility, if the person feels he or she still has a skilled need and the care is reasonable and necessary. Medicare puts out this booklet to explain the rules and how to challenge them. Each skilled nursing facility must give the patient notice before their Medicare coverage ends.
Paying for Care in a Skilled Nursing Facility
Here is a quick breakdown regarding what Medicare pays and what the patient pays.
For a person who has traditional Medicare and has a skilled need, the care in a skilled nursing facility is paid for as follows:
Day 1 to 20 – The patient pays nothing, Medicare covers 100%, including room and board.
Day 21 to 100 – The patient pays up to $200 per day for covered services (meaning they still have the skilled need, not just custodial).
After day 100 – The patient pays 100%.
There are also charges that Medicare does not cover, such as laundry fees and phone charges.
Does Medicare Pay for 24 Hour Care at Home?
The answer to does Medicare pay for 24 hour care at home is no, despite confusing language out there. Medicare pays for a home health benefit for people at home as long as certain criteria are met, but the services are provided on a “part time” or “intermittent basis,” meaning they are visits, usually less than 1 hour, they are not shift care. And Medicare does not fund “caregivers” or “personal care attendants”, with the exception of some Medicare Advantage plans that may authorize 12 visits of 2 hours.
To qualify for Medicare coverage of home health, the person must have a skilled need, such as nursing, physical therapy, occupational therapy, speech therapy, etc., just like in the skilled nursing facility. The goals at home may be different from what goal was already met in the skilled nursing facility. A hospital stay is not required, and neither is a skilled nursing facility stay. A person may be referred to home health after a visit to their emergency room or doctor’s office, and they need to be “homebound”, meaning it takes taxing effort for them to leave home alone.
Medicare does allow for home health aide visits if the person also has a skilled need and the doctor orders home health aide services. But the home health aide is not going to be there for an entire shift. He or she will stop by to help with bathing, dressing, meal prep or feeding and then will leave. A home health aide is not a caregiver, which is also known as a personal care assistant or homemaker. A home health aide is an entirely different certification. And caregiving does not require a doctor’s order.
Just as with the skilled nursing facility, custodial care at home, such as constant safety monitoring or companionship, is not covered by Medicare, the same way Medicare does not pay the rent for people living in assisted living for memory care.
What if I need Medicare home health and 24 hour care?
When an accredited and Medicare Certified agency like At Home Nursing Care provides Medicare Certified Home Health along with caregiving, we make sure the client is aware that services are divided along two separate service lines, provided by different legal entities. Clients are told which services are covered by Medicare and which are not. We have separate service agreements and also a separate private pay agreement for the caregiving services.
While having both services is beneficial, it can be frustrating to learn the answer to “Will Medicare Care for 24 Hour care?”, especially if the clients wish is to recover at home.