What’s the Difference Between Home Health Care and Nursing Home Care?
Medicare considers home health care to be skilled, in-home nursing care or outpatient therapy services to treat an illness or injury. Nursing home care services are somewhat similar, but delivered in a skilled nursing facility (SNF). Whether Medicare covers these services will depend on the type of nursing care you need and how long you need it.
Medicare home health care
Intermittent or short-term home health services (for example, if you’re recovering after a recent hospitalization) are covered under Medicare Part A and Part B. These services must be provided by a Medicare-certified home health agency that works with your doctor to manage your care.
To be eligible for Medicare coverage:
- Your doctor must order it medically necessary that you receive intermittent skilled nursing care or outpatient therapy services at home. Medicare defines “intermittent” care as care given less than seven days a week or less than eight hours a day, for no longer than 21 days. If you need more than intermittent nursing care, Medicare will generally not cover it except in special circumstances.
- Your doctor must determine that your condition will improve, and that your need for home health services is temporary.
- You must be homebound, meaning you can’t leave your home without assistance, or it might be dangerous to leave due to your health condition. Homebound doesn’t necessary mean bed-bound. You’re still considered homebound if you leave your home occasionally, for short periods of time, even for non-medical purposes like attending religious services.
Medicare covers your home health services over a 60-day period, after which the doctor must review your plan of care. However, there is no limit to the number of times your doctor can reorder this care for you, as long as it remains medically necessary to treat your condition.
Medicare-covered home health care may include:
- Skilled nursing services given by a registered nurse or licensed practical nurse
- Physical therapy, occupational therapy, or speech pathology services
- Home health aide services
- Medical social services
- Durable medical equipment (DME)
- Other supplies needed as part of your home care
Medicare coverage for in-home nursing care doesn’t usually include meals, homemaker services, or round-the-clock nursing. Custodial care isn’t covered if this is the only kind of care you need. Custodial care refers to personal assistance with daily living activities, such as bathing or getting dressed. These tasks are usually performed by home health aides and don’t require a medically trained nursing or rehabilitation team.
If you have Original Medicare, Part A and Part B, you pay nothing for the home health services and 20 percent of the Medicare-approved amount for any durable medical equipment (DME).
Medicare nursing home coverage
Medicare doesn’t generally pay for long-term nursing home care. Medicare Part A does cover medically necessary, short-term care in a skilled nursing facility under certain conditions. Part A covers a semi-private room, medical supplies used in the facility, meals, and other items; see What is Medicare Part A? for details.
To be eligible for nursing home coverage, Medicare requires you to meet criteria such as, but not limited to:
- You have a qualifying inpatient hospital stay of at least three days before entering the SNF.
- The SNF is Medicare-certified.
- Your doctor orders this type of skilled daily care for you, indicating that it can only be delivered by a skilled nursing or rehabilitation staff (or under the staff’s supervision).
- You’re enrolled in Medicare Part A, with days left in your benefit period.
- You need treatment for a hospital-related medical condition, or for certain medical conditions you develop in the SNF.
If you live in a nursing home, Medicare still covers hospital and medical services under Part A and Part B. If you take medications, pharmacies contract with Medicare Part D Prescription Drug plans to provide drug coverage for nursing home residents.
Although Original Medicare generally doesn’t cover long-term nursing home care, you may be able to get help with costs if you have limited income and qualify for Medicaid. Contact your state Medicaid office to find out if you’re eligible.
In addition, some Medicare Advantage plans (offered by private Medicare-approved insurance companies) may include coverage for nursing home services. In most cases, long-term nursing home care is only covered if you live in a nursing home that is contracted with your plan. However, some Medicare Advantage plans have Special Needs Plans (SNPs) that may help you if you live in a nursing home or have certain conditions, such as congestive heart failure.
What kind of care do I need?
If you need short-term, skilled nursing care to recover from an illness or injury, Medicare Part A’s home health benefit might cover you. If you’re recovering from a hospital stay, Part A’s skilled nursing facility coverage might cover your needs. Your Medicare-assigned doctor can recommend the kind of care you need and help place you in the appropriate situation.
However, if you need full-time or long-term care, Original Medicare coverage may not be sufficient. eHealth’s plan comparison tool can help you find Medicare plan options that may offer nursing home coverage. To see which Medicare plan options are available in your area, simply enter your zip code into the form on this page. You can also compare plans at Medicare.gov or by calling 1-800-MEDICARE (1-800-633-4227) (TTY users 1-877-486-2048), 24 hours a day, seven days a week.
Many beneficiaries will need long-term care at some point in their lives, whether that takes place at home, in an assisted living facility, or in a nursing home. If you need such care, visit LongTermCare.gov for information on long-term care options.
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