Who Pays for Home Care?

Here is a look at some typical payors and what they usually cover for home care services.

Medicare Not all home care agencies are approved by Medicare to provide services to Medicare beneficiaries. A home care agency who is approved by Medicare is called certified. A certified agency has met strict federal requirements for patient care and management and therefore can provide home health services that are paid for by Medicare or Medicaid. These agencies typically focus on medical-related care such as nursing, therapies, and home health aides, but can also provide a range of supportive services. Most commercial health insurers require that services they cover be provided by Certified agencies.

The federal Medicare program provides comparative data on their website as to how certified home health agencies compare in providing care for some of their patients. Quality information that can be used to help you compare home health agencies can be found on Medicare's website www.medicare.gov

If you are a Medicare beneficiary and meet certain criteria, Medicare will cover:

• Skilled nursing care on a part-time or intermittent basis. Skilled nursing care includes services and care that can only be performed safely and correctly by a licensed nurse (either a registered nurse or a licensed practical nurse).

• Home health aide services on a part-time or intermittent basis. A home health aide does not have a nursing license. The aide provides services that support any services that the nurse provides. These services include help with personal care such as bathing, using the toilet, or dressing. These types of services do not need the skills of a licensed nurse. Medicare does not cover home health aide services unless you are also getting skilled care such as nursing care or other therapy. The home health aide services must be part of the home care for your illness or injury.

• Physical therapy, speech-language pathology services, and occupational therapy:

• Physical therapy, which includes exercise to regain movement and strength to a body area, and training on how to use special equipment or do daily activities, like how to get in and out of a wheelchair or bathtub.

• Speech-language pathology services, which includes exercise to regain and strengthen speech and swallowing skills.

• Occupational therapy, which helps you become able to do usual daily activities by yourself. You might learn new ways to eat, put on clothes, comb your hair, and new ways to do other usual daily activities.

• Medical social services to help you with social and emotional concerns related to your illness. This might include counseling or help in finding resources in your community.

• Certain medical supplies, like wound dressings, that are ordered as part of your care.

The criteria you must meet to be eligible for Medicare’s home health benefit have been defined by Medicare:

Physician involvement - Your doctor must decide that you need medical care at home, and make a plan for your care at home.

Patient is homebound - You must be homebound, or normally unable to leave home unassisted. To be homebound means that leaving home takes considerable and taxing effort. A person may leave home for medical treatment or short, infrequent absences for non-medical reasons, such as a trip to the barber or to attend religious service. A need for adult day care doesn’t keep you from getting home health care.

Patient requires skilled care or SN,PT,ST (or OT with another skill) - You must need at least one of the following: intermittent skilled nursing care, or physical therapy, or speech-language therapy, or occupational therapy.

The services are part-time/ intermittent - Eligibility is also based on the amount of services you need. Medicare covers your home health services for as long as you are eligible and your doctor says you need these services. However, the skilled nursing care and home health aide services are only covered on a part-time or “intermittent” basis. This means there are limits on the number of hours per day and days per week that you can get skilled nursing or home health aide services.
Therapy services don’t have to be part-time or intermittent.

Medicare doesn’t pay for
• 24-hour-a-day care at home;

• meals delivered to your home;

• homemaker services like shopping, cleaning, and laundry

• personal care given by home health aides like bathing, dressing, and using the bathroom when this is the only care you need.

Although Medicare doesn’t cover prescription drugs as part of home health care, a recent law added new prescription drug benefits to the Medicare program as a whole.

Medicare HMO
Medicare Advantage is the name for the Medicare Managed Care Plan or HMO. Your Medicare HMO plan is required by Medicare to provide the same home care benefits as the regular Medicare plan.

If you belong to a Medicare Advantage Plan, you may only be able to choose a home health agency that works with the health care plan. Call your plan if you have questions about the plan’s home health care rules, coverage, appeal rights, and your costs. If you get services from a home care agency that doesn’t work with your Medicare Advantage Plan, neither the plan nor Medicare will pay the bill.

Medicaid
Most states provide state-funded supportive services to elders and disabled individuals who meet income and functional eligibility guidelines. These non-medical supportive services are designed to enable frail elders to remain in their homes.

Most states also provide for state-funded nursing or physical therapy services at home for those individuals who qualify.

Insurance
Medicare is not the only payor who pays for home care. Commercial health insurance policies typically cover some home care services for when a person is recovering from surgery or illness. However, benefits for long-term services vary from plan to plan. Commercial insurers generally pay for medical care in the home with a cost-sharing provision. Cost sharing varies with individual policies. You should contact your health insurer for more information.

As the public's need and preference for home care has grown, private long-term care insurance policies have expanded their coverage for in-home care. Home care benefits vary greatly among plans but most plans today cover home care.

Other payors
There are other sources of payment for home care services. These can include Workers Compensation, the Veterans Administration, the Military Health Program, the Older Americans Act and more. Many home care providers have foundations that will pay for home care for low-income families.

Private Pay
If an individual does not qualify for home care benefits through insurance or Medicare or Medicaid, that individual may want to consider arranging payment privately with the agency.