How is Home Health Care Paid For?

Home care and home health care services can be paid for by:

• Patient and family (out of pocket),
• Public third-party payers such as Medicare, Medicaid, and the Veterans Administration, or
• Private third-party payers such as health insurance companies and managed care plans.

Often, these services are paid by some third party. Third party payors have specific eligibility and coverage requirements, and it is important that caregivers be aware of these requirements so that payment to care providers can be efficiently made without any interruptions in needed services.

Private Pay or Self-Pay

If third-party coverage is not available or does not cover all the care that you need, you and your family can hire providers and pay for services out of pocket.

Public Third-Party Payers

Medicare—80% of all home health visits are paid by Medicare. The Medicare program covers the elderly (those 65 and over) and individuals who have been disabled for two or more years.

While Medicare has the most restrictive requirements for payment of home health services, it is frequently the only resource the elderly have for needed care.

Medicare Home Health Benefit is a federal program that has two parts—Part A and Part B. All home health services can be covered under either Part A or Part B while other forms of health care are only covered under one of the parts. Hospitals and short-term nursing home care are covered only under Part A, while doctor's visits, durable medical equipment, ambulance and outpatient services are covered under Part B.

If a patient is a Medicare beneficiary (who is enrolled in Part A, Part B, or both), Medicare will help cover home health care if the patient meets the following four (4) conditions:

• A doctor must decide that the patient needs skilled care in the home and prescribe or order home care, and
• Must need at least one of the following services: part-time intermittent skilled nursing care or physical therapy, speech-language services, and
• Must be homebound, and
• Must receive services from a home health agency that is "certified" (or approved) by Medicare.

If you meet all four of the conditions above, Medicare will help cover:

• Skilled nursing. This is care that can only be delivered safely by a registered nurse, or a licensed practical nurse under the supervision of a registered nurse. It is care like injections and complex wound care.
• Home health aide services. These services include help with personal care such as bathing, using the toilet or dressing. Medicare does not cover them unless you are also getting skilled care such as nursing or other therapy.
• Therapy. This includes physical therapy, speech-language services and occupational therapy. Your doctor must say you need these types of care.
• Medical social services. This is counseling to help with social and emotional concerns related to your illness.
• Certain medical supplies. This includes things like wound dressings and ostomy supplies.
• Certain durable medical equipment. This includes wheelchairs, hospital beds, oxygen and walkers (not all home health agencies provide equipment—and, if they do, you will be responsible for paying 20% of the cost of these items).

Medicare does not pay for:

• 24-hour per day care in the home.
• Prescription drugs (with a few exceptions—consult your physician).
• Meals delivered to the home.
• Homemaker services like cleaning, laundry and shopping.

Not all home care agencies are certified to provide care to people with Medicare. Those that are certified have met federal requirements for patient care. This allows them to provide home health services to patients covered by Medicare and Medicaid. Due to legal requirements, the agencies must report to Medicare, and their services are watched and controlled.

For more information about Medicare enrollment, or the Medicare Home Health Benefit, call 1-800-MEDICARE. Also, see the Centers for Medicare and Medicaid's document Medicare and Home Health Care.

Medicaid—Medicaid is a program administered by states that is designed to provide necessary health care to low income citizens. Eligibility is based on financial information, which is periodically reviewed. The reimbursement criteria differs from state-to-state and each state has its own process and criteria for participation. In all states, Medicaid pays for basic home health care:

Eligibility is based on financial information, which is periodically reviewed. The reimbursement criteria differs from state-to-state and each state has its own process and criteria for participation.

In all states, Medicaid pays for basic home health care:

• Part-time skilled nursing,
• Home health aide services, and
• Medical supplies and equipment.

Medicaid may pay for homemaker, personal care and other services not paid for by Medicare.

For information about how to apply for Medicaid, contact your state Medicaid agency.

In Florida, contact the Florida Department of Children and Families (DCF), 1-866-76ACCES (1-866-762-2237).

Veterans Administration—Veterans who are at least 50% disabled due to a service-related condition are eligible for home health care coverage by the Veterans Administration (VA). A physician must authorize these services, and the individual must be in need of intermittent nursing, physical therapy, speech therapy or occupational therapy services. The services must be provided through the VA's network of hospital-based home health providers.

For more information, contact the Social Services department of your closest Social Services department.

For Broward County, Florida residents, contact the Miami VA Healthcare System, 1-888-276-1785.

Older Americans Act (OAA)—Enacted by Congress in 1965, the OAA provides federal funds for state and local social service programs that enable frail and disabled older individuals to remain independent in their communities.

This funding covers home care aides, personal care, household chores, escort, meal delivery, and shopping services for those age 60 and older with the greatest social and financial need.

These services are often provided through your local Area Agency on Aging. To find your local Area Agency on Aging, you can contact the National Association of Agencies on Aging, 202.872.0888.

In Broward County, the Aging and Disability Resource Center is your local Area Agency on Aging. You may contact the Aging and Disability Resource Center by calling "Broward County's Elder Helpline" at 954.745.9779.

Social Services Block Grant Programs—Each year, states receive federal social services block grants for state-identified service needs. Portions of the funding are directed in programs providing home care aides and homemaker services.

For more information, contact your state health department or ACF Social Services Block Grant Program.

In Florida, contact the Florida Department of Health, 850.245.4444.

Community Organizations—Some community organizations, along with state and local governments, provide funds for home health and personal care. Depending on a person's eligibility and financial need, these groups may pay for all or a portion of needed services.

Your local office on Aging, the United Way, and your American Cancer Society are excellent sources about what's offered in your area.

Private Third-Party Payers

Commercial Health Insurance Companies—Commercial health insurance policies typically include home care benefits for short-term needs, but benefits for long-term care vary from plan to plan. Requirements for coverage vary greatly. Check with you insurance company for further information and be sure to ask about your insurance coverage not only for home care but also for home hospice care.

Managed Care Organizations—Managed Care Organizations (MCOs) and other group health plans sometimes include coverage for home care services. Managed Care Organizations that have contracts with Medicare must provide the full range of Medicare-covered home health services available. Coverage may be limited to doctor-directed medical services and treatments, but your choice of agency is restricted. Be sure to ask about you plan's coverage.

How Do I Choose a Home Health Agency?

>> Continue >>