For most home care to be covered by public and private payers it must be considered medically necessary and you must meet certain coverage requirements. Medicaid coverage varies depending on the state you live in and, of course, different private insurance carriers have different policies.
Home care services can be paid for by:
* patient and family
* public third-party payers such as Medicare, Medicaid, and the Veterans Administration (VA)
* private third-party payers such as commercial health insurance companies and managed care organizations
For services that are not covered, you may choose to pay out of your own pocket. Some agencies receive money from community groups or local and state governments to help patients pay for their care when they have no other way to get it. With support from charitable sources, some agencies provide care to all that need it, regardless of ability to pay.
Public Third-Party Payers
If you meet all the requirements, you may be eligible for services provided by a Medicare-certified home health agency. Depending on your condition, Medicare may pay for skilled nursing visits; physical, occupational, and speech therapies; medical social services; and medical equipment and supplies. If one of these skilled services is required, home care aide services may also be provided as part of home care for the illness.
The referring physician must authorize and regularly review your plan of care. With the exception of hospice care, the services you receive must be part-time and provided through a Medicare-certified home health agency in order to qualify for payment. For more information on Medicare and home care, you can order the booklet, “Medicare and Home Health Care” by calling 1-800-MEDICARE (TTY call 1-877-486-2048). The booklet contains a checklist for helping you choose an agency and another for helping you evaluate its quality.
Under federal Medicaid rules, coverage of home health services must include part-time nursing, home care aide services, and medical supplies and equipment.
Department of Veterans Affairs:
Different types of services are available in different areas of the United States . Most Veterans Affairs (VA) regions pay for skilled home care (SHC) and hospice, although the VA may not directly provide these services. The veteran must be referred by a VA doctor and meet medical requirements to qualify for SHC or hospice. The Social Services department of your local VA medical facility will be able to answer questions about eligibility in your area.
Older Americans Act (OAA):
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 and personal care, household chores, escort, meal delivery, and shopping services for individuals 60 and older with the greatest social and financial need. People often request these services through a local Area Agency on Aging or through the Department of Health and Human Services' Administration on Aging.
Some community organizations, along with state and local governments, provide funds for home health and supportive care. Depending on a person's eligibility and financial circumstances, these organizations may pay for all or a portion of services. Hospital discharge planners, social workers, local offices on aging, the United Way , and your American Cancer Society are excellent sources for information about what's available in your community.
Private Third-Party Payers
Commercial health insurance companies:
Most private insurance policies include some home care service for acute, short-term needs, but benefits for long-term care vary from plan to plan. Be sure to inquire about your insurance coverage not only for home care but also for home hospice care.
Previously known as the Civilian Health and Medical Program of the Uniformed Services (CHAMPUS), TRICARE covers home care services on a cost-shared basis for dependents of active military personnel and military retirees, their dependents and survivors. TRICARE offers hospice benefits that cover nursing, social work and counseling services, personal care, medications, and medical supplies and equipment.
Managed Care Organizations:
These group health plans sometimes include coverage for home care services. Managed care organizations contracting with Medicare must provide the full ranges of Medicare-covered home health services available in a particular geographic region. Coverage may be limited to doctor-directed medical services and treatments. Choice of agency, however, is restricted. Be sure to inquire about your plan's specific coverage.
Private pay or self-pay:
If insurance coverage is not available or is insufficient, you and your family can engage providers and pay for services out of pocket.