Home healthcare is paid for by a variety of different sources. Healthcare given in the home is usually less expensive, more convenient, and just as effective as care you get in a hospital or skilled nursing facility. The major sources of funding are:
Medicare is a national health insurance program designed primarily for people 65 years of age and older, some disabled people less than 65 years of age and people with end-stage renal disease. Medicare is provided by the Federal government. Medicare pays for you to get certain healthcare services in your home. This is known as the Medicare home health benefit.
If you have Medicare coverage, you can use your home health benefits if you meet all the following conditions:
- Your doctor must decide that you need medical care at home, and make a plan for this care.
- You must need one or more of the following: intermittent (not full time) skilled nursing care; physical therapy; speech pathology services or continued occupational therapy.
- The home health agency caring for you must be approved by the Medicare Program (Medicare-certified).
- 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 attend religious services. You can still get home healthcare if you attend adult day care.
Eligibility is also based on the amount of services you need
If you meet the conditions above, Medicare pays for your covered home health services for as long as you are eligible and your doctor says you need them. 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 or days per week that you can get skilled nursing or home health aide services.
If you meet all four (4) of the conditions, Medicare will cover:
- Skilled nursing on a part-time basis. This care can only be delivered safely by a registered or licensed practical nurse.
- Home health aide services on a part time basis. These services include help with personal care such as bathing, using the toilet, or dressing. Medicare does not cover home health aide services unless you are also getting skilled care such as nursing or other therapy.
- Physical therapy, speech language pathology services and occupational therapy if the doctor says you need it.
- Hospice care
- Medical social services to help with social and emotional concerns related to your illness.
- Certain medical supplies, like wound dressings but no prescription drugs.
Medicare does not pay for:
- 24-hours a day care in the home.
- Prescription drugs.
- Meals delivered to your home.
- Homemaker services like shopping, cleaning, and laundry when this is the only care you need, and when these services aren't related to your plan of care.
- Personal care given by home health aides like bathing, dressing, and using the bathroom when this is the only care you need.
Your rights as a person with Medicare"
In general, as a person with Medicare getting home healthcare from a Medicare-certified home health agency, you are guaranteed certain rights, including the following:
- To get a written notice of your rights before your care is started.
- To have your home and property treated with respect.
- To be told, in advance, what care you will be getting when your plan of care is going to change.
- To participate in your care planning and treatment.
- To get written information about your privacy rights and your appeal rights.
- To have your personal information kept private.
- To get written and verbal information about how much Medicare is expected to pay and how much you will have to pay for any services that you will be getting.
- To make complaints about your care and have the home health agency follow up on them.
- To know the phone number of the home health hotline in your state where you can call with complaints or questions about your care.
If you would like more information about Medicare, call 1-800-MEDICARE.
Medicaid is a joint Federal and state program that helps pay medical costs for some people with limited or low income and resources. Some people qualify for both Medicare and Medicaid. In general, most of your healthcare costs are covered if you have Medicare and Medicaid. To qualify for Medicaid, you must have a low income, little savings and have no other substantial assets, as defined by your state.
Medicaid programs vary from state to state. They may also be called by different names, like "Medical Assistance" or 'Medi-Cal." People with Medicaid may get coverage for services that aren't fully covered by Medicare, such as nursing home and home healthcare. It is up to the state to decide if it wants to provide any therapy or social services.
To find out more information on what Medicaid covers for home healthcare in your state, call your State medical assistance office.
Typically, insurance plans cover some home healthcare services for acute needs. As with Medicare, most insurance plans require that a doctor determine that the care is needed and has developed a plan for care in the home. There are four (4) major types of plans that pay for home healthcare:
- Indemnity plans
- Health Maintenance Organizations (HMOs)
- Blue Cross and Blue Shield
- Medicare Managed Care Organizations (MCO): Medicare MCOs must offer all the same services as Medicare
Home healthcare services paid for by private insurance generally require the patient to pay a portion of the services (co-pay and/or deductible).
Hospice care and long term care coverage vary from plan to plan. Check with your insurance company to see what services are covered, what you may be responsible to pay and any other plan requirements.
Payment by Individual (Out of Pocket)
There may be times when home healthcare is not covered by Medicare, Medicaid or private insurance such as:
- The benefits have been exhausted;
- The insurance will no longer cover the care;
- The person may not qualify for federal or state financial assistance;
- The person no longer meets the Medicare and/or Medicaid conditions to receive care.
Whatever the reason may be, the fact is, many patients and their families prefer to pay for home healthcare services privately. It allows them more flexibility in the type and amount of services they wish to receive. This avoids any limits on care that a government or insurance plan may fund.
Home healthcare services can be purchased by the hour or by the visit (for home health aides, a four hour minimum is common). Many home healthcare agencies have someone who will come to your house to evaluate your needs and help you to create a plan. These planning services are usually offered on an hourly basis and range in cost from $50 to $150 per hour.
Check with your local VNA for the types of services they have available. Find a Visiting Nurse Agency (VNA) near you now!