Who Pays for Home Care Services?

Self-Pay

Public Third-Party Payors
Medicare
Medicaid
Older American's Act (OAA)
Veterans Administration (VA)
Social Services Block Grant Programs
Community Organizations

Private Third Party Payors
Commercial Health Insurance Companies
Medigap Insurance
Long-Term Care Insurance
Managed Care Organizations
CHAMPUS

Home care services can be paid for directly by the patient and his/her family members, or through a variety of public and private sources. Hospice care is generally provided, regardless of the patient's and/or family's ability to pay. Public third-party payors include Medicare, Medicaid, the Older Americans Act, the Veterans Administration, and Social Services block grant programs. Some community organizations, such as local chapters of the American Cancer Society, the Alzheimer's Association, and the National Easter Seal Society, also provide funding to help pay for home care services. Private third-party payors include commercial health insurance companies, managed care organizations, and CHAMPUS.

Self-Pay
Home care services that fail to meet the criteria of third-party payors must be paid for "out of pocket" by the patient or other party. The patient and home care provider negotiate the fees.

Public Third-Party Payors

Medicare
Most Americans older than 65 are eligible for the federal Medicare program. If an individual is homebound, under a physician's care, and requires medically necessary, skilled nursing or therapy services, he/she may be eligible for services provided by a Medicare-certified home health agency. Depending on the patient's condition, Medicare may pay for intermittent skilled nursing; physical, occupational, and speech therapies; medical social work; HCA services; and medical equipment and supplies. The referring physician must authorize and periodically review the patient's plan of care. With the exception of hospice care, the services the patient receives must be intermittent or part time and provided through a Medicare-certified home health agency for reimbursement. Hospice services are available to individuals who are terminally ill and have a life expectancy of six or fewer months. There is no requirement for the patient to be homebound or in need of skilled nursing care. A physician's certification is required to qualify an individual for the Medicare Hospice Benefit. The physician must also re-certify the individual at the beginning of each six-month benefit period. In turn, the patient is required to sign a statement, indicating that he/she understands the nature of the illness and of hospice care. By signing this statement, the patient surrenders his/her rights to other Medicare benefits related to terminal illness. Back to Top

Medicaid
Medicaid is a joint federal-state medical assistance program for low income individuals. Each state has its own set of eligibility requirements. However, states are mandated only to provide home health services to individuals who receive federally-assisted income maintenance payments, such as Social Security income, Aid to Families with Dependent Children (AFDC), and individuals who are "categorically needy", such as certain aged, blind, and/or disabled individuals who have incomes that are too high to qualify for mandatory coverage, but below federal poverty levels. Individuals younger than 21, who meet income and resources requirements for AFDC, yet who otherwise are ineligible for AFDC, also qualify as categorically needy. Under federal Medicaid rules, coverage of home health services must include part-time nursing, HCA services, and medical supplies and equipment. At the option of the state, Medicaid may also cover audiology; physical, occupational, and speech therapies; and medical social services. Hospice is a Medicaid-covered benefit in 38 states. The Medicaid hospice benefit covers the same range of services that Medicare does. Back to Top

Veterans Administration
Veterans who are at least 50% disabled, due to a military service-related condition, are eligible for home health care, provided by the Veterans Administration (VA). A physician must authorize these services, which must be delivered through the VA's network of hospital-based home care units. The VA does not cover non-medical services provided by HCAs. Back to Top

Community Organizations
Some community organizations, along with state and local governments, provide funds for home health and supportive care. Depending on an individual's eligibility and financial circumstances, these organizations may pay for all, or a portion of, the needed services. Hospital discharge planners, social workers, local offices on aging, and the United Way are excellent sources for information about community resources. Back to Top

Private Third-Party Payors

Commercial Health Insurance Companies
Commercial health insurance policies typically cover some home care services for acute needs, but benefits for long-term services vary from plan to plan. Commercial insurers, generally pay for skilled professional home care services with a cost-sharing provision. Such policies occasionally cover personal care services. Most commercial and private insurance plans will cover comprehensive hospice services, including nursing, social work, therapies, personal care, medications, and medical supplies and equipment. Cost sharing varies with individual policies, but often is not required. Back to Top

Medigap
Individuals sometimes find it necessary to purchase Medigap insurance or long-term care insurance policies for additional home coverage. Such insurance is designed to bridge some of the gaps in Medicare coverage. Some Medigap policies offer at-home recovery benefits which pay for some personal care services when the policy holder's physician must order this personal care, in conjunction with skilled services. Home care coverage in Medigap policies is not designed to cover extended long term care. This type of coverage is most helpful to individuals recovering from acute illness, injuries, or surgery. Back to Top

What is Home Care?
"Home care" is a simple phrase that encompasses a wide range of health and social services. These services are delivered at home to recovering, disabled, chronically or terminally ill persons in need of medical, nursing, social, or therapeutic treatment and/or assistance with the essential activities of daily living. Back to Top

How to Choose a Home Based Health Provider
Generally, home care is appropriate whenever a person prefers to stay at home, but who needs ongoing care that cannot be easily or effectively provided solely by family and friends. More and more older people, electing to live independent, non-institutionalized lives, are receiving home care services as their physical capabilities diminish. Younger adults who are disabled, or recuperating from an acute illness, are choosing home care, whenever possible. Chronically ill infants and children are receiving sophisticated medical treatment in their loving and secure home environments. Adults and children who are diagnosed with terminal illness are, likewise, being cared for at home, receiving compassion and maintaining dignity at the end of life. As hospital stays decrease, increasing numbers of patients need highly skilled services when they return home. Other patients are able to stay at home to begin with, receiving safe and effective care. Back to Top

Who Provides Home Care?
· Home Health Agencies
· Hospices
· Homemaker and Home Care Aide Agencies
· Staffing and Private Duty Agencies
· Pharmaceutical and Infusion Therapy Companies
· Durable Medical Equipment and Supply Dealers
· Registries
· Independent Providers

Home care services are generally available 24 hours a day, seven days a week. Depending on the individual patient's needs, these services may be provided by an individual or a team of specialists, on a part-time, intermittent, hourly, or shift basis. Following are descriptions of the various types of home care providers.

Home Health Agencies

The term "home health agency" often indicates that a home care provider is Medicare-certified. A Medicare-certified agency has met federal minimum requirements for patient care and management and, therefore, can provide Medicare and Medicaid home health services. Individuals requiring skilled home care services usually receive their care from home health agencies. Due to regulatory requirements, services provided by these agencies are highly supervised and controlled. Some agencies deliver a variety of home care services through physicians, nurses, therapists, social workers, homemakers and HCAs, durable medical equipment and supply dealers, and volunteers. Other home health agencies limit their services to nursing and one or two other specialties. For cases in which an individual requires care from more than one specialist, home health agencies coordinate a care giving team to administer comprehensive, efficient services. Personnel are assigned according to the needs of each patient. Home health agencies recruit and supervise their personnel. As a result, they assume liability for all care. Back to Top

What Types of Services Do Home Care Providers Deliver?
· Physicians
· Registered Nurses and Licensed Vocational Nurses
· Physical Therapists
· Social Workers
· Speech/Language Pathologists
· Occupational Therapists
· Dieticians
· Home Care Aides/Home Health Aides
· Homemaker and Chore Workers
· Companions
· Volunteers

Registered Nurses (RNs) and Licensed Practical Nurses (LVNs) provide skilled services that cannot be performed safely and effectively by non-professional personnel. Some of these services include injections and intravenous therapy, wound care, education on disease treatment and prevention, and patient assessments. RNs may also provide case management services. RNs have received two or more years of specialized education and are licensed to practice by the state. LNs have at lease one year of specialized training and are licensed to work under the supervision of Registered Nurses. The intricacies of a patient's medical condition and required course of treatment determine whether care should be provided by an RN, or can be provided by an LVN.

Physical Therapists (PTs) work to restore the mobility and strength of patients who are limited or disabled by physical injuries, through the use of exercise, massage, and other methods. Using specialized equipment, PTs often alleviate pain and restore injured muscles. They also teach patients and care givers special techniques for walking and transfer.

Social Workers provide counseling and evaluate the social and emotional factors affecting ill and disabled individuals. They also help patients and their family members identify available community resources. Social workers often serve as case managers when patients' conditions are so complex that professionals need to assess medical and supportive needs and to coordinate a variety of services.

Speech/Language Pathologists work to develop and restore the speech of individuals with communication disorders. Usually, such disorders are the result of traumas such as surgery or stroke. Speech therapists also help retrain patients in breathing, swallowing, and muscle control.

Occupational Therapists (OTs) help individuals who have physical, developmental, social, or emotional problems that prevent them from performing the general Activities of Daily Living (ADLs). OTs instruct patients on using specialized rehabilitation techniques and equipment to improve their functions in tasks such as eating, bathing, dressing, and basic household routines.

Dietitians provide counseling services to individuals who need professional dietary assessment and guidance to properly manage an illness or disability.

Home Health Aides (HHAs) assist patients with ADLs, such as getting in and out of bed, walking, bathing, toileting, and dressing. Some aides have received special training and, under the supervision of a nursing professional, are qualified to provide more complex services. Back to Top