Home Care Agencies

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Who pays for home care?

Home care services can be paid for by:

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

For most home care to be covered by public and private payers it must be considered medically necessary. You must also meet certain coverage requirements. Different private insurance plans have different policies, and you may need to call them to find out what they cover. Medicaid coverage varies based on the state where you live.

For services that are not covered by insurance, you may choose to pay out of your own pocket if you can afford it. Some home care agencies get money from community groups or local and state governments to help lower the cost for patients who have no other way pay for their care. Some agencies get donations from individuals and charity groups so they can provide care to anyone who needs it, whether or not they are able to pay.

Public third-party payers

To qualify for the Medicare Home Care Benefit

Most Americans over age 65 are eligible for the federal Medicare program. Some people under the age of 65 may be eligible due to disability. To qualify for home care, a person with Medicare must meet all of the following:

  • Your doctor must decide that you need medical care at home and make a plan for your care at home.
  • You must need at least one of the following either part time or on and off: skilled nursing care, physical therapy, speech-language therapy, or occupational therapy.
  • You must be homebound and unable to leave the house without help. To be homebound means that leaving home takes a good deal of effort. But leaving home for medical treatment or short non-medical trips (such as for haircuts or religious services) do not usually disqualify you.

If you meet all the above 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
  • Medical equipment and supplies

If one of these skilled services is needed, home care aide services may also be provided as part of home care for the illness.

The doctor who refers you for home care must sign off on your plan of care and review it regularly. Except for hospice care, the services you get 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 Medicare, or you can read it on their website. (See the “To learn more” section for contact information.) The booklet contains a checklist to help you choose an agency and a second checklist to help you evaluate its quality.

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.

Medicare also covers hospice services for people with cancer who are expected to live for 6 months or less. For hospice coverage, you are not required to be homebound or in need of skilled nursing care. Call Medicare or visit their website to find out more about the Medicare Hospice Benefit. (For contact information, see the “To learn more” section.)

To qualify for Medicaid coverage of home care

States are required to provide health services to people who get money from federally assisted income programs, such as Social Security and Temporary Assistance for Needy Families (TANF).

Others who may qualify for Medicaid help include “categorically needy” people. These are people who meet the income and resource requirements for TANF but who are not getting it (for example, certain children under the age of 21, and some elderly, blind, and disabled persons whose income is below certain levels).

Under federal Medicaid rules, coverage of home health services must include part-time nursing, home care aide services, and medical supplies and equipment. At the state’s option, Medicaid may also cover audiology (hearing services); physical, occupational, and speech therapies; medical social services; and hospice.

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 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 skilled home care or hospice. The Social Services department of your closest VA medical facility should be able to answer questions about eligibility in your area.

Older Americans Act (OAA)

For many years the OAA provided federal funds for state and local social service programs that helped frail and disabled older people stay independent in their communities. This funding covered home care aides, personal care, household chores, escort, meal delivery, and shopping services for people age 60 and older with the greatest social and financial need. The OAA expired in 2011, and as of early 2013 has not been re-authorized. Some of these services are still provided through a local area Agency on Aging. To find your local Agency on Aging, contact the National Association of Area Agencies on Aging (see the “To learn more” section).

Social Services Block Grant Programs

Each year states get social services grants from the federal government. Part of the money is usually used for programs that offer home care aide and homemaker services. You can contact your state health department or local area Agency on Aging to learn more (see “To learn more”).

Community organizations

Some community groups, along with state and local governments, help pay for home health and personal care. Depending on a person’s eligibility and financial need, these groups may pay for all or part of services. Hospital discharge planners, social workers, local offices on aging, the United Way, and your American Cancer Society can help you find out what’s offered in your area.

Private third-party payers

Commercial health insurance companies

Most private insurance policies include some home care service for short-term needs, but benefits for long-term care vary from plan to plan. Be sure to ask about your insurance coverage not only for home care, but also for home hospice care.

Managed care organizations

These group health plans sometimes cover 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 your plan’s coverage. If you have problems with a Medicare Health Maintenance Organization, you can call the Medicare Rights Center to appeal (see the “To learn more” section).

Private pay or self-pay

If insurance coverage is not available or doesn’t cover all the care that you need, you and your family can hire providers and pay for services yourself. Keep in mind that you might be responsible for payroll taxes, Social Security, and unemployment insurance in some situations. (The IRS can tell you more – see “To learn more” for contact information.) It may help to shop around, as these services can cost a lot.

Last Medical Review: 05/08/2013
Last Revised: 05/08/2013