Who pays for home care for cancer patients?
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
Medicare Part A and/or Part B cover eligible home health services. 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, you may be eligible for care from a Medicare-certified home health agency. The Centers for Medicare and Medicaid Services has a lot more information about this. Call them toll-free at 1-800-633-4227 (1-800-MEDICARE) or visit www.cms.hhs.gov.
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 aren’t 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. To find VA-operated home health agencies call the Department of Veterans Affairs toll-free at 1-800-827-1000, or visit www.va.gov.
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 contact your health care plan to get the details about your insurance coverage for home 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.
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.) It may help to shop around, as these services can cost a lot.
National Association for Home Care & Hospice. What Are The Standard Billing and Payment Practices? Accessed at www.nahc.org/consumer-information/standard-billing-and-payment-practices/ on April 15, 2016.
Last Medical Review: 04/19/2016
Last Revised: 05/13/2016