While home health care agencies are more cost-effective than hospitals, nursing homes and assisted living facilities, you will want to use all of your available resources before paying out of pocket. Two of the most common sources for home health care funding are Medicare and Medicaid. What’s important to keep in mind is that just because you may be eligible for Medicare or Medicaid, does not mean they will pay for all the services you want.

Medicare
If you are on Medicare, and wish to receive services from a home health care agency, you must meet four specific criteria.

1) You must be home bound. Congress has defined homebound as meaning that leaving home is a major effort, you are normally unable to leave home unassisted, and when you leave home, it must be to get medical care, or for short, infrequent non-medical reasons such as a trip to get a haircut, or to attend religious services or adult day care.

2) Your doctor must decide that you need medical care at home, and make a plan for your care.

3) You must need at least one of the following: intermittent skilled nursing care, or physical therapy or speech-language therapy or continue to need occupational therapy. Skilled services are required to initiate therapy, but do not have to be continued for the duration of receiving home health services.

4) The home health agency caring for you must be approved by the Medicare program. There is no co-pay for approved services.

If you are eligible for Medicare, and your physician has determined that you need home health care, then you have the right to choose which home health care agency you choose. However, just because you have chosen an agency does not mean the agency has availability to service you. Some plans contract with particular service providers.

Medicaid
Administered by individual states, 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 only mandated to provide home health services to individuals who receive federally assisted income maintenance payments, such as Social Security Income and Aid to Families with Dependent Children (AFDC), and individuals who are “categorically needy.” Categorically needy recipients include 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 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 state’s option, Medicaid also may 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.

To qualify for Medicaid home health care support, you must meet your monthly spend down (if any), skilled services are not necessary except for supervision, and prior authorization is required.