The Role of Medicare and Medicaid in Home Health Care

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 meet all of Medicare’s eligibility requirements, then you can get benefits from Medicare for the following types of home care:

  • Part-time or Intermittent Skilled Nursing Care: These services require an RN or LPN in order to ensure safety.
  • Part-time or Intermittent Home Health Aide Care: Home health aides don’t have a license for nursing. Instead they help with daily tasks like bathing, dressing, and personal care. In order for this to be covered, you must also be getting skilled care or another therapy and the aide services must be a part of the care you receive for your injury or illness.
  • Physical, Speech-language, and Occupational Therapy: These services are covered by Medicare for as long as your doctor deems it necessary.
  • Medical Social Services: These home care services are designed to help you deal with the social and emotional needs resulting from your illness. For some seniors, this will include counseling or finding community resources.
  • Medical Supplies: Certain types of medical supplies such as wound dressings are covered while prescription medications and biological are not.
  • Durable Medical Equipment: Items such as wheelchairs and walkers are covered through Medicare.
  • Osteoporosis Medications: Some FDA-approved injectable osteoporosis medications are covered for certain circumstances.

Of course, there also things Medicare will not cover including 24-hour daily home care; home meal delivery; housekeeping services such as cleaning, laundry, and shopping; and personal care from home a home health aide when aide care is the only type of care you require.

Even with this information, figuring out what is covered can be difficult. For more information on the benefits provided by Medicare, you can visit their website at Medicare.gov.

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.

As you can see, you do not have to be stuck in your home every day without human contact to qualify.

Medicare will pay for the services (in most cases) that your doctor decides is needed.  This includes skilled nursing care on a part time basis, home health aides, physical therapy, social services, medical supplies (dressings, testing supplies–not medications), durable medical equipment (canes, shoes, wheelchairs), FDA-approved drugs for some conditions.

Medicare does not pay for full time home care, meal delivery, maid-type services, or ADL assistance care (personal care assistance) if this is the only care required.

While it may seem daunting that Medicare does not pay for full time care, if you need ‘fill in’ care when a family member is away from home, Medicare will be a huge help.  Medicare in combination with insurance may relieve all of the costs related to home health care.

Before choosing a home health option, you can contact your doctor or Medicare customer service for advice on your specific situation.  You do have a choice in the home health provider assigned to you, though you may have more limited options than if you were paying for the care out of pocket or with private insurance.

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.