Paying for Home Health and Hospice Care

Home health care services may be paid for directly by the patient or family, through private insurance coverage, or through other sources. Many hospice care programs are provided to the patient regardless of the patient's ability to pay, although most costs for hospice are covered by Medicare. Always check with your insurance provider regarding terms of coverage. The following are sources of payment for home health care services:

• Self-pay. If a patient does not meet the requirements of third-party payers, he or she may have to pay for home health care services. According to the Centers for Medicare and Medicaid Services, only 10 percent of patients use this form of payment.

• Public third-party payers:

  • Medicare. If you are older than 65, you are probably eligible for the federal Medicare program. Patients who are unable to be active outside the home, under a doctor's care and need medically necessary skilled nursing or therapy may be eligible for Medicare coverage. A doctor must authorize and at different times review the home health care plan of the person. Home health care services covered by Medicare must be part-time. It must also be provided by a Medicare-certified home health agency, or an agency that meets the minimum federal requirements of care and cost. Hospice care coverage by Medicare requires certification from a doctor that the patient is terminally ill.

  • Medicaid. Medicaid is a joint federal-state medical assistance program for low-income individuals. Eligibility differs from state to state. However, all states are required to provide home health care coverage to people who:

    1. Receive federally assisted income maintenance payments, such as Social Security income or Aid to Family with Dependent Children.

    2. Are determined to be "categorically needy." Categorically needy individuals are those people who are aged, blind, and are disabled with incomes too high to qualify for coverage below the federal poverty level. Under the federal Medicaid rules, coverage of home health programs must include services such as part-time nursing, health care agency services, and medical supplies and equipment. Some states may provide audiology, physical, occupational, speech therapies, and medical social services as well. Medicaid hospice care coverage is essentially the same as Medicare.

  • Older Americans Act. The Older Americans Act funds state and local social service programs for frail and disabled older individuals to continue independent living in their communities. Coverage may include home health care agencies, personal care, assistance with chores, meals, and shopping. Individuals must be age 60 or older.

  • Veterans Administration. Home health care is provided for veterans through the Veterans Administration if the individual is at least 50 percent disabled as a result of a service-related injury or illness. Authorization from a doctor is needed. Services must be provided through the Veterans Administration's hospital-based home care units. Nonmedical home health care services are usually not covered under this provision.

  • Social services block grant programs. On a yearly basis, federal social services block grants are awarded to the states for service needs. Some of these funds are provided to home health care agencies and homemaker or chore worker services. Individuals may contact their state health departments and offices on aging for additional information.

  • Community organizations. Some community organizations may pay for all or part of the necessary home health or hospice care services, depending on a patient's eligibility and financial circumstances.

• Private third-party payers:

  • Commercial health insurance. Most commercial health insurance policies typically cover some home health care services for immediate or acute medical needs. However, coverage for long-term services varies from plan to plan. Sometimes commercial insurance companies will pay for skilled professional home health care under a cost-sharing plan.

  • CHAMPUS (TRICARE standard). CHAMPUS, or the Civilian Health and Medical Program of the Uniformed Services, covers certain home health care in a cost-sharing plan to dependents of active military personnel and military retirees. CHAMPUS also provides a hospice benefit to its terminally ill beneficiaries. This benefit may provide nursing, social work services, therapies, personal care, medications, and medical supplies and equipment.

  • Workers' compensation. If a person requires medical home health care services as a result of an injury on the job, he or she may be eligible for coverage through a workers' compensation plan.

  • Managed care organizations. Managed care organizations are group health plans whose coverage may include home health and hospice care services. Managed care organizations contracting with Medicare must provide the full range of Medicare-covered home health and hospice services that are available. These organizations must be preapproved.