Home health care services offer valuable support for those facing health challenges, but for those with Medicaid coverage, a common question many caregivers and family members ask is “does Medicaid cover home health care?”
To help you understand whether home health care is covered by Medicaid, it is helpful to learn what counts as home health care, who is eligible for this type of care and what questions you should ask about coverage depending on the state you live in. In this article, we’ll take a closer look at these topics as well as other frequently asked questions about home health care and Medicaid coverage.
What is Home Health Care?
First, it is important to understand some basic differences between the terms home care and home health care.
Home care often refers to non-medical or non-clinical services. Non-medical or non-clinical services include assistance with daily tasks like light housekeeping, meal preparation, personal care and transportation, as well as companionship.
Home health care offers skilled clinical care in the home, including services like nursing, physical therapy, speech therapy, occupational therapy, medication management, wound care, and injectable or intravenous medication administration.
Understanding Medicaid Coverage for Home Health Care
Each state operates their Medicaid program, determining the types of services covered as outlined in their state Medicaid plan, following federal guidelines. Each state administers their Medicaid program differently, so there is variation from state to state. States have flexibility in administering their programs.
In general terms, Medicaid offers coverage for a broad variety of community-based, in-home covered services to help those with various needs. Some programs are designed for individuals with disabilities, some for the elderly and others with additional needs or conditions. The level of care and types of services and the program names and program offerings vary by state.
Eligibility Criteria for Medicaid Coverage of Services
There are financial and functional or need-based eligibility criteria that are outlined in each state’s Medicaid plan. Medicaid coverage is applied for in the state in which a patient lives and is designed for those with limited resources. Programs offered within a state may have varying eligibility criteria.
1. Financial Requirements
Medicaid programs calculate financial eligibility requirements based on a combination of income and assets, with limits varying by state of residence. For specific Medicaid programs related to Home and Community Based Services (HCBS) waivers, other income limits may apply. 1
2. Functional/ Level of Care Need Requirements
Functional or level of care requirements that demonstrate a need for assistance must also be met. Patients must often demonstrate the need for assistance with daily tasks called activities of daily living (ADLs) and/or instrumental activities of daily living (IADLs). 2 Other functional abilities may be assessed depending on the specific Medicaid program and state that is paying for the care.
For patients seeking coverage and assistance through state HCBS waivers, there must be a level of care need consistent with the type of care provided in a nursing facility, called Nursing Facility Level of Care (NFLOC). 3 This means the patient requires 24-hour/7-days-per-week care, much like that received in a nursing home.
What Types of Home Care Does Medicaid Cover?
Medicaid may cover a variety of services in the home, dependent on the state’s program offerings. Services may include:
- Skilled nursing services
- Physical, speech, and occupational therapy
- Home health aides
- Durable medical equipment
- And more
Home health care, which is the clinical/skilled care delivered in the home, is included in this coverage. It is important to remember that coverage will vary by state. You can learn more about the coverage and eligibility requirements through your state Medicaid agency. Also, not all home health care providers are Medicaid licensed, so it’s important to ask about this when considering a provider.
Other Medicaid and Home Health FAQs
There are a few other commonly asked questions related to Medicaid coverage and home health care:
1. Will Medicaid pay family members to provide home care?
Medicaid provides for what is called “self-directed” care for home care in most states, depending on individual state laws. 4 This may allow patients to hire relatives or friends to provide a part of the care they receive, such as personal care and homemaker services. Medical care, such as that provided through a home health care agency, still requires professional and licensed services.
2. How many hours of home health care does Medicaid cover?
The number of hours of nursing care or other medical care covered by Medicaid depends on each state’s laws. In some states, there are specific provisions to cover 24-hour care, but generally the care has daily and weekly total limits for the number of hours allowed.
3. Where can I learn more about my state’s Medicaid plan and eligibility?
You can obtain contact information for your state Medicaid agency and learn more here.
4. Can I use both Medicaid and Medicare to pay for home health?
Some people are eligible for coverage through both Medicare and Medicaid, also called dual eligible. 5 Medicare home health eligibility will depend on the type of Medicare plan, whether traditional or Medicare Advantage. For those who can receive coverage through Medicare, both programs may cover a part of the services provided via home health.
5. Where can I find Medicaid licensed providers in my state?
From the Medicaid.gov website, there are links to state specific program information including providers.
6. What is a Managed Care Organization?
Some states work with Managed Care Organizations (MCOs) to administer their Medicaid program and deliver services to Medicaid recipients. More information is available through your state Medicaid program.
7. Do my home health services under Medicaid require prior authorization?
Prior authorization may be required as outlined in a state’s Medicaid plan. Prior authorization may also be called pre-authorization or prior approval or precertification. The healthcare provider/agency will be able to explain how this may apply to your services/plan of care/treatment.
8. What is Electronic Visit Verification?
Electronic Visit Verification (EVV) is a federal requirement each state Medicaid program complies with, through the use of technology/electronic systems to verify home visit data. EVV reduces improper payments and prevents fraud. EVV collects information such as the time, date, location and services provided during the course of a visit. It is important to know that EVV does not have an effect on your Medicaid home health services, but is a tool used to make sure visit reporting is accurate. Medicaid providers, including home health agencies comply with their state’s EVV reporting requirements.
Choosing a Home Health Care Agency
At Amedisys, our goal is to give you or your loved ones the tools and resources to help control your disease, achieve your health goals and live life to the fullest based on your doctor’s orders and clinical needs. We’re Medicaid licensed in several states and our home health care includes specialized empowerment programs for heart failure, COPD, diabetes and fall reduction, and our quality ratings reflect the dedication of our teams of skilled home health nurses, home health aides, and physical, occupational and other therapists.
To find out more about home health including services in your area, fill out our form today to speak with a home health specialist.
Barbara D’Aunoy, MBA, BSN, RN, CWS, CHC, serves as Assistant VP of Regulatory Affairs and Clinical Risk for Home Health at Amedisys. With 35 years of healthcare experience, 29 years of which have been in home health, she is dedicated to serving as a subject matter expert on state and federal regulatory requirements for home health.
