When recovering from surgery, managing a chronic condition or healing from an illness, many patients prefer to receive care in the familiar comfort of their own homes. One of the most common questions about home health care is simple but crucial: Will insurance cover it? Let's explore how different insurance options can help pay for home health care services.
Understanding Home Health Care
Before diving into coverage options, it's important to understand what the service actually entails. Home health care is skilled care provided wherever the patient calls home by licensed professionals, which can include registered nurses, physical therapists, speech therapists and occupational therapists based on the patient’s condition and plan of care. It is distinct from personal care or private duty services which primarily focus on companionship and assistance with activities of daily living.
Private Insurance and Home Health Care Coverage
Many private insurance plans provide some level of coverage for home health care, but the specifics may vary depending on the insurance provider, policy, state regulations and more. Here’s what to consider:
Key Coverage Factors
Your coverage will depend on several important elements:
Medical Necessity: Like most medical services, home health care must be deemed medically necessary by your treating healthcare physician/allowed practitioner (Physician Assistant, Nurse Practitioner or Clinical Nurse Specialist in accordance with their state law), who will oversee your plan of care. Insurance typically won't cover services that are considered not medically necessary like custodial care.
Network Requirements: Most insurers limit coverage to services provided by in-network home health agencies. Choosing an out-of-network provider could result in higher costs or denied coverage.
Policy Limits: Your plan may impose specific restrictions, such as:
- Maximum number of visits
- Required pre-authorizations
- Coverage for specific services only
- High deductibles before coverage begins
Short-Term vs. Long-Term Home Health Care
It’s important to note that this article is referencing short-term home health care, like recovering from a hospitalization, rehabilitation after surgery or acute illness treatment. While most private insurers will cover this type of home health care, chronic or long-term home health care services may require additional specialized policies.
How to Determine Your Coverage for Home Health Care
Consider the following steps in understanding what your insurance may cover for home health care:
- Review Your Insurance Policy – Check the Summary of Benefits and Coverage (SBC) to check if home health care services are included.
- Contact Your Insurance Provider – Call your insurer to verify coverage details, including copays, deductibles and visit limits.
- Obtain Orders from your Treating Physician/Allowed Practitioner – Work with your treating physician/allowed practitioner to obtain an order stating the service is medically necessary.
- Choose an In-Network Provider – Ensure that the home health care agency is within your insurance provider’s network.
- Understand Cost-Sharing Responsibilities – Be aware of any out-of-pocket costs such as copayments, deductibles or uncovered services.
Home Health Care with Medicare or Medicaid
Medicare can cover home health care for patients who meet specific criteria to help determine if their condition and home environment warrant home health care coverage. These include:
- Being Homebound/Confined to the Home – To be considered homebound, patients must be unable to leave home, require considerable effort to do so or have a medical condition that worsens when leaving home.
- Demonstrating a Medical Need – The patient must require intermittent skilled nursing care or therapy services.
- Under the Care of a Physician or Allowed Practitioner- The patient’s treating physician/allowed practitioner must approve a plan of care/treatment the patient’s home health care, certifying a medical need.
- Choosing a Medicare-Certified Provider – The agency you choose for home health care must be approved and certified by Medicare.
Medicaid may pay for home health care to help eligible individuals receive care wherever they call home. Depending on your state, some people with disabilities, the elderly and families may be eligible for Medicaid. Check your eligibility [1] and benefits [2], as Medicaid rules vary by state.
Generally, to be eligible to receive home health care and other services under Medicaid, patients must meet both financial and functional requirements.
Other Options to Pay for Home Health Care
Home health care can also be covered in the following ways:
State-Funded Programs
If your loved one doesn’t qualify for Medicaid, they may be eligible for some state in-home assistance programs. Most states have programs designed to keep seniors at home, where they most want to be, for as long as possible. Services vary widely from state to state, as do eligibility requirements.
Veterans Benefits
Eligible veterans may have access to benefits from the Department of Veterans Affairs (VA) that may cover nursing care, therapy services, social worker services and more. Contact the VA, your social worker or case manager for more information about available benefits in your area. You may learn more about VA benefits [3] and obtain contact information.
Private Pay
For those with the resources, private pay may be an option for some, using a combination of private savings, home equity loans, reverse mortgages, annuities or life insurance plans with cash value or accelerated benefits.
Find Care at Home with A Local Home Health Agency
Find out which benefits are available to you. Talk with your treating provider/healthcare team or local home health agency about eligibility requirements. You can also complete our online assessment quiz or simply complete the form below to speak to a home health specialist about next steps.
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.
