When it comes time to make a major healthcare decision, one of the first questions is what will my health insurance cover?  In this post, we explain some of the basics of insurance coverage for home health care.

Remember, you can always check if a home health agency is part of your insurance network for free with repisodic.

It’s very important to understand the difference between home health care and home care when considering insurance coverage.  Home health care is often confused with non-medical home health care, more commonly known as home care. Home health care services are medical in nature and assist patients recover after a hospital stay or illness. Home care services, on the other hand, are non-medical in nature and are typically used on an ongoing basis to support aging individuals complete day-to-day tasks in their own home.

Home Care and Other Non-Medical Assisted Living Services

In general, these services are NOT covered by Medicare or other private insurance programs.  Although there are many misconceptions around Medicare’s benefits for home care, Medicare does not pay for non-medical care at all. It’s safe to assume that in almost all cases assistance for non-medical care provided in the home is not covered by insurance programs.

Medicaid, an insurance program for low income persons, will pay for non-medical home care, home health care and other in-home supports to help individuals remain living in their homes. However, because Medicaid rules are state-specific, the coverage and eligibility will vary by location. Refer to your local Medicaid office if you think you or yourself qualifies for Medicaid home care.

Medicare Home Health Care Insurance Coverage

Home health care, when considered medically necessary is covered, at least in part, by Medicare and other health insurance programs. All people with Medicare Part A and/or Part B who meet all of these conditions are covered:

  • You must be under the care of a doctor, and you must be getting services under a plan of care established and reviewed regularly by a doctor.
  • You must need, and a doctor must certify that you need, one or more of these:
    • Intermittent skilled nursing care (other than just drawing blood)
    • Physical therapy, speech-language pathology, or continued occupational therapy services. These services are covered only when the services are specific, safe and an effective treatment for your condition. The amount, frequency and time period of the services needs to be reasonable, and they need to be complex or only qualified therapists can do them safely and effectively. To be eligible, either: 1) your condition must be expected to improve in a reasonable and generally-predictable period of time, or 2) you need a skilled therapist to safely and effectively make a maintenance program for your condition, or 3) you need a skilled therapist to safely and effectively do maintenance therapy for your condition.
  • The home health agency caring for you must be Medicare-certified.
  • You must be homebound, and a doctor must certify that you’re homebound.

During home health care visits, Medicare will not pay for any personal care that is provided during that visit. Visits tend to be brief and procedural in nature and are typically provided by a registered nurse (RN) or licensed practical nurse (LPN).

Private, Commercial and Employer-Sponsored Insurance Home Health Care Coverage

These plans vary widely in their coverage and policies for home health care. The majority of plans typically provide some sort of coverage for medically necessary home health care, similar to Medicare coverage policies.   Private insurance companies will typically only pay for home health care services for providers that are considered “in-network.” Some policies will cover services from providers that are “out-of-network,” but they usually do not cover as much of the cost and can leave patients with additional out-of-pocket costs. That’s why it’s so important for patients to check if a home health agency is part of their insurance network. This is the first step in determining insurance coverage and costs and should be factored into any search for home health care.

Health insurance payment options and programs that cover home health care services are quite complex and regularly subject to change. A patient’s individual insurance policy determines what post-acute care services are covered and paid for. repisodic encourages all patients to consult with their insurance company or administrator for final determination of what post-acute care or home health care their policy covers.

Learn more about home health care here.