Who pays for home care?
The maze of health care insurance coverage is becoming more complex. Eligibility criteria and coverage for home health care services differs for each insurer and health plan. In addition, a single health insurer may have differing plans and benefits for different employers or coverage groups.
For all payors, the goal is to provide the appropriate level of medically necessary care for patients in the most cost-effective and appropriate setting. For those who have limited health insurance coverage or no coverage, home health agencies may still be able to provide care if the patient is appropriate for home care and the necessary resources are available.
Creative use of resources: The inherent flexibility of home health services provides some leeway for creative management of limited financial resources. Home health agencies are willing to work with physicians and other providers to develop care plans that use the limited financial and clinical resources as effectively and appropriately as possible. Non-profit home care agencies dedicate time to obtaining funds and services for those in need who do not have the financial resources to pay for all or some of the care.
Negotiating for home health coverage: If the individual’s health insurance coverage does not include a home health benefit, the home health agency may be able to negotiate with the insurance company to arrange for reimbursement of home health services. Insurers are increasingly willing to pay for non-covered services like home care that will prevent the use of more expensive covered services.
- Many home health agencies receive community funds through donations, town appropriations or other arrangements from cities and towns to provide care to local residents.
- Not-for-profit home health agencies raise money from individuals and businesses in their communities to provide free care. With the tightening parameters for health insurance coverage, many more people are under-insured or have no health insurance at all. As a result, not-for-profit home health agencies must carefully manage their limited funds to ensure that those truly in need receive care.
- Free care funds are limited. To be eligible for free care, patients must meet the general eligibility criteria for home care such as homebound status, medically necessary and intermittent care. Home health agencies may provide care on a sliding-fee scale.
- The home health agencies receiving funds from the local towns and cities provide specific services for residents of those communities, which vary from community to community.
- The main emphasis of managed care is to control utilization of services to achieve appropriate, efficient use of resources along with positive outcomes. As a result, managed care organizations (MCOs or health plans) employ such strategies as pre-authorizations, re-authorizations and on-going case review.
- Most often patient care under managed care is coordinated by a managed care case manager who may follow patients through all settings (i.e., inpatient, outpatient, community-care, etc.) or just specific settings (i.e., coordinates only community-based care)
- Benefit packages for home care differ from health plan to health plan and even within a single health plan. Yet managed care organizations have a strong commitment to using home health services whenever safe and appropriate to help reduce reliance on more costly inpatient and emergency care.
- To be eligible for home health services, patients do not necessarily have to be homebound. However, most managed care programs place an emphasis on getting the patient to the point where he or she can receive care in an outpatient or physician office setting.
- The actual home health coverage authorized for an individual is likely to be based on the initial assessment done by the home health agency. Based on that assessment, the case manager will determine the extent and frequency of the home health services that can be provided. Often a finite number of home care visits are authorized with further visits authorized after re-evaluation
- Some managed care organizations developed Medicare managed care programs (senior risk programs) that offer Medicare enrollees the same array of benefits available from the standard Medicare program, as well as additional benefits such as preventive care and prescription coverage. Home health is covered under these programs, however, the utilization of home health services will be managed just like under any other managed care plan. These plans are generally not available in New Hampshire at this time.
- The current Medicare program offers a home health benefit to individuals age 65 and older and to disabled adults
- This section should serve as a guide with the understanding that Medicare regulations and criteria frequently undergo changes. If you have specific questions regarding any aspect of Medicare home health eligibility and coverage, call your local home health provider
- The major emphasis of the Medicare home health program is on acute health services. As a result, custodial care, including routine personal care, is not covered unless there is also a skilled or acute health care need
- Medicare will pay for home health services to Medicare enrollees only if all four of the following criteria are met:
- The patient requires intermittent, skilled nursing care, physical therapy or speech therapy. Care can be provided on a non-daily basis for as long as the care is skilled in nature, reasonable and necessary. By the term “skilled,” Medicare means services that could only have been performed safely by a skilled professional, such as a nurse or physical therapist.
- The patient is homebound. A patient is considered homebound if he or she has reasonable difficulty leaving the home unattended and leaves home infrequently for reasons other than medical appointments. Therefore a patient may go to physician appointments or other similar activities and still be considered homebound. (See additional information below)
- The patient is under the care of a physician who determines the patient needs home health care. The physician must participate in establishing the home care treatment plan. Care must be reasonable and necessary.
- The home health care agency providing services is a Medicare certified agency.
Home Health Services Covered by Medicare
- Skilled nursing care
- Physical therapy
- Occupational therapy
- Speech therapy
- Certified nurses aides (home health aides)
- Medical social services
- Durable medical equipment (80%) (if the equipment meets Medicare’s specific criteria)
Home Health Services NOT Covered by Medicare
- 24-hour a day nursing care at home
- Drugs and biologicals
- Homemaker services
- Blood transfusions
- Venipuncture (if it is the only skilled service provided)
What You Need to Know About Medicare Homebound Status
For such a simple term, the word “homebound” poses substantial confusion and consternation. A key factor in determining whether an individual is eligible for Medicare home health services, the term is increasingly under the microscope. The present criteria were most recently reviewed by the Health Care Financing Administration (HCFA) in 1999, and it was concluded that the existing definition is sufficient.
Under the current definition, several factors contribute to the determination that a patient is homebound.
According to the Medicare regulations, a patient is considered homebound if:
- leaving home would require a considerable and taxing effort (patient does not have to be bedbound);
- he has a condition due to an illness or injury that restricts his ability to leave his place of residence except with the aid of supportive devices, the use of special transportation or the assistance of another person, or if he has a condition where leaving home is medically contraindicated;
- the patient’s illness is manifest in part by a refusal to leave her home environment or is of such a nature that it would not be considered safe for her to leave home unattended, even if she has no physical limitations.
Homebound patients may leave home if the absences are infrequent or for periods of relatively short duration (such as a visit to the barber), or for the purpose of receiving medical treatment.
Medicare Changes Due to the Balanced Budget Act
The Balanced Budget Act (BBA) of 1997 contained some of the most extensive changes in the Medicare program since its inception in 1965. Though the eligibility criteria for Medicare home health benefits remains unchanged by the BBA, the intent was to reduce the Medicare program growth. As a result, there have been some changes in home health practice patterns.
Most important has been a renewed emphasis that Medicare home health is an acute care service with the focus on skilled care and not a program for long-term care where there is more need for custodial services such as homemakers and housecleaning. While some individual’s care needs to qualify them to receive skilled care for lengthly periods of time, routine supportive care alone does not qualify for Medicare coverage.
Medicare Managed Care Programs (Senior Risk Programs)
Several health plans have developed Medicare managed care programs for eligible Medicare enrollees. By joining these programs, Medicare enrollees are guaranteed to receive the same benefits they would under the traditional Medicare program. Many also receive preventive care and prescription benefits.
While patients in these programs are still eligible for home health services, there may be an additional pre-authorization process as well as oversight and management of service utilization by a case manager.
At present there are few if any senior risk programs available to New Hampshire residents.
- The traditional indemnity insurer is fading from the health care environment. Though some still exist, private insurance companies are developing managed care and preferred provider product lines to meet the needs of employers and individuals. This category also includes the growing array of corporations that have become self-insured
- While home health coverage is not typically a standard benefit, more insurers are discovering the benefits of reducing inpatient hospital stays whenever possible and appropriate. As a result, home health care is gaining greater utilization
- Long term care insurance policies are also growing in popularity, and many include some home health as well as nursing home coverage. Be sure to examine policies for home care coverage, and consider optional riders for home care if it’s not part of the basic long-term care policy.
- The New Hampshire Medicaid Program helps pay health care costs for all persons who receive public assistance and for certain persons with low incomes who can’t afford the cost of health care. For people whose income is greater than the Medicaid limits but have medical bills they can’t afford, Medicaid may be able to assist them through the “In and Out Medicaid” program
- Once patients are accepted by the Medicaid program, they are assigned a case worker who oversees and coordinates their care
- Medicaid is administered by the State of New Hampshire through the Department of Health and Human Services. It is based on federal and state rules and people must meet income and resource limits to qualify. During the last several years, the state has moved toward more emphasis on community-based care as opposed to nursing home placements for long-term care.
- Some people are covered by both Medicare and Medicaid. Medicaid pays Medicare deductibles and coinsurance. Medicaid may limit the number of payments for certain services.
Who is Eligible for Medicaid?
People who receive financial assistance
- Aid to Families with Dependent Children (AFDC)
- Old Age Assistance (OAA)
- Aid to the Needy Blind (ANB)
- Aid to the Permanently and Totally Disabled (APTD)
Others who may be eligible:
- Pregnant women with low incomes
- Children with severe disabilities
- Children born after September 30, 1983
- Some children in foster care and adoption subsidy programs
New Hampshire Medicaid has several specialty programs to provide medical assistance to specific populations or individuals. Two such programs are the Home Care for Children with Severe Disabilities (formerly known as the “Katie Beckett” program) and Home and Community Based Care for the Elderly and Chronically Ill (HCBC-ECI), which is designed as an alternative to nursing facility care.