Who Pays For Home Health Care?

Who Pays For Home Care?
Medicare Pays If....

  • Services are determined medically necessary and ordered by a physician.
  • The patient is homebound because of illness or injury.
  • The patient needs part time or intermittent nursing care, physical therapy, or speech-language pathology. Occupational therapy, medical social services and home health aide (i.e. personal care) services are covered only if the patient is also receiving nursing care, physical therapy, or speech-language pathology.
  • Routine medical supplies.

Up to 100 of your home health care visits will be covered under Medicare Part A (Hospital Insurance) if you have a hospital or skilled nursing facility stay of at least three days within the past 14 days.  If you require more than 100 visits or have not had a qualifying hospital or skilled nursing facility stay, your home health care visits will be covered if you are enrolled in Medicare Part B (Medical Insurance).  There are no co-payments. If you have only Part A or Part B coverage, all of your home health visits will be covered by the Part you have.

Medicare Part B...

Also covers home visits by your physician and management and certification of the plan of care by your physician with a 20% co-payment.

Medicare Part A will pay for hospice care if the patient...

  • is certified to be terminally ill with a prognosis of six months or less.
  • understands that hospice care provides comfort, not curative treatments.
  • elects the Medicare Hospice Benefit, which waives coverage of other Medicare services for only the terminal diagnosis. Other services provided in relation to conditions other than the terminal diagnosis are covered under the regular Medicare benefit.

Medicaid Home Health

Public assistance recipients (AFDC, SSI) that are covered by Medicaid can receive home health benefits as an alternative to more costly hospital or nursing home care, and is limited to skilled nursing, physical therapy, occupational therapy, and home health aide services.

Medicaid Hospice

Hospice is available to Medicaid recipients under the same conditions as the Medicare hospice benefit.
Long Term Care Pays If....

The Texas Department of Aging and Disabilities (DADS) provides long-term skilled home health and personal assistance services to those meeting financial and medical and/or functional criteria through a variety of Medicaid or other government funded programs. These programs include Primary Home Care, Family Care, Community Attendant Services; Medically Dependent Childrens' Program waiver; Community Based Alternatives waiver; Community Living Assistance and Support Services waiver; In-Home and Family Support Services; Client-Managed Attendant Services. Area Agencies on Aging (AAAs) provide homemaker/housekeeping and personal assistance services through contracts with DADS. Contact your local DADS office or AAA (listed in the Blue Pages) for additional information regarding these programs and services.

Other specialized services for children are provided through the Early Childhood Intervention (ECI) program, Texas Department of Assistive and Rehabilitation (DARS) for ages 0-3; Children with Special Health Care Needs at the Texas Department of State Health Services (DSHS); and EPSDT-CCP Private Duty Nursing and Therapies at the Texas Health and Human Services Commission (HHSC).

NOTE: Medicare and Medicaid managed care plans (Medicare Advantage plans; Medicaid STAR; Medicaid STAR Plus) may limit benefits, require co-payments, or limit your choice to certain participating providers.

Private Insurance

Employer or union-offered group medical coverage and individual health insurance policies may cover home health services. Many long-term care insurance policies will pay for care at home, and some base qualifications on functional rather than medical need. Each insurance plan should be reviewed for specific coverage information.

Source: Texas Association for Home Care, Inc.