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Home Health Therapies - Paying For Care

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There are a number of sources for paying for home care, depending on the insurance coverage available, the primary diagnosis, and the type of services needed. In 1997 over $32 billion was spent on home care in the United States. Table 2 shows the breakout by payer.

The types of services that are covered vary by payer, and approval of all services depends on the needs of the patient. Though coverage varies, common payment requirements are that the patient is under a physician's care, and that the services ordered are reasonable and necessary to treat the patient's condition. In many cases the patient must also be homebound.

Please note that the information in this article is a general guide to what different types of insurance cover, and should be used for reference purposes only. Because of the potential for financial liability, both a physician and the insurance provider should be consulted before a person receives home care.

Medicare is a national health insurance program designed primarily for people age sixty-five and over. Limited home care coverage is available under Medicare Part A. Medicare provides home care only if there is a need for intermittent skilled nursing care or physical, speech, or occupational therapy. In addition a physician must certify that the patient is homebound. (Medicare's definition of "homebound" is that the condition of the patient is such that there is a normal inability to leave home and, consequently, that leaving home would require a considerable and taxing effort.) The patient has to be under the care of the physician who certifies that care in the home is necessary. All home care services must be provided through a CHHA. There is no copayment for home care services under Medicare, though any related durable medical equipment is subject to a 20 percent copayment. No Medicare coverage is available for people who require only personal care.

Table 2 SOURCE: National Health Expenditures Projections 1998-2008.Health Care Financing Administration, Office of the Actuary.

Medicaid is a program, jointly funded by the federal and state (and in some cases local) governments, that provides comprehensive medical care coverage for people whose income and assets fall below a specific level. Each state administers its own Medicaid program, so eligibility requirements and the specific benefits vary by state. In some cases, Medicaid may provide a more generous home care benefit than Medicare. Coverage is often available for unskilled needs over longer periods of time.

Private health insurance, usually administered through employers, typically covers only relatively short periods of post-acute home care. Managed care organizations (e.g., HMOs) usually have strict precertification requirements for all nonemergency services, including home care. Many managed care plans require a copayment for each home care visit (e.g., $10 per visit) and limit the number of home care visits allowed in a plan year. Coverage is usually limited to a post-acute benefit focused on skilled nursing or rehabilitation therapies.

Since the 1990s, long-term care (LTC) insurance has become increasingly popular. Many LTC policies provide some compensation for home care within a specified period of time. The actual amount paid for each home care visit, the limit on the number of visits, and what triggers the LTC payments vary widely, depending on the policy. Therefore the LTC policy that is chosen determines the extent of the home care benefit (as well as how using that home care benefit affects the nursing home benefit).

Persons who are not covered by insurance or who need care in addition to what is covered by insurance, can pay for home care themselves. Home care costs vary by location and agency, so it is important to find out the cost of care beforehand. It may be helpful to compare the costs of different agencies and to check with the local department of health or aging to get a better understanding of home care prices.

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