Medicare pays for home health care services if the following conditions are met:
- Individual must be eligible for Medicare benefits.
- There must be a need for skilled nursing care, physical therapy or speech therapy on an intermittent basis (less than full time).
- Individual must be homebound.
- Physician signs orders for home care.
- The home health agency providing care must be Medicare-certified.
There is no requirement for a prior hospital stay in order to receive home health benefits. If all of the above criteria are met, Medicare also covers services by home health aides, medical social workers and occupational therapists. These services must also be ordered by the physician.
Medicaid provides the same home health benefits as Medicare for individuals eligible for Medicaid benefits. A special Medicaid program called Home and Community Based Waiver Program provides supportive care in the home for those Medicaid recipients who are eligible for care in a nursing facility. These services are not ordinarily covered under Medicaid's home health benefit, and there are special income and eligibility requirements.
All private insurance carriers in Kentucky must offer some home health benefits, but coverage varies widely. Each policy holder should check with his/her insurance company or with a home health agency to determine how much coverage is available. Information to ask would include: amounts and limits of coverage; co-pays and deductibles; and need to verify coverage and prior authorization.
Personal funds are used to pay for home health services not covered by a third party payor as well as private duty caregiver services not covered by insurance. Charges should be discussed and agreed upon before services are received.
The home health agency will assist you in identifying payment sources and in obtaining reimbursement.
If you receive services paid for by Medicare, you will never receive a bill. Payment goes directly from Medicare to the home care company. Medicaid is similar unless there is a spend-down payment required. In the case of private insurance, the home care company will bill your carrier for whatever percentage they pay and bill you directly for your co-pay if you owe one.
Private pay is generally billed directly to you or whomever is handling your financial affairs every two weeks.
For further information, call (502) 581-8621 or (800) 346-4577.