If you or a loved one are recovering from surgery, injury or illness, home health care might be the best option for receiving care in the comfort of your own home. However, one crucial question often arises: does insurance cover home health care?
Understanding the types of coverage available and the requirements for home health services can help you make informed decisions about how to pay for care. Here, we’ll explore what home health care entails, what insurance typically covers, and how to navigate your policy to find out if home health care is an option for you.
What is Home Health Care?
Home health care refers to a wide range of services that are provided at home rather than in a hospital or skilled nursing facility. These services can include skilled nursing care, physical therapy, occupational therapy, and help with daily living activities like meal preparation and bathing. Home health services are often prescribed by a physician for patients recovering from surgery or managing a health condition that requires ongoing treatment. Services may include:
- Skilled Nursing Care: This may include administering medications, wound care, wound dressings, monitoring vital signs, and educating you on how to manage your recovery.
- Physical Therapy: Physical therapy services are crucial for those recovering from a surgical procedure. A physical therapist works with you to improve mobility, strength, and function.
- Occupational Therapy: Occupational therapists help patients regain their ability to perform daily tasks that may have been affected by surgery, such as dressing, cooking, or bathing.
- Speech-Language Pathology Services: For those who have had surgeries that impact speech or swallowing, speech therapy can be part of home health care.
- Medical Social Services: These services may include counseling, helping you navigate healthcare providers, and providing support for family members during recovery.
- Certified Home Health Aides:These professionals help individuals with personal hygiene, activities of daily living, instrumental activities of daily living, and other personal assistance duties from home, all while coordinating care with our multidisciplinary team.
Click here to learn more about Boost Homehealth’s services.
Does Insurance Cover Home Health Care?
The answer depends on your insurance type and your eligibility for coverage. Here’s a breakdown of the most common options:
Medicare/Medicare Advantage Plans
Medicare is a federal health insurance program for people 65 and older, as well as for certain younger individuals with disabilities. If you’re covered by Medicare, you may be wondering whether it will cover home health care after surgery.
Medicare Part A and Part B provide coverage for a variety of home health services under certain conditions. However, it’s important to understand Medicare’s rules when it comes to home health care:
- Medicare Part A: This part of Medicare covers inpatient hospital stays and some home health care services when you meet specific criteria. Part A generally pays for home health services if you are recovering from a hospital stay and meet certain requirements, such as needing skilled care (e.g., skilled nursing or physical therapy). Learn more.
- Medicare Part B: While Medicare Part B typically covers outpatient services, it can also cover some home health services. If your physician orders home health care services, such as therapy services, Medicare Part B will typically cover 80% of the costs after you meet the deductible. This includes things like physical therapy or speech therapy after surgery. Learn more.
- Medicare Advantage Plans (Part C):This type of Medicare health plan is offered by Medicare-approved private companies that must follow rules set by Medicare. Most Medicare Advantage Plans include drug coverage (Part D) Drug coverage (Part D). Learn more.
To qualify for Medicare home health care, you must meet the following criteria:
- You must be under the care of a physician, who must order home health care.
- You must need skilled care that can only be provided by a skilled nursing professional or therapist.
- Your physician must establish a personalized plan of care that is updated regularly.
- You must be homebound or have difficulty leaving home without assistance.
What you pay for Medicare will vary based on what coverage and services you receive. There’s no yearly limit on what you pay out-of-pocket, unless you have supplemental coverage, like a Medicare Supplement Insurance (Medigap) policy, or you join a Medicare Advantage Plan.
Medigap insurance is a supplemental plan paid for out-of-pocket. While designed to help cover gaps in standard Medicare plans (co-payments, deductibles, and co-insurance), it does not cover home health services or items that are not covered by Medicare, such as hearing aids, routine vision care, and long-term care. Click here to learn more about Medigap insurance from Medicare.gov.
Click here to learn more about Medicare Home Health Services that are covered and Medicare costs, or visit Medicare.gov.
Private Insurance
Many commercial insurance plans cover skilled care, such as nursing or therapy after surgery, with little or no out-of-pocket costs. Coverage for non-medical services, like personal care, may be limited.
Some private insurance plans cover home health services as part of their overall health care benefits. In general, private health insurance will pay for skilled care after surgery, including nursing care, therapy, and the rental of durable medical equipment. Contact your insurance representative to confirm coverage for home health services.
Long-Term and Life Insurance Policies
Long-term care insurance policies may cover services like home health aides or assistance with daily living activities. Check with your insurer to confirm waiting periods, benefit caps, and other policy details. This will help you determine if there are waiting periods before you can access your funds and the right time to initiate your claim. Benefit periods are typically three to five years, and correspond to the lifetime benefit cap, or the maximum dollars that will be paid by the insurance company on the policy; these figures are related in terms of the maximum daily benefit over the number of years in the benefit period. (source: American Association for Long-Term Care Insurance)
Medicaid/Medi-Cal/State-managed Medicaid Programs
Medicaid and Medi-Cal follow almost identical coverage guidelines as Medicare, however, coverage varies by each state. The difference is that unlike Medicare, which is available to all adults 65 years old or more, regardless of financial stability, Medicaid and Medi-Cal provide additional health care for older adults living below a certain economic level.
Medicaid will cover a variety of in-home care services and supports, in addition to case management, to promote aging in place. Benefits may be available in one’s home, the home of a friend or relative, a foster care home, or even an assisted living residence, depending on the state and the program. (source: American Council on Aging) While the compiled list below includes a wide selection of potential services, the exact benefits available vary by state and program.
- Assistance with Activities of Daily Living (bathing, mobility, dressing/undressing, eating, and toiletry)
- Assistance with Instrumental Activities of Daily Living (shopping for essentials, laundry, light housecleaning, and meal preparation)
- Home Health Care
- Home Modifications (to improve accessibility and safety, such as grab bars, widening of doorways, non-slip flooring, and wheelchair ramps)
- Vehicle Modifications
- Durable Medical Equipment (wheelchairs and walkers)
- Adult Day Care / Adult Day Health Care
- Skilled Nursing Care
- Respite Care
- Transportation (medical & non-medical)
- Therapy Services (physical, speech, & occupational)
- Meal Delivery / Congregate Meals
- Personal Emergency Response Services (PERS) / Medical Alerts
PACE Programs
PACE (Program of All-Inclusive Care for the Elderly) is a Medicare and Medicaid program that helps people meet their health care needs in the community instead of going to a nursing home or other care facility.
The program relies on guidelines similar to Medicare and Medi-Cal when it comes to home care coverage, although individuals qualifying for PACE have a team of interdisciplinary medical and social services professionals overseeing their care.
This often provides the advantage of connecting clients/patients with home-care-oriented community services and support that might not be provided or advertised via Medicare/Medi-Cal.
PACE covers all Medicare- and Medicaid-covered care and services, and anything else the health care professionals in your PACE team decide you need to improve and maintain your health. This includes prescription drugs and any medically necessary care.
Another benefit of PACE is that depending on an individual’s qualifications, it may cover co-payments and deductibles not covered by Medicare, in return for a minimal monthly premium.
To find out if you’re eligible and if there’s a PACE program near you, search for PACE plans in your area , or call your Medicaid office.
Veteran’s Benefits
Veterans may qualify for skilled home health services through the U.S. Department of Veterans Affairs. Services include nursing care, therapy, and case management.
The program is for Veterans who need skilled services such as: skilled nursing, case management, physical therapy, occupational therapy, speech therapy, wound care, or IV antibiotics. Skilled Home Health Care can be used in combination with other Home and Community Based Services. The care is delivered by a community based home health agency that has a contract with VA.
All enrolled Veterans are eligible for Skilled Home Health Care IF they are eligible for community care and meet the clinical criteria for the service. Services may vary by location.
Contact your VA social worker/case manager to complete the Application for Extended Care Benefits (VA Form 10-10EC) to learn the amount of your copay. Learn more.
Workers’ Compensation
Workers’ compensation is a no-fault insurance program which provides employees who become injured or ill at the workplace coverage of medical costs and partial wage replacement. It consists of a unique program in each state and a series of programs for federal employees. Contact your employer to discuss home health care coverage if you or your loved one was injured due to a work-related accident or event.
We’re Here to Help
Paying for home health care can feel overwhelming, but you don’t have to navigate it alone. At Boost Home Healthcare, our goal is to simplify the process. At Boost Home Healthcare, our goal is to make the process easier. You shouldn’t have to choose between your family’s physical and financial well-being. We offer a variety of payment options that can help you manage the cost of care. Many patients experience little or no out-of-pocket costs for Boost Home Healthcare services when they use:
Our team can help you explore your options and find the most affordable route for care. Call us today at 1-800-227-9540 to get started.
Click here to learn more about the benefits of Boost Home Healthcare’s personalized approach to care, whether you are recovering from an injury or illness or managing a complex medical condition.
Boost Home Healthcare understands that when you’re recovering from an illness or injury, transitioning from a hospital stay or working to regain independence, there’s nothing you crave more than the comfort and privacy of your home.
Boost Home Healthcare delivers the care you need in the space you love. We offer more convenient – and often more affordable – care compared to hospitals or skilled nursing facilities. And as an added benefit, our approach is entirely personalized for you and your changing needs.
Ready to learn more about how home health services can support your recovery and independence goals? Start your assessment today by connecting to a Boost Home health care location near you.
Helpful Resources:
- Home Health Services Coverage (Medicare.gov)
- Does Medicare Cover Home Health Care? (AARP)
- Medicare & Home Health Care Guide (Medicare.gov)
- Understanding Long-Term Care Insurance (AARP)
- Medicaid and Home Health Care & Non-Medical, In-Home Care (American Council on Aging)
- Program of All-Inclusive Care for the Elderly (PACE)
- Am I eligible for Skilled Home Health Care? (U.S. Department of Veterans Affairs)
