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Home Care, Visiting Nurse, Elderly Care, home care providers

Who Pays for Homecare?

Homecare services can be paid for directly by the patient and his or her family members or through a variety of public and private sources. Private duty will only provide care to those who can afford it, whereas home health may provide medical care regardless of ability to pay. Public third-party payors include Medicare, Medicaid, the Older Americans Act, the Veterans Administration, and Social Services block grant programs. Some community organizations, such as local chapters of the American Cancer Society, the Alzheimer’s Association, and the National Easter Seal Society, also provide funding to help pay for home care services. Private third-party payors include commercial health insurance companies, managed care organizations and workers’ compensation.

Self-pay

Homecare services that fail to meet the criteria of third-party payors must be paid for “out of pocket” by the patient or other party. The patient and home care provider negotiate the fees.

Public Third-party Payors

  • Medicare: Most Americans older than 65 are eligible for the federal Medicare program. If an individual is homebound, under a physician’s care, and requires medically necessary skilled nursing or therapy services, he or she may be eligible for services provided by a Medicare-certified home health agency. Depending on the patient’s condition, Medicare may pay for intermittent skilled nursing; physical, occupational, and speech therapies; medical social work; home health aide services; and medical equipment and supplies. The referring physician must authorize and periodically review the patient’s plan of care. With the exception of hospice care, the services the patient receives must be intermittent or part time and provided through a Medicare-certified home health agency for reimbursement.Hospice services are available to individuals who are terminally ill and have a life expectancy of six months or less; there is no requirement for the patient to be homebound or in need of skilled nursing care. A physician’s certification is required to qualify an individual for the Medicare Hospice Benefit. The physician also must re-certify the individual at the beginning of each six-month benefit period. In turn, the patient is required to sign a statement indicating that he or she understands the nature of the illness and of hospice care. By signing this statement, the patient surrenders his or her rights to other Medicare benefits related to terminal illness.
  • Medicaid: Administered by the states, Medicaid is a joint federal-state medical assistance program for low-income individuals. Each state has its own set of eligibility requirements; however, states are only mandated to provide home health services to individuals who receive federally assisted income maintenance payments, such as Social Security Income and Aid to Families with Dependent Children (AFDC), and individuals who are “categorically needy.” Categorically needy recipients include certain aged, blind, and/or disabled individuals who have incomes that are too high to qualify for mandatory coverage but below federal poverty levels. Individuals younger than 21 who meet income and resources requirements for AFDC, yet otherwise are ineligible for AFDC, also qualify as categorically needy. Under federal Medicaid rules, coverage of home health services must include part-time nursing, home health aide services, and medical supplies and equipment. At the state’s option, Medicaid also may cover audiology; physical, occupational, and speech therapies; and medical social services. Hospice is a Medicaid-covered benefit in 38 states. The Medicaid hospice benefit covers the same range of services that Medicare does.
  • Older Americans Act (OAA): Enacted by Congress in 1965, the OAA provides federal funds for state and local social service programs that enable frail and disabled older individuals to remain independent in their communities. This funding covers HCA, personal care, chore, escort, meal delivery, and shopping services for individuals with the greatest social and financial need who are 60 years of age and older. Increasingly, individuals who can afford to pay for some of these services are being asked to contribute in proportion to their income. Individuals often request the services they need through an Area Agency on Aging, which will provide them directly or in cooperation with local organizations.
  • Veterans Administration: Veterans who are at least 50% disabled due to a service-related condition are eligible for home health care coverage provided by the Veterans Administration (VA). A physician must authorize these services, which must be delivered through the VA’s network of hospital-based home care units. The VA does not cover nonmedical services provided by home health aides.
  • Social Services Block Grant Programs: Each year states receive federal social services block grants for state-identified service needs. The government allocates these funds on the basis of the state’s population and within a federal limit. Portions of the funding often are directed into programs providing home health aide and homemaker or chore worker services. Individuals should contact their state health departments and local offices on aging for additional information.

Private Third-party Payors

  • Commercial Health Insurance Companies: Commercial health insurance policies typically cover some homecare services for acute needs, but benefits for long-term services vary from plan to plan. Commercial insurers, including Blue Cross and Blue Shield and others, generally pay for skilled professional home care services with a cost-sharing provision. Such policies occasionally cover personal care services. Most commercial and private insurance plans will cover comprehensive hospice services, including nursing, social work, therapies, personal care, medications, and medical supplies and equipment. Cost-sharing varies with individual policies, but often is not required.Individuals sometimes find it necessary to purchase Medigap insurance or long-term care insurance policies, for additional home care coverage.Medigap insurance is designed to bridge some of the gaps in Medicare coverage. Some Medigap policies offer at-home recovery benefits, which pay for some personal care services when the policyholder is receiving Medicare-covered skilled home health services. The policyholder’s physician must order this personal care in conjunction with the skilled services. Home care coverage in Medigap policies is not designed to cover extended long-term care. This type of coverage is most helpful to individuals recovering from acute illness, injuries, or surgery.Long-term care insurance primarily was intended to protect individuals from the catastrophic expense of a lengthy stay in a nursing home. However, as the public need and preference for home care has grown, private long-term care insurance policies have expanded their coverage of personal care, companionship, and other in-home services. Considerable care should be taken in selecting a long-term care insurance policy, as home care benefits vary greatly among plans. Consumers should be aware of limitations on coverage, such as prior hospitalization requirements, and pre-existing condition exclusions. Some policies may only pay for services that are already covered by Medicare.
  • CHAMPUS: On a cost-shared basis the Civilian Health and Medical Program of the Uniformed Services (CHAMPUS) covers skilled nursing care and other professional medical home care services for dependents of active military personnel and military retirees and their dependents and survivors. CHAMPUS offers a comprehensive hospice benefit to its terminally ill beneficiaries, which covers nursing, social work and counseling services, therapies, personal care, medications, and medical supplies and equipment.
  • Workers’ Compensation: Any individual requiring medically necessary home care services as a result of injury on the job is eligible to receive coverage through workers’ compensation.

What is a Visiting Nurse Association (VNA)?

A Visiting Nurse Association is a non-profit organization and unlike many private homecare companies they can accept Medicare for a variety of services that others may not. VNAs are capable of providing home healthcare for patients of all ages – from infants to the elderly.

What Are The Standard Billing and Payment Practices?

When services are covered by Medicare and/or Medicaid, homecare providers must bill their fees directly to the payor to Medicare or Medicaid. Providers often will bill other third-party payors directly as well. Any uncovered costs are later billed to the client. However, if a client receives services from a registry or independent provider, he or she must pay the provider directly. Later the client may file for reimbursement from the insurance company if the services qualify as covered benefits. Payment options are detailed below.

Home Health Agencies
Medicare, Medicaid, and most private insurance plans pay for services that home health agencies deliver. Payment from these sources depends on whether the care is medically necessary and the individual meets specific coverage criteria. Individuals may opt to pay out of pocket for services that are not covered by other sources. Some agencies receive special funding from state and local governments and community organizations to cover the costs of needed care when other options are not available.

Hospices
Coverage for hospice care is available through Medicare, Medicaid programs in 38 states, and most private insurance plans. If insurance coverage is insufficient or unavailable, the patient and his or her family may pay for services out of pocket. Most hospices may provide free services to individuals who have limited or no financial resources.

Homemaker and HomeCare Aide Agencies
Individual consumers usually pay for services from homemaker and home health aide agencies. However, some states contract with these agencies to deliver personal care and homemaker services within their social services and medical assistance programs. On rare occasions, commercial insurers may pay for a portion or all of the costs of these services. Some agencies draw assistance from charitable community funds when other sources of payment are not available.

Staffing and Private-duty Agencies
Typically, the individual or his or her commercial insurance carrier pays for services provided by staffing and private-duty agencies, provided that the insurance policy’s coverage requirements are met. Some staffing agencies contract with state Medicaid programs to provide nursing and personal care services.

Durable Medical Equipment and Supply Dealers
Fees for durable medical equipment and supplies are usually covered by Medicare, Medicaid, and commercial insurance programs, provided that the products are ordered by a physician and are medically necessary to treat an illness or injury.

Independent Providers
Usually the individual pays for services rendered by independent providers. Some commercial insurance policies will provide reimbursement if the services qualify as covered benefits.

How much does Homecare Cost?

Although many of the procedures and qualifications for caregivers/nurses are the same across the board the pricing can change from provider to provider.

Custodial Care: Any form of daily non-medical service offered by a CNA. This can range from bathing, feeding, eating, cleaning and errands to name but a few.

Private Pay (aka Private Duty): An hourly rate charged for duties performed on behalf of the senior. This is the preferred payment option of many agencies and primarily will cover all non-medical forms of care.

Certified Nursing Assistant (CNA)

Registered Nurse (RN)

Advanced Practice Nurse (APN)

Most homecare agencies primarily accept private pay, which is normally charged by the hour. In some cases providers may take private insurance and/or medicare but this takes a special accreditation from the government, so make sure to ask or explore their website fully before going forward with services.

What Services Do Home HomeCare Companies Provide?

The term “homecare” covers a vast range of services that can be offered to the individual. The below are examples of the type of services that are provided by our huge network of homecare providers. Remember that there are differences in how certain types of homecare companies operate, so pay attention to whether they are private duty or home health.

Services provided by Caregivers:

  • Light Housekeeping and Cleaning
  • Changing Bed and Linens
  • Washing and Drying Dishes
  • Dusting and Tidying Rooms
  • Laundry and Light Ironing
  • Sweeping and Vacuuming

Transportation

  • Medical and Doctor Appointments
  • Hair and Beauty Salon
  • Visiting Family and Friends
  • Shopping and Entertainment
  • Errands

Housekeeping

Personal Care

  • General Care and Supervision
  • Companionship and Comfort
  • Helping with all Activities of Daily Living (ADLs)
  • Bathing and Showering Assistance
  • Dressing and Clothing Assistance
  • Walking and Transferring Assistance
  • Helping with Wheelchair / Walker
  • Personal Grooming and Skin Care
  • Incontinence Care and Toileting
  • Assisting with Medications
  • Helping with Range of Motion
  • Helping with Exercises and Physical Therapy
  • Positioning in Bed and Night Checks
  • Answering and Screening Calls
  • Updating Immediate Family or Friends

Meal

  • Meal and Menu Planning
  • Special Dietary Restrictions
  • Preparing, Cooking and Serving
  • Assist to Dining Room
  • Eating Assistance
  • Grocery Shopping
  • Delivery
  • Clean-Up

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