Home Health Care & Health Insurance—Understanding Your Coverage

By Anonymous

Home Health Care & Health Insurance—Understanding Your Coverage

There are two distinct types of home health care: skilled home health care and non-skilled or custodial home health care. Which type you need and why you need it may determine whether or not your health insurance will pay for your care.

Skilled home health care is care that, due to its inherent complexity, requires the services of a licensed health care professional such as a registered nurse, licensed practical nurse, occupational therapist, physical therapist, speech-language pathologist, or medical social worker.

For a more in-depth definition and examples, see “What is Skilled Care & How Does It Work?”

When you need skilled home health care, in some cases the nurse or therapist will provide all of the care. However, in many cases, he or she will teach you or a capable caregiver how to provide some of the care yourself.

For example, if you need IV antibiotics four times daily for six weeks, rather than coming to your home four times a day for six weeks to administer each IV infusion, the IV nurse will probably teach you or a caregiver to administer the IV antibiotics yourself using an automated pump. After you’ve demonstrated that you can safely administer the IV antibiotics yourself, the nurse will visit periodically to assess and maintain your IV site, change your IV dressing, evaluate your response to the IV therapy, and perhaps draw any necessary blood tests.

What exactly your health insurance covers ultimately depends on how your health insurance policy is written.

However, skilled home health care is usually covered by health insurance because it’s less expensive than getting that same care in a hospital or inpatient rehabilitation facility.

Because skilled home health care may cost more than getting care at an outpatient clinic or doctor’s office, some health plans, notably Original Medicare, require you to be homebound to qualify for home health care benefits.

For example, if you’re capable of going to an outpatient physical therapy center, your health insurer will be less willing to pay for the more expensive option of a physical therapist coming to your home.

Whether or not your health insurance will cover skilled home health care may also depend on how long you’re expected to need the care and whether you need care continuously or intermittently.

If you need skilled home health care temporarily while you’re recovering from an illness or injury, your health insurance is likely to cover it. If you’re expected to need this skilled home health care for the rest of your life, your health insurance may be less willing to cover it, instead directing you to seek coverage from long-term care insurance. Or, your health insurer may agree to cover skilled home health care visits for a limited period of time so that a family member or caregiver can be trained to provide your care on a long-term basis.

Additionally, health insurers usually limit home health care coverage to intermittent skilled home visits rather than continuous care. For example, your health plan would be less likely to cover a home health nurse providing continuous care in your home 24 hours a day than it would be to cover the services of the same nurse making a one-hour home visit three times a week to address a skilled care need.

Non-skilled home health care, otherwise known as custodial care, is care that can be provided by non-licensed caregivers. This type of care doesn’t require special medical assessment skills, highly technical skills, advanced medical knowledge and decision making, or in-depth knowledge of social services. Instead, custodial care involves hygiene and other activities of daily living. For a more in-depth definition and examples, see “What Is Custodial Care?”  

Because non-skilled home health care is provided by non-licensed staff, there are legal limits as to the type of care they can provide.

For example, a home health aide may be permitted to remind you that it’s time to take your medicine, but not be permitted to administer the medication to you.

Non-skilled home health care may be provided by home health aides, nurse’s aides, companions, sitters, or other non-licensed health care personnel.

Home health care agencies that provide non-skilled personnel may require those personnel to be supervised intermittently by a licensed health care professional such as an RN. In this case, the RN may visit your home occasionally to check up on the non-licensed caregiver and make sure you’re getting the care you need.

Health insurance doesn’t usually cover non-skilled home health care, but some non-skilled home health care may be covered by long-term care insurance. Custodial home health care in the United States is often paid for out-of-pocket by the patient or provided free of charge by the patient’s family members and loved ones.

However, there are exceptions to this rule. For example, if you’re receiving skilled intermittent home health care visits covered by Medicare, it may also cover the services of a home health aide to help with bathing and hygiene a few times a week. Whether or not your health insurer will cover custodial care services when provided in conjunction with skilled care at home depends on how your insurance policy is written.

If you need skilled, intermittent home health care services, the most efficient way of getting these services is through an accredited home health care agency rather than hiring private individuals. Home health care agencies hire, vet, and supervise a full range of licensed home health care personnel so you won’t have to worry about checking the licensure and backgrounds of each and every staff member that comes to your home. In fact, your health insurer may require that you use an accredited home health care agency.

If you have managed care health insurance such as an HMO, PPO, or EPO, choosing a home health agency that’s in-network with your health plan will mean you pay lower copays or coinsurance than if you choose an out-of-network agency. If you have Original Medicare, you must choose a Medicare-certified home health agency or Medicare won’t pay.

To cover home health care services, your health insurer will probably require a physician’s order specifying which skilled services you need and information about why those services are medically necessary. Additionally, it may require that your physician approve of and supervise the home care agency’s care plan.

If you’re to receive skilled home health care after being discharged from the hospital, rehab facility, or nursing home, that facility’s case manager, discharge planner, or social worker will help you arrange for home health care services and coordinate with your health insurance.

If you need skilled home health care services without having first been hospitalized, in a rehab facility, or in nursing home, you have a couple of options for arranging this care:

Although terminally ill patients frequently get skilled health care in their homes through hospice, your health insurance may have different coverage rules for hospice than it does for home health care. For example, hospice benefits may provide for continuous care during difficult times, a benefit not usually offered for non-hospice home health care.

Hospice Medicare Benefit—How It Works & What It Covers