What is Home Care?

Home care describes services provided in a client’s home that address medical or non-medical needs, the goal of which is to keep the client safely in their home. The services divided into two categories: 1) Home Health Care which typically describes skilled nursing and therapy services, and, 2) Home Care which typically describes non-medical services that address functional needs such as meals and bathing. There also are two categories of people who provide these services. The largest category are the informal caregivers: family and friends. Then there are the paid caregivers, some of whom are licensed professionals such as nurses and therapists and others are non-medical personnel such as Aides, Companions and Homemakers.

Home Health Care Services
Home health care services can be described as skilled nursing care within the home. Some of these services include: IV Therapy, Wound Care, Post-surgical care, physical therapy, medication management, infusion therapy and many other services that can only be preformed by a licensed professional.
Non-medical Home Care
The services described as non-medical home care are more general in nature. These services are generally used to assist with the activities of daily living (ADLs) including: dressing, grooming, cooking, light housekeeping and transportation. These services do not require a skilled or licensed professional.

Who pays for Home Care Services?
Home care services can be paid for directly by the patient and his or her family members or through a variety of public and private sources. 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, long term care policies and workers' compensation.

Self-pay
Home care services that fail to meet the criteria of third-party payors are paid for "out of pocket" by the patient or another party.

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 skilled nursing; physical, occupational, and speech therapies; medical social work; HCA 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 visits to the home, not continuous care or part time and provided through a Medicare-certified home health agency for reimbursement.

• 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." Many states have special programs designed to help senior stay at home instead of move to nursing homes. There are often referred to as “waiver programs.”

• 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 HCAs.

• 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 HCA and homemaker or chore worker services. Individuals should contact their state health departments and local offices on aging for additional information.

• Community Organizations
Some community organizations, along with state and local governments, provide funds for home health and supportive care. Depending on an individual's eligibility and financial circumstances, these organizations may pay for all or a portion of the needed services.

Private Third-party Payors

• Commercial Health Insurance Companies
Commercial health insurance policies typically cover some home care services for acute needs, but benefits for long-term services vary from plan to plan. Commercial insurers, generally pay for skilled professional home care services with a cost-sharing provision. Such policies occasionally cover personal care services. 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. 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.

• Managed Care Organizations
Managed care organizations (MCOs) and other group health plans sometimes include coverage for home care services. MCOs contracting with Medicare (Medicare Advantage Plans) must provide the full range of Medicare-covered home health services available in a particular geographic area. Medicare beneficiaries who are enrolled with an MCO may elect their hospice benefit from the hospice of their choice. These organizations only pay for services that are pre-approved.

• Workers' Compensation
An individual requiring medically necessary home care services as a result of injury on the job is eligible to receive coverage through workers' compensation.