Who Pays for Home Health Care?

Traditional Medicare pays 100 % of a home health benefit as long as there are physician orders, the patient needs skilled care and they are homebound.  Homebound definition does not mean the patient cannot leave the home.  It means the patient requires the assistance of another person, is a ?taxing-effort? to leave the home or requires the use of an assistive device, as long as it is not ?frequent? and of ?long duration?. 

Managed Medicare Programs/ HMO?s may or may not pay 100 % and some require pre-authorization.  It is solely dependent upon the individual?s plan.  The home health agency must have copies of the orders, the history and physical in order to pre-authorize the services.   The patient must quality for home health, meaning needing skilled services, have a physicians order and be homebound. 

Insurance almost always requires pre-authorization.  Some insurance plans pay 100% and others have a patient deductible and co-pay.  Again, it is dependent upon the individual?s policy.  The home health agency must verify benefits prior to beginning care.  The patient must also quality for home health. 

Medicaid and Managed Medicaid Programs  will pay for the first 30 days of skilled home health services after a 3 day qualifying hospital stay without preauthorization.  If the patient does not have the 3 day hospital stay prior to home health, then pre-authorization is required.   Many Medicaid participants have a ?spend down? which is a portion they are responsible to pay for.  Once the spend-down has been met, then Medicaid will pay 100 % as long as the patient is qualified. 

Home Health agencies need a face-sheet, the Dr?s order, discharge summary and history and physical for a referral.  This information is needed prior to care for the authorization.