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Paying for Home Care

Home healthcare and hospice services are covered under and paid for by a number of sources, including Medicare, Medicaid, commercial insurance, and private pay. Eligibility, coverage, and reimbursement for services by a particular payer is determined by several factors.

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Medicare
Medicaid
Other Payment Options

Medicare

Traditional Medicare

These comprehensive services are provided by nurses, therapists, home health aides and other direct-care staff under the direction of a physician’s order. The focus of these patient-centered services includes prevention, recuperation, and/or an alternative to higher-cost institutional care that would otherwise be provided in a hospital or nursing facility. Generally, home care services are appropriate whenever a person prefers to stay at home, or is homebound, but needs ongoing care.

Home Health

To qualify for home health services under Medicare's home health benefit, a person must be homebound, under a physician’s plan of care, and must need medically necessary skilled nursing or therapy services. A physician or certified home health agency (CHHA) can help individuals determine whether they are eligible for Medicare home health services. CHHAs receive Medicare payment based on either a 30-day episodic payment or on a fee-for-service (FFS), per visit basis for cases with low utilization of services. Medicare pays CHHAs on an FFS basis for the following services: Nursing, Physical Therapy, Occupational Therapy, Speech Language Pathology, Medical Social Services and Home Health Aide.

Hospice

Hospice is a model of care that focuses on relieving symptoms and supporting patients with a life expectancy of six months or less. Patients must elect to participate in the hospice program in order to receive this Medicare benefit; curative care and services are not allowed to be provided.

Hospices are reimbursed by Medicare for delivery of services that fall into four categories: Routine Home Care (RHC), Continuous Home Care (CHC), Respite Care (RC) and General Inpatient Care (GIP).

Visit Medicare.gov

Medicare Advantage

Medicare Advantage (also known as Medicare Part C) is a type of Medicare health plan offered by a private company that contracts with U.S. Centers for Medicare and Medicaid Services (CMS). These plans incorporate Part A, Part B, and usually Part D (prescription drug benefit) Medicare services. Some may also offer extra benefits (such as wellness, dental, vision and/or personal care services) that traditional Medicare does not cover. 

Individual Medicare Advantage plan decisions affect how much individuals pay for coverage, what services one can get, what physicians or practitioners one can use and one’s overall quality of care.

Medicare Advantage plans typically pay CHHAs, Licensed Home Care Services (LHCSAs) and hospices on a negotiated FFS basis, although some plans do pay providers on a negotiated episodic basis more similar to the way Traditional Medicare handles home health reimbursement.

Medicaid

Traditional Medicaid

Medicaid is a joint Federal-State medical assistance program for low-income individuals, administered individually by each state. 

In New York, the State Department of Health (DOH) regulates home healthcare and hospice programs that are available to certain Medicaid-eligible people under the State's Medicaid program.

Home healthcare Services that may be provided under New York’s Medicaid program in accordance with an individual’s plan of care include the following type of services: nursing, home health and personal care aide services, physical therapy, occupational therapy, speech therapy, medical social services, nutritional services, homemaker service and housekeeper or chore services.

The New York State DOH pays CHHAs a Medicaid payment based on either a 60-day episodic payment or on a fee-for-service (FFS) per visit basis for cases with low utilization of services. Medicaid pays LHCSAs on an FFS basis, and reimburses hospices based on which of four categories the services delivered fall into.

Medicaid Managed Care

Medicaid Managed Care streamlines the delivery of services (short or long term) to people who have acute service needs or are chronically ill or disabled and who wish to stay in their homes and communities.

These services, such as home care or adult day care, are provided through Medicaid managed care plans that are approved by the New York State Department of Health. 

Medicaid Managed Care Plans pays CHHAs and LHCSAs a Medicaid payment based on either a negotiated episodic payment or on a negotiated fee-for-service (FFS) per visit basis.

Other NYS Coverage

The New York State Office for the Aging (NYSOFA) regulates additional home healthcare programs that are provided through county offices for the aging, including the Expanded In-Home Services for the Elderly Program for elderly people who do not qualify for Medicaid.

Visit Medicaid.gov

Other Payment Options

Private Insurance

Commercial Insurance

Commercial health insurance policies normally include a home health benefit covering services for acute needs. Many commercial plans will also cover comprehensive hospice services.

Long-term Care Insurance

Long-term care insurance is becoming a common way for individuals to prepare for the eventual need for long-term care services. Originally developed as a way to cover lengthy stays in nursing homes, private long-term care policies have expanded their coverage of personal care and other home services. Home care benefits vary among plans and there may be limitations and exclusions.

Workers Compensation

Individuals with medically necessary home care needs as a result of an injury on the job can often receive coverage through workers' compensation.

Self– or Private Pay

Individuals who are not covered for home care or hospice services by any of the third-party options may pay directly for services, negotiating fees with the CHHA, LHCSA or Hospice.

Medicaid Managed Care Plans pays CHHAs and LHCSAs a Medicaid payment based on either a negotiated episodic payment or on a negotiated fee-for-service (FFS) per visit basis.

Learn more about the New York State Home Healthcare Landscape