Who Pays the Bills for Home Care and Hospice?

Payment for home care can come from many sources. Depending on your age, diagnosis or financial status, Medicare or Medicaid may pay for your care in the home. Persons who are under age 60 and have severe disabilities may qualify for the Illinois Department of Human Services' Home Services Program. Persons age 60 or older may qualify for such programs as the Illinois Department on Aging's Community Care Program or other programs listed below. Also, private insurance offers coverage of homecare services and of course, you can pay yourself for care in the home.

Home health agency staff help you verify coverage before services are provided. Most home care agencies take care of all paperwork and billing.

1. Medicare

Most Americans older than 65 are eligible for home care services through the federal Medicare program. If an individual is homebound, meaning he/she cannot leave the home without physical assistance, is under a physician's care, and requires medically necessary 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 equipment may also be paid for. 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 part time and provided by a Medicare-certified home health agency for reimbursement. This means a nurse, therapist or home health aide comes to the patient's home for brief periods. Medicare does not cover care in the home for shift-type care - only specific tasks performed by a nurse, therapist or home health aide.

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. Hospice is covered by most insurance plans, including Medicare and Medicaid, with few out-of-pocket costs to the patient. The Medicare hospice benefit covers costs related to the terminal illness, including the services of the hospice team, medical equipment and supplies

2. Medicaid

Medicaid is a joint federal-state health care program for low-income individuals. Illinois' Medicaid program, administered through the Department of Healthcare and Family Services, pays for home care and has other programs for in home supports if people meet eligibility requirements. Prior approval is required for Medicaid home care services and home care equipment (durable medical equipment).

3. Private Insurance

Commercial health insurance policies typically cover some home care services for when a person is recovering from surgery or illness. But benefits for long-term services vary from plan to plan. Commercial insurers, including Blue Cross and Blue Shield and others, generally pay for medical care in the home with a cost-sharing provision. Such policies occasionally cover personal care services such as help with meal preparation and light housekeeping. 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 sometimes it is not required.

4. Long-Term Care Insurance

As the public's need and preference for home care has grown, private long term care insurance policies have expanded their coverage for in-home care as well as nursing home care. Home care benefits vary greatly among plans but most plans today cover home care.

5. Self-Pay

People can arrange to pay for homecare services themselves if they desire. Homecare providers coordinate arrangements and billing. Rates and services available vary by provider.

6. Waiver Programs

These are programs for the elderly, children, developmentally disabled or disabled and handicapped adults. The Illinois Department on Aging and the Illinois Department of Health Care and Family Services administer Medicaid waiver programs for those who meet certain eligibility requirements related to their physical and financial needs. Waivers may not claim the parental or spousal income in order to provide the services for an individual client. Authorization for this service is made by conducting an appropriate assessment. For information on services contact the Illinois Department on Aging at 1-800-252-8966 or the Illinois Department of Health Care and Family Services at 1-800-843-6154.

7. Worker's Compensation

Following an injury or accident, home care services may be ordered for rehabilitation and recovery. Each insurance company has information on the policy coverage. Services provided vary upon the policy and nature of injury or illness.

8. Veteran's Benefits

A veteran may be eligible for home care services through authorization of skilled and custodial services. Often the order for home care services is made through a Veteran's hospital or clinic.

Other Resources / Definitions:

1. Black Lung Benefits Act

The Black Lung Benefits Act (BLBA) is administered by the Office of Workers’ Compensation Programs (OWCP). The Act provides for monthly payments to and medical treatment for coal miners totally disabled from pneumoconiosis (black lung disease) arising from employment in or around the nation's coal mines. The BLBA also provides for monthly payments to certain survivors of miners who died due to pneumoconiosis. Current and former coal miners (including certain coal transportation and coal mine construction workers who were exposed to coal mine dust) and their surviving dependents, including surviving spouses, orphaned children, and totally dependent parents, brothers, and sisters, may file claims for black lung benefits.

Individual coal mine operators are liable for the payment of benefits to miners/employees. For purposes of determining responsibility for paying benefits, a coal mine operator includes: any owner, lessee, or other person who operates, controls, or supervises a coal mine or preparation plant; or any independent contractor performing services or construction at a mine; or certain entities involved in coal transportation.

2. Health Maintenance Organization (HMO)

A type of health insurance plan that usually limits coverage to care from doctors who work for or contract with the HMO. It generally won't cover out-of-network care except in an emergency. An HMO may require you to live or work in its service area to be eligible for coverage. HMOs often provide integrated care and focus on prevention and wellness.

3. Illinois Department on Aging

The Illinois Department on Aging helps older adults live independently in their own homes and communities. As the population ages, services and programs for older adults must evolve as well because longevity means more when quality of life is enhanced. To best serve older adults, we must also serve their families and teach younger people about the realities of aging, so many of our programs have an intergenerational emphasis. Working with Area Agencies on Aging, community-based service providers and older adults themselves, the Illinois Department on Aging strives to improve quality of life for current and future generations of older Illinoisans.

4. Illinois DHS Division of Rehabilitation Services

DHS's Division of Rehabilitation Services is the state's lead agency serving individuals with disabilities. DoRS works in partnership with people with disabilities and their families to assist them in making informed choices to achieve full community participation through employment, education, and independent living opportunities.

5. Preferred Provider Organization (PPO)

A type of health plan that contracts with medical providers, such as hospitals and doctors, to create a network of participating providers. You pay less if you use providers that belong to the plan’s network. You can use doctors, hospitals, and providers outside of the network for an additional cost.

6. Private Pay

Insurance plans often have restrictions and limits. If your insurance does not cover the services you need, or discontinues payment for services sooner than you are ready for or expect, you are generally left to pay the difference ‘out-of-pocket.’ Private Pay, also referred to as ‘out-of-pocket payments’, helps to cover the difference in situations such as this.

Outside help paying for in-home care services is limited and usually covers only short-term home health care needs. Paying privately for home healthcare services is often a necessary option for individuals who want to remain living independently in their homes. Since Medicaid and Medicare typically do not pay for Long-Term Care, the burden of payment becomes that of the individual or their extended family. Individuals using insurance, such as Long-Term Care Insurance, are considered ‘private pay’ since they are not being covered by a government program.

7. Sliding Scale

A scale in which indicated prices, taxes, or wages vary in accordance with another factor, as wages with the cost-of-living index or medical charges with a patient's income.

8. UIC Division of Specialized Care for Children

A big part of meeting the needs of children is meeting the needs of their families and caregivers. That’s why the care Specialized Care for Children coordinates is family-centered—they focus on partnering with the family, listening to the family’s needs and preferences and then tailoring a plan for how they can best help the family move forward in a coordinated, confident way.

At first, that care might look like helping the family get a diagnosis and learn more about the child’s condition. Later, the family might need help arranging special medical care, working with the child’s doctors and teachers, or making the most of the family’s insurance plan. Down the road, they’ll help smooth the child’s transition into adulthood.

Whatever the family’s needs are, the staff at the 12 regional offices have the experience, knowledge, and networks to guide the family along the way.

9. TriCare

TRICARE is the health care program for almost 9.5 million beneficiaries worldwide—including active duty service members, National Guard and Reserve members, retirees, their families, survivors, certain former spouses and others registered in the Defense Enrollment Eligibility Reporting System (DEERS).

TRICARE is a health program for:

  • Uniformed Service members; Includes active duty and retired members of the:
    • U.S. Army,
    • U.S. Air Force,
    • U.S. Navy,
    • U.S. Marine Corps,
    • U.S. Coast Guard,
    • Commissioned Corps of the U.S. Public Health Service, and
    • Commissioned Corps of the National Oceanic and Atmospheric Association. and their families,
  • National Guard/Reserve members Includes members of the:
    • Army National Guard,
    • Army Reserve,
    • Navy Reserve,
    • Marine Corps Reserve,
    • Air National Guard,
    • Air Force Reserve, and
    • U.S. Coast Guard Reserve. and their families,
  • Survivors,
  • Former spouses,
  • Medal of Honor recipients and their families, and
  • Others registered in the Defense Enrollment Eligibility Reporting System (DEERS).
10. Voluntary Donations

Persons willingly giving funds to those in need.