Medicare & Insurance Coverage Guide
Comprehensive information about Medicare coverage, insurance reimbursement, and payment options for home health services.
Medicare Coverage for Home Health
Medicare Part A and Part B cover home health services when certain conditions are met. Understanding these requirements helps ensure proper coverage for your patients.
Eligibility Requirements
- • Patient must be homebound
- • Physician must certify need for care
- • Requires skilled nursing or therapy
- • Care must be intermittent (not 24/7)
- • Agency must be Medicare-certified
Covered Services
- • Skilled nursing care
- • Physical therapy
- • Occupational therapy
- • Speech-language pathology
- • Medical social services
- • Home health aide services
Understanding Medicare Parts
Medicare Part A
Covers home health services if you're homebound and need skilled care. No deductible or copayment for covered home health services.
- • 100% coverage for eligible services
- • No limit on number of visits
- • Must meet homebound criteria
Medicare Part B
Covers home health services if you don't have Part A or if you've exhausted Part A benefits. Also covers durable medical equipment.
- • 100% coverage for home health visits
- • 20% copay for durable medical equipment
- • Annual Part B deductible applies to equipment
Medicare Advantage (Part C)
Private insurance plans that provide Medicare benefits. Coverage varies by plan but must cover at least what Original Medicare covers.
- • May have different copays and deductibles
- • Often includes additional benefits
- • Network restrictions may apply
Private Insurance Coverage
Private insurance plans vary significantly in their home health coverage. Understanding each plan's requirements helps ensure proper authorization and reimbursement.
Prior Authorization
Many plans require pre-approval before home health services begin. Verify requirements before patient discharge.
Network Providers
Most plans have preferred provider networks. Using in-network agencies ensures better coverage and lower costs.
Visit Limits
Private plans may limit the number of visits or require periodic reauthorization for continued services.
Medicaid Coverage
State-Specific Programs
Medicaid coverage for home health services varies by state. Each state has different eligibility requirements, covered services, and reimbursement rates.
- • Coverage requirements differ by state
- • Some states have home and community-based waivers
- • Dual-eligible patients (Medicare + Medicaid) may have enhanced benefits
- • Prior authorization often required
Insurance Verification Best Practices
Before Patient Discharge
- ✓ Verify active insurance coverage
- ✓ Check if prior authorization is required
- ✓ Confirm home health benefits are available
- ✓ Identify any copays or deductibles
- ✓ Verify the agency is in-network
Documentation Requirements
- ✓ Physician orders and plan of care
- ✓ Face-to-face encounter documentation
- ✓ Homebound status justification
- ✓ Medical necessity documentation
- ✓ Progress notes and visit records
Questions About Coverage?
Our team can help you understand insurance requirements and connect you with agencies that accept your patients' coverage.