Who Pays for Home Health Care and When?
Medicaid
Medicaid is primarily a state program designed to provide necessary health care to low income citizens. Eligibility to receive services under the program is determined based on financial information, which is periodically reviewed. The reimbursement criteria differs from state to state.
In North Carolina, ten to fifteen percent of all home health visits are paid by the Medicaid program. The North Carolina Medicaid program funds a number of special assistance programs in addition to certified home health services. These include the Community Alternative Programs (CAP), Personal Care Services (PCS), Durable Medical Equipment (DME) and Total Parenteral and Enteral Nutrition. The focus of Medicaid is on both acute and long-term care needs of the eligible population.
To be eligible for home health services under the North Carolina Medicaid program, a client must:
- Have a valid Medicaid card covering the entire period when services are rendered.
- Be determined that the home is the most appropriate setting for homecare due to one of the following: medical hardship, contraindicated by the patient’s fragile and unstable condition, or interfere with effectiveness of the service.
- Be under a physician’s plan of treatment.
- Require the services of a nurse, physical therapist, speech therapist, occupational therapist or home health nursing assistant on an intermittent basis.
Requirements for the North Carolina Medicaid special assistance programs (i.e., CAP and PCS) vary from those for home health services. These programs generally do not require patients to be homebound or focus on the intermittent criteria. In addition, these special programs generally cover a wider scope of services than the conventional home health program.
