Are you managing an illness or injury for yourself or a loved one that requires in-home care? You may wonder if insurance covers this type of care and are exploring options to help cover the costs. Understanding what insurance covers can feel overwhelming, especially when balancing care needs with financial planning.
We know that caregiving can come with unique challenges, and most people are unsure where to start when coordinating care. Here, we’ll guide you through various insurance options for in-home care, how to determine if your policy covers it, and what other resources are available if you need financial assistance.
Types of Insurance That Cover In-Home Health Care
Various insurance programs offer some form of in-home healthcare coverage, though the extent of this coverage often depends on state regulations and the type of insurance plan. We’ll explore three main scenarios you or your loved one may face: private health insurance, government healthcare programs, and out-of-pocket healthcare services.
Private Health Insurance: Does It Cover In-Home Care?
For most people, private health insurance offers very limited in-home care coverage. Generally, coverage is limited to short-term, medically necessary services, such as part-time skilled nursing or physical therapy prescribed by a doctor. Full-time or long-term in-home care, as well as non-medical support (e.g., help with dressing or bathing), are typically not covered under standard private insurance plans.
If you’re unsure about your coverage, here’s how to confirm what’s included in your plan:
- Check Your Policy Documents: Look for specific terms like “home health care,” “skilled nursing,” or “personal care assistance.” You can find these details in your insurance policy’s benefits booklet or employee benefits handbook.
- Contact Your Insurance Provider: Call the number on your insurance card and ask specifically about coverage for “in-home care,” “home health care,” or “personal care services.” Make sure to ask:
- What specific in-home care services are covered (e.g., nursing, therapy, personal care)?
- Are there limits on the duration or amount of coverage?
- Do I need prior authorization or a doctor’s prescription?
- Look for Online Resources: Many insurance providers list FAQs on their website. Additionally, the National Association of Insurance Commissioners (NAIC) can offer insights into standard coverages and help you understand state-specific requirements.
If your private insurance does not cover the in-home care you need, long-term care insurance may be a more suitable option.
Long-Term Care Insurance
Long-term care insurance is designed to cover services that help with activities of daily living, such as personal care, health aides, and home modifications for accessibility. Unlike standard health insurance, it typically covers long-term, non-medical support services and allows more flexibility in choosing home-based care.
To find out if your long-term care policy covers in-home care:
- Review Your Policy’s Eligibility Requirements: Coverage often activates when you cannot perform a certain number of daily activities (e.g., bathing, dressing) independently.
- Gather Documentation from Your Healthcare Provider: Insurance often requires a doctor’s statement or care assessment to verify your need.
- Ask About Claims Process: Long-term care policies usually have specific claims requirements, so check the steps required to file for benefits.
Clara Home Care can assist in coordinating long-term in-home care, managing administrative tasks such as payroll, taxes, and insurance, to help streamline your care experience while maximizing cost savings, and can work with your long-term care insurance provider to manage claims and reimbursement.
Government Programs That May Cover In-Home Health Care
If private insurance does not fully cover in-home care needs, government programs such as Medicare and Medicaid are worth exploring. While these programs can cover certain types of in-home care, each has unique qualifications and application processes.
Medicare
Medicare is a federal program for individuals aged 65+ and certain younger people with disabilities. Coverage for in-home care is available, but is typically limited to part-time, medically necessary skilled services (e.g., nursing, physical therapy) rather than non-medical or long-term care.
To determine your Medicare in-home care coverage:
- Review Eligibility for Home Health Services: Medicare covers in-home health care if it is medically necessary and prescribed by a doctor. Services include intermittent skilled nursing, physical and occupational therapy, and home health aide services for limited, short-term care.
- Use Medicare’s Online Tools: Go to Medicare.gov to check eligibility requirements, review benefits, and find providers near you. The site also includes a provider search tool to locate Medicare-approved in-home care services.
- Contact Medicare Directly: For questions specific to your situation, call Medicare at 1-800-MEDICARE (1-800-633-4227).
Medicaid
Medicaid is a joint federal-state program offering broader in-home care benefits than Medicare, especially for individuals with limited income and resources. Each state administers Medicaid differently, so eligibility and coverage for in-home services can vary.
Medicaid’s Home & Community-Based Services (HCBS) program offers support for in-home care, personal assistance, and, in some cases, services that help maintain independence at home.
To find out what Medicaid covers in your state:
- Visit the CMS Website: CMS.gov provides detailed information on Medicaid’s HCBS program, eligibility requirements, and covered services.
- Contact Your State Medicaid Office: State-specific Medicaid offices offer guidance on applying for HCBS and other in-home care benefits. Search for your state’s Medicaid contact on CMS’s website or visit your local office.
What to Do If Your Insurance Doesn’t Cover In-Home Care
In cases where insurance doesn’t cover in-home care, other financial assistance options are available. Planning for these costs may require combining different funding sources to ensure you or your loved one can remain safe and comfortable at home.
Alternative Financial Assistance Options
Some states offer grant programs to help cover in-home care for those who don’t qualify for Medicaid. Eligibility for these programs varies, but they generally focus on supporting older adults or disabled individuals.
If you’re looking for local resources, consider contacting your Area Agency on Aging or using the Eldercare Locator. Additionally, Clara Home Care can connect families with trusted caregivers and handle payroll, taxes, and insurance, providing valuable support while reducing administrative burdens.
Paying Out-of-Pocket
For those ineligible for other assistance, paying out-of-pocket is an option. Private pay options include using personal income, savings, or home equity, or exploring tools like reverse mortgages and annuities.
Visit LongTermCare.gov for more information on private pay options, including tips on financial planning and long-term care strategies.
Next Steps for Finding and Funding In-Home Care
Here are some actionable steps to help you assess and manage in-home care coverage and costs:
- Check Your Policy for In-Home Care: Review your policy documents, then call your insurance provider with specific questions about home health care and personal care services. The National Association of Insurance Commissioners can provide guidance on state-specific insurance coverages.
- Explore Medicare and Medicaid: Visit Medicare.gov for Medicare’s in-home health benefits and CMS.gov to learn about Medicaid’s HCBS program and state-specific benefits.
- Apply for Long-Term Care Insurance, If Eligible: If you have long-term care insurance, consult your policy for daily living assistance coverage. You may need a doctor’s note and care assessment to file a claim.
- Look into Social Security Benefits: If you receive SSI or SSDI, these benefits may help fund care. Check SSA.gov or your local Social Security office for guidance.
- Seek Community Resources: The Eldercare Locator and local Area Agencies on Aging can connect you with community-based in-home care resources and caregiver support.
Finding the right coverage for in-home care can be challenging, especially when coverage is limited. Clara Home Care offers solutions by connecting families with qualified caregivers and handling administrative tasks, including payroll, taxes, and insurance, for a streamlined and affordable care experience.
This article was reviewed and fact-checked by Megan Jones, MSW, LSWAIC.
Sources:
“What to Ask When Shopping for Health Insurance.” NAIC, https://content.naic.org/sites/default/files/inline-files/cmte_b_consumer_information_related_shopping_health_insurance%5B1%5D.pdf.
“Home - Centers for Medicare & Medicaid Services.” CMS.Gov, www.cms.gov/.
