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How to Qualify for Home Health Care on Medicaid

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There is understandably much confusion over the difference between home health care and home care and how Medicaid and Medicare pay for these home care services.

As someone who needs personal care services and skilled nursing care, it can be challenging to get the medical and personal care services you need.

What is Medicaid?

Medicaid is a joint state and federal program that provides programs and services to low-income individuals.

Each state determines income and asset limits for participation and develops a state plan for how they want to use Medicaid money.

Medicaid pays for skilled nursing services, in-home care, adult day care, respite care, aide services, and home health care. Medicaid recipients still have to meet eligibility requirements, and qualifying for many of the available programs can be arduous.

Some Medicaid programs are consumer-directed and others are part of waiver programs that waive specific Medicaid requirements, and others are called HCBS Waiver programs which expand where individuals can receive services.

Community-based services aim to keep patients out of institutional settings and provide various services, including case management, nursing, therapies, and personal care. It costs far less to bring assistance to a Medicaid recipient at home rather than to have them in a nursing home. 

One of the challenges with Medicaid is that Medicaid coverage, although adequate, often doesn’t pay home care companies at a profitable rate. What this means for the consumer is that there may not be many companies or limited access to programs where you live.

What is Medicare?

Medicare is not income based. It is the federal insurance program for people 65 and older and younger disabled individuals. Some people qualify for both Medicare and Medicaid. They are low-income, over 65 or younger, and disabled.

What is Home Care?

Home care is caregiver services that you either pay for or, if you qualify for Medicaid, you can apply for Medicaid home care caregivers. Wait lists could be long, and due to national staffing shortages, you could have difficulty meeting your care needs on the schedule you require.

Due to differing state regulations, most home care personnel cannot provide medical services or medical care. But they can assist with activities of daily living. Medicaid covers home care, but you or your loved one must meet the eligibility requirements for participation. 

Medicare does not pay for home care caregivers except with enrollment in home health care. Even in those cases, caregivers are restricted to specific functions. 

What is Home Health?

Home health care is an insurance-covered, time-limited medical service for people who meet the criteria. To qualify for home health you have to have a doctor’s order, be home-bound, and have a skilled need.

Most people, whether on Medicaid or Medicare, choose home health care when needed due to the intensive services they provide.

Home health care offers:

  • Physical therapy 
  • Home health aides 
  • Other therapy services 
  • Nursing 
  • Occupational therapy  
  • Some medical equipment to help you recover from an accident or illness
  • Social services

However, home health services are not round-the-clock and are not intended to provide long-term care.

A nurse develops a care plan after receiving a doctor’s order for home health. The other challenge with home health care is that aides are only permitted to help with activities of daily living. They can’t cook, offer transportation, shop, or provide companionship. All home health programs are time-limited under both Medicare and Medicaid except under specific circumstances.

Suppose you or a family member need more assistance, or your level of care requirements are around the clock.

In that case, neither Medicare nor Medicaid care may be able to provide what you need. You may have to consider assisted living or a nursing home.

What are the Benefits of Medicaid and Home Health Care?

If you can, it is almost always beneficial to get a doctor’s order for home health care for these reasons:

  • Home health can help you recover function and become more independent
  • You can receive services in the comfort of your home
  • A nurse can help you with medications and monitor your progress
  • A social worker can assist you with accessing additional resources

What are the Challenges of Medicaid and Home Health Care?

Although Medicaid does pay for home health care, there are some challenges to be aware of:

  • You may not have many home health agencies to choose from since most in your area contract with Medicare only.
  • You may have additional personal care needs that you can’t afford to pay for, but you don’t qualify for or have to wait for any Medicaid program to help.
  • Your home health care services may discharge you because you have met your goals but still need assistance. Or, you cannot meet goals and therefore are discharged from service.

Home Health Care and Medicaid

Both Medicaid and home health care are valuable resources for you and your family if you have a chronic illness or are recovering from an accident.

It can be tricky to maximize the benefit of both. But with enough education about criteria and availability limits, you can leverage these programs to improve your health.

Amanda Lambert

A Certified Care Manager, Aging Life Care Professional, and Certified Master Guardian Emeritus. She is also the founder of Lambert Care Management, providing care management and consultation services to older and disabled adults. She has 20+ years of experience in geriatrics, with expertise in mental health, home health, and guardianship, as well as all aspects of care planning, including assessment, projected costs of care, client advocacy and education, caregiver coaching, and advance directives. She is also co-author with Leslie Eckford of Choose Your Place: Rethinking Home as You Age (2020), Aging with Care: Your Guide to Hiring and Managing Caregivers at Home (Rowman and Littlefield 2018).

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