July 2001

Health Insurance Coverage for Home Health Care Services
Did you know that nurses and therapists can come to your home to help you with your health problems? The challenge is to find out if your health insurance covers these services.

Home health care, finally

Peg is an active 75 year old widow who lives alone. She slipped while doing yard work and broke both her wrists trying to brace herself during the fall. She was admitted to the hospital for surgery. She had casts from her fingers to her elbows. She could not feed herself or even clean herself after going to the bathroom.

The social worker at the hospital told her she did not qualify for any assistance at home. She could go to a nursing home, but home health care was not available. Peg asked another social worker and was given the same answer. Peg did not want to go into a nursing home.

When Peg went home she hired a nursing assistant to help her during the day. She had to pay for this care herself. Her daughter, who lived 300 miles away, came to stay with her as well. Two days after discharge from the hospital, Peg and her daughter went for a follow-up visit to the doctor. They decided to ask again about Peg's eligibility for home health care. The doctor told her that she did qualify for services under Medicare, and arranged for a nurse to visit her that afternoon.

Peg qualified to have a nursing assistant daily and a nurse two times a week. She also had an occupational therapist work with her to increase her independence, and a physical therapist to make sure she did not have any further damage to her arms.

Unfortunately, not all hospital staff is aware of benefits provided under Medicare. Peg and her daughter did not give up asking for help, and their persistence paid off.


As part of the discharge plan, the hospital should have arranged for home health care. Each state has a peer review organization that investigates these lapses in care. Peg could have informed the hospital that she planned to call the state peer review organization. Generally a hospital would prefer to resolve the issue with the patient and not be referred to the peer review organization for investigation.

Medicare and most insurance plans have provisions for home health care. If you need home health services, first check with your primary care provider. Generally, a medical order is necessary for home health services. The provider may not be familiar with local services, however, so you might need to do some detective work to find the services you need. The following are places to can call to determine if you are eligible for services:

  • Your local health department. Many health departments have programs for specific health problems.
  • Home health agencies in the phone book. Many agencies are affiliated with hospitals. Call an agency and ask if they can provide services and if you qualify under your insurance.

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