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Thread: How do you pay for your home health aid?

  1. #1

    Question How do you pay for your home health aid?

    I've been trying to figure out how to get insurance to pay for my home health aid. I've got a Blue Shield PPO, and my current home health aid does not work for one of their preferred agencies. To get coverage, either I'd have to switch to someone else, or she'd have to switch agencies. Neither option seems worthwhile unless I can get insurance to cover a substantial portion of my cost.

    The policy states that they cover 70% of the cost of home health care, up to a maximum of 180 hours per year. My home health aid works 38 hours/week at $15/hour. So, the total value of this insurance benefit is $1,890/year, whereas my cost is $27,300/year. The Blue Shield representative said that I might be able to increase the amount they cover by making an argument that home health care is a medical necessity.

    To top it all off, I haven't even been able to get a list of the Blue Shield preferred home health agencies in my area. When I inquired, they said "Tell us what agency you're interested in, and we'll look up whether they're on our provider list."

    What's a quad to do? Has anyone had any experience with this particular battle that they'd like to share? Any insights you have would be greatly appreciated.

    Thanks,

    Jill

  2. #2
    How is "home health care" defined in your policy? In most, it will say in the small print that they will only pay for 'skilled' nursing care (that which requires an RN or LVN to do) and only from a certified and licensed home health agency. These rules may prevent you hiring your own aide directly under that policy. It may also prevent you from getting HHA (home health aide) care from the agency (paid by insurance) for all that you need since things like help with dressing, bathing, dressing, ROM, and ADLs is not considered skilled care. In addition, things like bowel care, dispensing medications, or catheterization cannot be done by a nurses aide working for a HHA in CA. They would require this to be an RN or LVN. The HHA might pay their aides around $15/hour, but they bill the insurance more like $25/hour. An RN will run more like $50-70 per hour for either insurance payment or private pay.

    Most people who have a PCA help with care either pay out of pocket (from their salary, family funds or a settlement) or through IHSS or similar programs in their state, which require you to be very low income/assets (Medi-Cal eligible) and in most counties in CA only pays a little over minimum wage (and you cannot supplement this).

    My mother has Blue Cross and Medicare, and she has never gotten either to pay for home care in 20 years other than a one-time OT evaluation and a nurse who came for 3 days for doing catheterizations when my mother's private paid attendant was briefly hospitalized. She has 4 different PCAs that she pays now since my father passed away as she also needs them to cook, run errands, etc. for her now (the things my dad used to do).

    People who have long-term care insurance may have coverage for in-home aide care of their own choosing, depending on how the policy is written. If you have that, check your policy.

    You can certainly file an appeal regarding your insurance company's decision on this, but I would be extremely surprised if you were to win an appeal like this.

    (KLD)
    Last edited by SCI-Nurse; 05-25-2009 at 07:01 PM.

  3. #3
    I have a state agency who provides hours to another company. I get my caregiver hours from their. I find them on Craig's list and referring to the agency to get paid. It works out really well and we more or less play by my rules. The provider of my hours is a combination of the state agency and Medicare, although I don't think Medicare makes much of a difference.
    C-5/6, 7-9-2000
    Scottsdale, AZ

    Make the best out of today because yesterday is gone and tomorrow may never come. Nobody knows that better than those of us that have almost died from spinal cord injury.

  4. #4
    Thanks for the replies, even though they weren't the magic solution I was hoping for.

    Jill

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