Payment Criteria
When you are paying for a service out-of-pocket or with your money; usually, the only criteria are your willingness and ability to pay.
If someone else is paying, there usually are conditions or criteria to be met; before they pay or authorize a service. This is the case with insurance companies.
Let’s look at two basic criteria*
There are countless policies and criteria but generally speaking let’s start here with two categories that, for the most part, have different payers.
Skill vs NonSkill
Skill Service
Services that must be performed by a licensed professional like a nurse, doctor or physical/occupational/speech therapist and is ordered by a doctor. Skilled services may be performed at home (skilled home care) or in a facility (skilled nursing facility/rehab).
Some examples of skilled care: some wound care treatments, intravenous antibiotic administration, rehabilitation, teaching new medical procedures…
$ Who pays (if they meet the criteria)
Medicare or Managed Medicare
Insurance companies (e.g. United Health Care, Humana, Aetna …)
Veteran benefits
Sometimes Medicaid (usually, if there are none of the above policies or benefits or it may cover the rest of what’s covered by above)
Nonskilled service or Custodial care
Non-medical services to assist with activities of daily living (ADLs) e.g. eating, dressing, bathing, toileting…
$ Who pays (if they meet the criteria)
Medicaid or Managed Medicaid
Long term insurance (personal purchase)
Veteran benefits (if criteria is met)
You (out-of-pocket or self-pay)
Medicare, Managed Medicare and Insurance companies usually do not pay for these services (if that’s all that’s needed).
Important Considerations
Having an idea about “who pays what”, helps advocate for your loved-one and to navigate the healthcare system.
Remember, clarify with the insurance company or payor what services are covered, because in the end, they authorize payment.
Your doctor’s input is needed but it is not the only determinant if the insurance company will pay. The insurance company holds the “purse strings”.
Meanwhile, if you need assistance teasing it out a bit more, check out services.
Looking forward to partnering with you!
*Contact your insurance provider for the specifics. You should always speak with them to confirm service coverage.