Home Health Care Attendant Care Respite Care

Medicare Home Health Coverage

Historical Development of the Prospective Payment System

The Balanced Budget Act of 1997, as subsequently amended, established a prospective payment system for Medicare home health services. Medicare home health coverage is subject to statutory, clinical, and administrative requirements. Among other criteria, a patient generally must:

• Be certified as homebound by an authorized practitioner;
• Need intermittent skilled nursing care, physical therapy, speech-language pathology services, or continued occupational therapy; and
• Receive services under an established plan of care from a Medicare-certified home health agency.

Coverage and payment rules depend on the beneficiary’s circumstances and the applicable Medicare benefit. Readers should consult current Medicare guidance rather than relying on historical visit-limit descriptions.

From HHRGs to PDGM

Historically, Medicare home health episodes were classified using Home Health Resource Groups (HHRGs). Beginning in 2020, Medicare adopted the Patient-Driven Groupings Model (PDGM) for home health payment. To learn more about how PDGM restructures 30-day payment periods, view our detailed guide on Home Health Patient-Driven Groupings (PDGM)^[2].

Attendant Care and Respite Care

Attendant care generally helps an individual perform activities of daily living (ADLs) and instrumental activities of daily living (IADLs). Respite care provides temporary substitute care, allowing a primary family caregiver a temporary break. Coverage depends on the program, plan, medical-necessity criteria, functional limitations, and an individualized service plan.

Habilitative services are among the essential health benefits identified under the Affordable Care Act (ACA). States retain significant authority over how habilitative benefits are defined and administered. Coverage for services such as applied behavior analysis (ABA) may also depend on state mandates, health plan type, and terms of the applicable benefit policy.

State Medicaid Programs

Medicaid is jointly funded by the federal government and individual states, but each state administers its own program within broad federal guidelines. As a result, covered home health, personal-care, attendant-care, habilitation, and respite-care benefits vary widely by state and eligibility group^[3].

Depending on the state, home and community-based services may be delivered through:

• Institutional or nursing-facility Medicaid programs;
• Home and Community-Based Services (HCBS) waivers;
• State-plan personal-care or attendant-care options; or
• Medicaid Managed Care Organizations (MCOs).

Texas Home and Community-Based Programs

Texas offers several specialized service models for eligible individuals who need assistance with daily living activities. Program availability, enrollment pathways, and eligibility standards are managed by state administrative agencies; consult the Texas Health and Human Services Commission (HHSC)^[4] for current operational policies.

STAR+PLUS

Texas Senate Bill 7 directed the state to implement cost-effective options for attendant and habilitation services for individuals enrolled in STAR+PLUS. STAR+PLUS serves qualifying persons with disabilities and adults aged 65 or older, supporting care in home and community-based settings to avoid institutionalization.

Community First Choice (CFC)

Community First Choice (CFC) allows states to provide qualifying home and community-based attendant services and supports under the Medicaid State Plan. Eligibility generally requires Medicaid eligibility, an assessed need for ADL assistance, and satisfaction of institutional level-of-care criteria.

Covered assistance under CFC typically includes:

• Hands-on assistance with activities of daily living (ADLs) and instrumental activities of daily living (IADLs);
• Household tasks necessary to maintain a clean, sanitary, and safe living environment;
• Escort assistance to ensure access to community services and medical appointments; and
• Certain health-related tasks delegated under state nursing regulations.

Primary Home Care (PHC) & Community Attendant Services (CAS)

Primary Home Care (PHC) and Community Attendant Services (CAS) provide nontechnical, medically related personal care services for qualifying individuals whose chronic health conditions limit functional independence. Financial and clinical eligibility parameters are re-evaluated annually by state administrators.

Medical Coding and Billing

In legal disputes and compliance audits, understanding how services are coded and billed relative to Usual, Customary, and Reasonable (UCR) charges is essential.

Attendant-Care and Respite-Care HCPCS Codes

Attendant-care and respite-care services are commonly reported using Healthcare Common Procedure Coding System (HCPCS) Level II national codes, such as:

S9125 – Respite care, in the home, per diem

S5125 – Attendant care services, per 15 minutes

Code descriptors, billing rules, state-specific modifiers, unit increments, prior authorization requirements, and fee schedules vary across Medicaid fee-for-service and managed care payers. Always verify the active code set and payer-specific manual prior to claim submission.

References

1. Centers for Medicare & Medicaid Services (CMS). Home Health Prospective Payment System (HH PPS) Overview and Policy Updates. U.S. Department of Health and Human Services. cms.gov/medicare/payment/hh-pps ↩
2. Arrigo, M. F. (2019). Home Health Patient Driven Groupings (PDGM) Analysis and Case-Mix Groupings. No World Borders. noworldborders.com/2019/12/29/home-health-patient-driven-groupings/ ↩
3. Medicaid.gov. Home & Community-Based Services (HCBS) Program Authorities and Community First Choice. Centers for Medicare & Medicaid Services. medicaid.gov/medicaid/hcbs ↩
4. Texas Health and Human Services Commission (HHSC). Medicaid and CHIP Home and Community-Based Services Handbook & Guidelines. State of Texas. hhs.texas.gov/services/health/medicaid-chip ↩