What Qualifies a Person for Home Health Care?

Find even more information about home health care here!

Patient Is Homebound

A doctor must certify that the patient is homebound. Patients who are homebound find leaving the home a major effort. This means that the patient has trouble leaving their home without help. This could include using a cane, walker, wheelchair, or crutches, special transportation, or help from someone else. If leaving the home could be detrimental to their condition, a person can also be considered homebound.

A person can still be considered homebound and qualify for home health care if they are able to leave the house for brief, infrequent trips. These types of trips include attending religious services or an occasional trip the barber. If the person is able to attend a unique event like a graduation or a funeral, or adult day care, they still could be homebound.

Patient Is Under a Doctor’s Care

The patient must be under the care of a doctor and receiving treatment under an established plan of care. A doctor must review the plan of care when necessary. The doctor must see the patient face-to-face to certify that the patient needs home health services.

Patient Needs Skilled Services

The patient’s doctor must certify that he or she needs one or more of the following medical treatments:

• Intermittent skilled nursing care. Intermittent means fewer than 7 days a week and less than 8 hours a day, for up to 21 days. Medicare may extend the 21-day limit, but only under exceptional circumstances and only if the doctor can predict when the need for skilled nursing care will end. Skilled nursing care is provided by a registered nurse (RN) or a licensed practical nurse (LPN).
• Physical therapy, speech-language pathology, or continuing occupational therapy. These services are considered necessary at home if they’re specific and effective for the patient’s treatment and if they’re complex enough that they must be performed by, or under the supervision of, a qualified therapist.

Patient Receives Home-Based Care From a Medicare-Approved Agency

For Medicare to pay for home health care, the patient must be treated by a Medicare-approved agency. Patients and their families are able to choose their own agency, but the agency must be Medicare certified.

What Is Covered for Home Health Care?

Part-time or intermittent skilled nursing care, which means medical services provided by an RN or an LPN, fewer than 8 hours a day and 28 or fewer hours per week. These services may include giving IV drugs; injections; tube feedings; changing wound dressings; and teaching about prescription drugs or diabetes care. It is not considered skilled nursing care if the patient or a non-medical person could administer the treatment.

Physical therapy, occupational therapy, and speech language pathology services are covered when ordered by a doctor. Part-time home health aide services (like personal care) may be covered if the patient is also receiving skilled nursing care. The total, combined amount of health aide and skilled nursing services can’t exceed the 8 hour per day and 28 hour per week limit.

If a patient is receiving home-based skilled nursing services, medical social services – like counseling or help finding resources in the community – may be covered. A doctor must order these services, to help with emotional or social concerns that may affect a patient’s recovery. Medical supplies, like wound dressings, are covered if the doctor orders them as part of the treatment. Medicare pays separately (usually 80% of the cost) for durable medical equipment, like wheelchairs and walkers.

What Types of Home-Based Services Do Not Get Covered?

Medicare doesn’t pay for long-term care or custodial care. They will not cover 24-hour care, help with activities of daily living (ADLs), meal delivery, homemaker services, or personal care (unless included in the doctor-ordered home health care plan).