Home health care benefits are provided by many private insurance and Medicare programs to treat illnesses or injuries that make it difficult or impossible, to leave home to receive treatment. These services are typically less expensive and more convenient for patients and their families than an extended hospital stay or treatment administered in a skilled nursing facility.
- Eligibility Requirements
- Home Health Care Services
- Services NOT Covered by Home Health Care Benefits
Given a patient’s insurance or Medicare plan, they must meet ALL of the following criteria in order to take advantage of their respective home health care benefits:
- The patient must be under the care of a doctor, and receiving care based on a plan of care that is outlined and reviewed regularly by this doctor.
- A doctor must certify the patient’s need for one or more of the following:
- Continued occupational therapy
- Intermittent skilled nursing care
- Physical therapy
- Speech-language pathology services
- The home health care agency providing the patient’s home care must be approved by the patient’s insurance company or by Medicare.
- The patient must be homebound and be certified as homebound by a doctor.
- Homebound, for the sake of home health care coverage, means:
- Leaving your home is not recommended because of your injury or illness
- Your illness or injury keeps you from leaving home without assistance (i.e. the use of a walker or wheelchair, special transportation, or assistance from another person)
- Leaving home becomes a monumental task and requires a huge effort
The patient may leave home for medical treatment or for short stints such as for religious services. These absences will not affect a patient’s eligibility.
The amount of services a patient needs also affects eligibility. If a patient requires more than part-time skilled nursing care they are not eligible for home health benefits. Part-time or ‘intermittent’ skilled nursing care is defined as care that is given or needed less than seven (7) days each week or fewer than eight (8) hours each day for twenty-one (21) days or less.
These limitations may be extended under special circumstances-when the doctor can specify when the need for home health care will end.
A patient’s home health benefit only pays for those services provided by the home health agency. Any other medical service, such as doctor visits are covered under the patient’s regular medical insurance or Medicare benefits.Return to top
Home Health Care Services
The following are standard home health care services typically covered under most private insurance and Medicare plans:
Skilled Nursing Care. Skilled nursing services are covered as a home health benefit when they are given on a part-time basis and if they are deemed necessary. These nursing services must be ordered by your doctor for your specific illness or injury. Also, you must be homebound but NOT need full-time nursing care.
Examples of skilled nursing services include giving IV drugs, shots or tube feedings; changing wound dressings, and teaching about the administering of prescription drugs or diabetes care. In addition to these services, home health nurses also provide instruction to the patient and the patient’s caregivers regarding the patient’s care.
Care that can be administered properly and safely by non-medical personnel (including the patient) is not considered skilled nursing care and will not be covered under home health benefits.
Physical Therapy, Occupational Therapy, and Speech-Language Pathology services. The following guidelines are used to determine the need for therapy services provided in the home:
- The therapy must be a specific, safe, and effective treatment for your injury or illness.
- Your condition must require therapy services that can only be safely and effectively performed by qualified therapists.
- One of the three following conditions must exist:
- The patient’s current condition is expected to improve in a reasonable and generally-predictable period of time.
- The patient’s current condition requires a skilled therapist to outline an effective maintenance program.
- The patient’s current condition requires a skilled therapist to perform the maintenance therapy.
- The amount, frequency, and duration of therapy services must be reasonable.
Medical Social Services are covered when given under the direction of a doctor. These services will help with the social and emotional concerns related to the patient’s condition. Some of these services might include counseling or help finding resources in the patient’s community.
Medical Supplies such as wound dressings are covered as a home health care benefit when they are ordered as part of the patient’s care.
Durable medical equipment (i.e. walker or wheelchair) must meet certain criteria to be covered under the patient’s home health benefit plan. If the home health agency does not supply durable medical equipment directly, the home health agency staff will typically arrange for items to be delivered to the patient’s home by a home equipment supplier.Return to top
Services NOT Covered by Home Health Care Benefits
The following are examples of what is not covered under a private insurance or Medicare plan with home health care benefits.
- 24-hour, around-the-clock, home care
- Meals delivered to the patient’s home
- Homemaker services such as shopping, cleaning, and laundry when this is the only care that is needed, and when these services do not relate to the plan of care
- Personal care administered by home health aides such as bathing, dressing, or toileting when this is the only care that is needed