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Eligible for Home Health under Medicare

Medicare beneficiaries are eligible for coverage of home care if they are considered “homebound” and their physician orders skilled nursing or therapy services.

A patient is defined as homebound if a physician certifies that the patient is confined to his/her home. An individual does not have to be bedridden to be considered as confined to the home, but leaving home would require a considerable and taxing effort. The patient may still be considered homebound if there are absences from the home that are infrequent or for periods of relatively short duration, and are attributable to the need to receive health care treatment such as attendance at adult day centers to receive medical care, ongoing receipt of outpatient kidney dialysis, or the receipt of outpatient chemotherapy or radiation therapy. Occasional absences from the home for non-medical purposes, such as attendance at a religious service, family reunion, funeral, graduation, or other infrequent or unique circumstances will not cause the patient to lose his/her status as homebound.

What is Certified Home Health Care?

Certified home health care services are provided for treatment and recovery after an illness or injury. Medicare will pay for home health services provided by a Medicare-certified home health agency if the following conditions apply:

  1. The patient needs intermittent skilled nursing, physical therapy, speech therapy or continuing occupational therapy (when a prior need for nursing, physical therapy or speech therapy has been established)
  2. The patient is homebound
  3. The patient is under the care of a physician who determines the need for care, subsequently sets up and periodically reviews the plan of care

These services include:

  • Skilled Nursing, including Infusion Therapies
  • Physical, Occupational and Speech Therapies
  • Medical Social Worker Services
  • Home Health Aide Services

The home health agency will typically coordinate home medical equipment needs and any specialized services.

Who Pays for Home Health?

Medicare

  • Patient must be covered by Medicare
  • Patient’s physician must develop a Plan of Care stating the nature, frequency and duration of care the patient needs
  • Physician’s Plan of Care must require skilled nursing or physical, speech or occupational therapy as “reasonable and necessary” for the patient’s condition
  • Services must be provided by a home health agency that is certified by Medicare
  • Patient must be homebound. (Physician certifies that patient is normally unable to leave home, without “considerable and taxing effort.”)

Medicaid
State-specific rules of eligibility govern coverage of services provided to the elderly and disabled for home health and community-based care. Consult your local Medicaid office or hospital social worker for guidance.

Private Insurance, Managed Care Plans and Workers Compensation
Many private insurance policies, HMOs, PPOs and Workers Compensation cover home health care when prescribed by a physician. Please consult your policy for specific terms. For insurance cases, AHCP will verify the patient’s coverage, including any co-payment, and bill the insurance company or other third-party payer for the patient.

How are Private Duty Services Reimbursed?

Private duty care may be covered by private insurance, Workers Compensation, private pay, managed care HMO, PPO or Trust Funds.

Who Provides Home Health Care in My Home?

Depending on your health care needs, various individuals may be assigned to provide care in your home. The types of individuals and the activities they typically provide include:

Registered Nurses (RN’s) or Licensed Practical/Vocational Nurses (LPN’s/LVN’s) provide skilled nursing care, which includes but is not limited to:

  • Assessment of patient’s condition and general health
  • Wound care
  • Administration of medications
  • Catheter changes
  • Disease management and patient education

Specially trained RN’s and LPN’s/LVN’s provide high-tech care, including:

  • Home IV therapy
  • Complex wound and ostomy care
  • Anticoagulation monitoring
  • Medications monitoring
  • Anodyne® therapy

Physical Therapists (PT’s)

  • Assessment of patient’s condition, rehab potential and needs
  • Therapeutic exercises
  • Gait training
  • Range of motion exercises
  • Rehabilitation following joint replacement
  • Rehabilitation for amputees
  • Instruction in use of assistive devices (walkers, wheelchairs, etc.)
  • Anodyne® therapy

Occupational Therapists (OT’s)

  • Assessment of functional skills and home environment
  • Treatment to restore function to perform activities of daily living
  • Training in use of adaptive equipment

Speech Therapists (ST’s)

  • Treatment for speech problems resulting from illness, stroke or other neurological impairment
  • Treatment for swallowing disorders
  • Speech/language exercises
  • Instruction in alternate communication devices

Medical Social Workers (MSW’s)

  • Assessment of social and emotional factors related to patient care
  • Assistance in adjusting to illness/incapacity in home environment
  • Assistance in finding appropriate community resources
  • Counseling patient and family

Home Health Aides (HHA’s), under the direction of a nurse, may provide:

  • Assistance with the activities of daily living (eating, dressing, ambulation, transfer, active range of
    motion exercises)
  • Personal care (bathing, toileting, shaving, grooming, mouth & skin care)
  • Monitoring vital signs
  • Meal planning and preparation
  • Light housekeeping (maintenance of patient’s immediate environment)

Home Health Aides who pass certification examinations are Certified Home Health Aides (CHHA’s) or Certified Nurse Aides (CNA’s).

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