As the costs for medical care increase and technology improves, home health care is becoming a more viable option for people who need medical therapies and services after leaving the hospital. According to a 2007 Fact Sheet published by Georgetown University, approximately six percent of Americans on Medicare received medical care and services at home in 2004. However, you must meet specific conditions before Medicare or other insurers will pay for you to receive health care services in your home.
Physician Approval
Your doctor must determine that you need to receive medical treatment and services at home before Medicare will pay for home health care. A physician must sign an order requesting the services and set up a care plan detailing the medical services, which you will need in your home. In the case of veterans covered under VA insurance, the Veterans Administration requires that a veteran must be at least 50 percent disabled as the result of a service-related injury or condition. Services are delivered through the VA network or a hospital-based home care program. A VA physician must prescribe the medically necessary home health care services.
Need for Medical Services
Your doctor must say that you need to receive medical services in your home on an intermittent or part-time basis. Medically necessary services may include skilled nursing care, assistance provided by a home health aide, physical and occupational therapies, speech-language therapy, medical social services, medical supplies and durable medical equipment. The home health staff must keep your doctor informed of your progress. Only a registered nurse or licensed practical nurse can perform any skilled nursing care or services. If you are receiving skilled nursing care in your home, you may also qualify for home health aide services to assist you with activities of daily living such as bathing, dressing and toileting. Only part-time care is provided and it is usually temporary. Medicare beneficiaries who continue to meet the conditions for coverage can receive up to 28 hours of services each week. Workers' Compensation also provides coverage for home care services to individuals who need medically necessary services at home as the result of injuries that occurred while on the job.
Homebound
In order to qualify for home health care, you must not be able to leave your home without a good deal of assistance from another person. You are allowed to leave your home for medical appointments and treatment. Any other absences from your home must be short and infrequent. Attending church services is one example. Individuals may be temporarily homebound while recuperating from a serious illness or recovering from surgery or an injury.
Certification
Medicare guidelines require that the home health agency you select to provide care must be Medicare certified. Medicare-approved programs can be hospital based, public or private. In order to become Medicare certified, an agency must plan to contract with a significant percentage of Medicare beneficiaries who require physician-ordered home health services. The agency must submit an enrollment application to that state's certifying agency, after which time the state then submits the application to the Medicare fiscal intermediary for that region. When Medicare enrollment is approved, the state survey agency will begin a survey to make certain that the home health organization is in compliance with all state regulations.
Federal Guidelines
Medicaid, a program designed to help states meet the medical needs of low-income individuals, basically follows the same federal guidelines that apply to Medicare. One difference is that each state establishes its own criteria for the duration and range of coverage provided. However, medically necessary home health services must be provided long enough to achieve the intended goal. While not all managed care organizations and group health plans include coverage for home care services, those that do establish similar eligibility guidelines. The range of home care benefits provided by commercial insurers varies from plan to plan. Home care benefits offered by long-term care insurance policies also vary among plans.
