The process of obtaining home health services (HHS) involves a formal, multi-step referral system to ensure the care is medically necessary and appropriately funded. HHS focuses on providing skilled medical care for an illness or injury in a patient’s residence, delivered by licensed professionals such as registered nurses and physical therapists. This care is distinct from non-medical home care, which provides custodial assistance like housekeeping or companionship. This type of care is often short-term and intermittent, intended to help a patient recover, regain self-sufficiency, or manage a complex medical condition at home. Accessing these services always begins with a medical order from a qualified clinician.
Role of the Referring Clinician
A referral for home health services must originate from a physician or an authorized non-physician practitioner (NPP), such as a nurse practitioner or physician assistant. This initial order serves as the official request and certification that the services are medically necessary for the patient’s recovery or condition management. The clinician who signs the order is responsible for establishing and regularly reviewing the patient’s plan of care throughout the episode of service.
Documentation supporting the referral must include a description of the patient’s clinical condition and the specific skilled services required. Federal regulations mandate a face-to-face encounter between the patient and the referring clinician, or an allowed practitioner, within a specific timeframe around the start of care. This encounter must be documented and must directly relate to the primary reason the patient needs HHS, supporting the necessity of skilled care and the patient’s homebound status. This step ensures the physician has personally assessed the patient’s need for care in the home setting.
Meeting the Eligibility Requirements
After the initial order, the patient must meet specific clinical and situational criteria, most notably the dual requirements of needing skilled services and being certified as “homebound.” Skilled services require the expertise of a licensed professional to be carried out safely and effectively, such as complex wound care, intravenous therapy, or specialized physical therapy. If the patient only requires assistance with daily activities, such as bathing or meal preparation, without a corresponding need for skilled intervention, they do not qualify for home health services.
The patient must also be determined to be “homebound,” meaning leaving the home requires a considerable and taxing effort. The Centers for Medicare & Medicaid Services (CMS) defines this as a patient who needs the aid of supportive devices, special transportation, or another person to leave the home, or for whom leaving the home is medically inadvisable due to their condition. Brief, infrequent absences from the home for non-medical reasons, such as attending religious services or a family event, are generally permissible, provided the patient maintains a normal inability to leave home.
Coverage and Payment Confirmation
Once clinical eligibility is established, the referral moves into the financial phase, where the funding source must approve the claim. The vast majority of home health services are covered by Medicare Part A and/or Part B, which require the patient to meet all the eligibility criteria for the home health benefit. For Medicare, the home health agency must be Medicare-certified, and the services provided must be part-time or intermittent.
Medicaid and private insurance plans also cover home health, but their authorization requirements can vary significantly. Private insurers often require prior authorization before services begin, which involves submitting the physician’s order and clinical documentation for review and approval. Medicaid programs, which are state-run, have specific eligibility rules for low-income individuals, and coverage may be managed through a managed care organization or a direct fee-for-service model. The home health agency staff typically verifies coverage and informs the patient of any potential out-of-pocket costs before the start of care.
Agency Intake and Start of Care
The final step involves the home health agency’s internal intake process, transitioning the approved referral into active care delivery. The agency receives the physician’s order and the supporting documentation, then contacts the patient or family to schedule an initial home visit. This visit, which must occur promptly following the referral, is a comprehensive assessment known as the Start of Care.
During this initial visit, a qualified clinician, such as a registered nurse or physical therapist, completes the Outcome and Assessment Information Set (OASIS). The OASIS is a standardized patient assessment tool used to measure patient status, determine the appropriate payment level, and track quality outcomes. Based on this assessment and the physician’s order, the agency develops a formal, individualized plan of care. Services are then initiated according to this plan, marking the commencement of home health services.