Home health care (HHC) provides skilled medical services delivered directly within a patient’s residence. These services are typically for individuals recovering from an illness, injury, or managing a chronic condition. Securing this specialized support involves establishing medical necessity, clarifying funding options, and selecting a qualified provider.
Defining Home Health Care Services
Home health care focuses on intermittent, medically necessary, and skilled care provided by licensed professionals. Services include skilled nursing for wound care, injections, or monitoring unstable health status. Other skilled services commonly covered are physical therapy, occupational therapy, and speech-language pathology to help patients regain function and independence.
A distinction must be made between skilled care and non-medical, custodial care. Custodial care focuses on assistance with activities of daily living (ADLs) like bathing, dressing, and meal preparation. While a home health aide may provide personal care linked to a skilled need, HHC programs generally do not cover non-medical, 24-hour support.
Establishing Medical Eligibility
Receiving home health care begins with establishing a medical need certified by a physician. The doctor must confirm the patient requires intermittent skilled services or therapy and establish a formal plan of care outlining the services and frequency. This plan must be reviewed and recertified by the physician every 60 days.
For coverage under programs like Medicare, a patient must also meet the “homebound” requirement. Being homebound means leaving the home requires a considerable and taxing effort, often needing supportive devices or another person. Patients are allowed to leave the home for medical treatments, religious services, and short, infrequent absences without jeopardizing their status.
Navigating Payment Options
Funding depends heavily on the specific payer and medical necessity. Medicare, the largest payer, covers HHC under both Part A and Part B for eligible beneficiaries. This coverage is limited to medically necessary, part-time skilled care and does not extend to long-term custodial services.
For services covered by Medicare, patients pay nothing for the home health services themselves, though a 20% coinsurance may apply to durable medical equipment. Medicare Part B covers home health services even without a prior hospital stay. Part A may cover care immediately following a qualifying hospital or skilled nursing facility stay. Medicare Advantage Plans must cover all Original Medicare services, but they may have different cost-sharing rules and network requirements.
Medicaid is another significant funding source, determined by individual state rules. Unlike Medicare, Medicaid often covers both skilled medical services and long-term, non-medical personal care for financially eligible individuals. Many states utilize Home and Community-Based Services (HCBS) waivers to provide comprehensive in-home support, including assistance with daily living activities.
For those who do not qualify for government programs, private insurance and out-of-pocket payment are the primary options. Private health insurance policies must be carefully reviewed, as coverage varies widely and often requires pre-authorization. Patients paying privately have the most flexibility in service selection and scheduling but involve direct payment for all care costs.
The Steps to Selecting a Provider
Once medical eligibility is confirmed and a payment source is identified, the final step is selecting a qualified home health agency. The Centers for Medicare & Medicaid Services (CMS) provides the Care Compare website, a resource allowing users to search for and evaluate Medicare-certified agencies. This tool provides quality ratings, including a star rating system summarizing an agency’s performance.
Before committing, conduct thorough due diligence by vetting the agency’s credentials and performance history. Review patient survey results, which indicate how patients rate their experience. Confirm that the chosen agency accepts the patient’s specific insurance or government funding source to prevent unexpected financial responsibility.