Home health care refers to skilled, intermittent medical services and therapy provided within a patient’s place of residence. Securing coverage requires meeting specific medical and administrative criteria, which vary depending on the funding source. This care is distinct from non-medical home care, such as custodial or companion services, which provide personal assistance with daily living activities. Qualification hinges on establishing a clear medical need that is temporary or restorative in nature.
Defining Medical Necessity and Homebound Status
The two foundational requirements for accessing home health services, regardless of the payer, are medical necessity and homebound status. Medical necessity dictates that the services sought must require the specialized skills of a licensed nurse or a qualified therapist, such as a physical, speech, or occupational therapist. Services that can be safely and effectively performed by an untrained family member or a non-medical aide are generally not considered medically necessary. This medical need must also be reasonable and effective for treating an illness or injury, or preventing further decline.
The concept of “homebound status” is a fundamental requirement, especially for Medicare coverage. A person is considered homebound if they have a condition that makes leaving the home a considerable and taxing effort. Leaving the residence must require the aid of supportive devices, special transportation, or the assistance of another person. Absences from the home are permitted only if they are infrequent, short in duration, or related to receiving medical treatment, such as going to a physician’s office or a dialysis center.
Medicare’s Specific Eligibility Criteria
Medicare, the primary payer for many home health services, has the most rigid and standardized set of requirements. To qualify, a patient must be under the care of a physician or allowed practitioner, who establishes and regularly reviews a Plan of Care. This practitioner must certify that the patient meets the homebound definition and requires intermittent skilled nursing care, physical therapy, or speech-language pathology services.
The requirement for “intermittent” care means that the services must be short-term and non-continuous. Skilled nursing and home health aide services are generally limited to fewer than eight hours per day and 28 hours per week. The intent is to provide temporary care for recovery, not long-term, 24-hour custodial assistance.
An additional administrative requirement is the face-to-face encounter, which must occur no more than 90 days before or 30 days after the start of home health care. This in-person visit ensures the patient’s medical condition supports the need for services. Finally, the services must be provided by a home health agency certified by Medicare.
Qualification Through Medicaid and Private Insurance
Qualification criteria diverge when considering other payers like Medicaid and private insurance plans. Medicaid, a joint federal and state program, is designed for individuals with limited income and resources, meaning financial eligibility is tied to state-specific criteria. Unlike Medicare, many state Medicaid programs offer broader coverage for long-term personal care and supportive services, which may not require the strict “homebound status.”
Medicaid eligibility is frequently based on functional needs, where a high level of functional impairment or a need for assistance with activities of daily living (ADLs) can qualify a person for services. Individuals must contact their state’s Medicaid office to determine specific financial and functional requirements, as programs vary by state. For private insurance, qualification is governed entirely by the terms of the specific policy contract. Patients must contact their insurer directly to verify benefits, check for deductibles, and confirm the chosen home health agency is within the approved network.
The Home Health Certification Process
Once the medical need is established, the physician formally orders the home health services and signs the certification of eligibility. The home health agency then conducts a comprehensive assessment of the patient’s physical, functional, and cognitive status. This assessment is used to develop an individualized Plan of Care, which details the specific services, frequency, and duration of all necessary skilled care.
The initial certification establishes eligibility for a 60-day period of care. To continue receiving services beyond this initial period, the physician must complete a recertification, typically every 60 days, affirming the patient’s ongoing need for skilled care. The recertification process requires the physician to review the updated Plan of Care and confirm that the patient still meets the eligibility requirements, including the homebound status.