Home health care (HHC) is a specific medical benefit providing skilled, intermittent services to patients in their own residences. This type of care is distinct from non-medical custodial care, which involves assistance with daily activities like bathing or dressing without a medical need. Qualification requires meeting two criteria: medical necessity determined by a physician, and financial eligibility based on the payer source, such as Medicare or Texas Medicaid.
Establishing the Core Medical Criteria
Patients must meet fundamental medical requirements regardless of the payer source. The initial requirement is physician certification stating the patient needs skilled care. This certification initiates the official Plan of Care (POC), which the doctor must sign and review periodically.
A core criterion is the need for “skilled care,” meaning services require a licensed professional, such as a Registered Nurse (RN) or Physical Therapist (PT). Examples include administering intravenous medications, performing wound care, or providing complex physical rehabilitation. If the only service needed is personal care, the patient does not qualify for HHC.
The third requirement is “homebound status,” meaning leaving the home demands a considerable and taxing effort. A patient is considered homebound if they require supportive devices, such as a walker or wheelchair, or the assistance of another person to leave the residence. Absences must be infrequent and short, generally limited to medical appointments, religious services, or adult day care.
Qualification Requirements for Medicare Coverage
The federal Medicare program covers limited home health services for eligible beneficiaries who meet the core medical requirements. To qualify, a patient must be enrolled in Medicare, typically available to individuals aged 65 or older or those with certain disabilities. The care must be medically reasonable and necessary to treat an illness or injury.
Medicare coverage is designed for short-term, acute needs, such as recovery following a hospital stay, rather than long-term maintenance. The care must be “intermittent,” meaning it is not continuous, 24-hour care. Intermittent care is defined as skilled nursing provided fewer than seven days per week or less than eight hours per day for up to 21 days.
The services covered must be skilled. These include intermittent skilled nursing, physical therapy, speech-language pathology, and occupational therapy. Home health aide services for personal care are only covered if the patient is also receiving one of the skilled services. Medicare does not cover 24-hour care, meals delivered to the home, or non-medical homemaker services.
Qualification Requirements for Texas Medicaid Programs
For Texans seeking long-term home-based care, eligibility is determined through Medicaid programs overseen by the Texas Health and Human Services Commission (HHSC). Unlike Medicare, Texas Medicaid is designed to cover maintenance and long-term services, but it imposes strict financial and functional eligibility criteria. Applicants must first meet financial requirements, generally involving limited income and assets.
For long-term services provided through Medicaid waivers, the income limit for a single applicant is typically capped (e.g., $2,829 per month in 2024), with countable assets limited to $2,000. Applicants whose income exceeds this cap may still qualify by establishing a Qualified Income Trust, or Miller Trust, to redirect excess income. The financial criteria for standard State Plan Medicaid are lower, often limited to the Supplemental Security Income (SSI) rate.
Functional necessity is also evaluated, requiring the patient to meet the criteria for a Nursing Facility Level of Care (NFLOC), meaning the individual needs the level of care provided in a nursing home. The STAR+PLUS Home and Community-Based Services (HCBS) program is the primary Texas Medicaid managed care option for adults aged 21 or older with disabilities or those 65 or older who meet this NFLOC requirement. STAR+PLUS delivers comprehensive health care and long-term services through a managed care organization (MCO).
The Community First Choice (CFC) program is a state plan option that provides personal assistance, habilitation, and emergency response services to Medicaid-eligible individuals needing help with Activities of Daily Living (ADLs). Unlike the STAR+PLUS HCBS waiver, CFC is an entitlement, meaning there is no interest list or waiting period for those who meet the Medicaid and functional requirements. CFC services offer non-skilled support, often in conjunction with other Medicaid programs, to help individuals live independently.
Initiating Services: Referral and Assessment
The process begins with a physician referral once the patient meets the financial and medical criteria. The doctor must issue an order for home health services and complete Face-to-Face encounter documentation related to the need for care. This referral is then sent to a Medicare-certified Home Health Agency (HHA) chosen by the patient.
The HHA initiates the process by conducting a comprehensive in-home assessment, often within 48 hours of receiving the referral. A registered nurse or therapist performs this initial assessment, which includes the standardized Outcome and Assessment Information Set (OASIS) data collection tool. OASIS evaluates the patient’s clinical condition, functional status, and overall care needs, which also determines the agency’s Medicare payment.
The HHA then collaborates with the physician to finalize the individualized Plan of Care (POC), outlining the specific skilled services, their frequency, and the goals for the patient’s recovery or maintenance. The physician must sign this POC before the agency can bill for the services. Once the POC is certified, the home health services begin, with the agency continuously monitoring the patient’s progress and coordinating care with the physician.