Who qualifies for home health care?

Medicare describes home health eligibility in a few short requirements (Medicare.gov home health services). Each one is checked during intake, and all of them must be met.

1. Under a doctor's care with a plan. A physician or allowed practitioner, such as a nurse practitioner, clinical nurse specialist or physician assistant, establishes and regularly reviews the plan of care.
2. A skilled need. The patient needs intermittent skilled nursing, physical therapy or speech-language pathology, or continuing occupational therapy.
3. Homebound status. Leaving home requires considerable and taxing effort, or is not medically advised.
4. A face-to-face encounter. The certifying practitioner documents a visit related to the main reason for home health, held within 90 days before or 30 days after the start of care.

Homebound does not mean bedbound. A patient can be homebound and still leave home for medical appointments, religious services, adult day care or occasional short trips such as a haircut or a family event. What matters is that leaving home takes considerable effort, for example needing a walker, wheelchair, special transportation or another person's help, or that the physician advises against leaving because of the patient's condition.

Example: a North Texas patient two weeks after hip replacement who uses a walker and needs a family member to drive and help her to the car is usually considered homebound. A patient who drives himself to the gym is not.

Skilled care is care that must be performed by, or under the supervision of, a licensed nurse or therapist to be safe and effective. Examples include wound care, teaching a new insulin routine, managing a complex medication list, post-surgical physical therapy and swallowing therapy after a stroke. Help with bathing or meals on its own is not a skilled need, although an aide can help with those tasks when a skilled service is also in place.

If a patient qualifies, Original Medicare pays for covered home health services in full: part-time skilled nursing, therapy, medical social services and home health aide visits. Durable medical equipment such as a walker is usually covered at 80% after the Part B deductible, leaving a 20% coinsurance (Medicare.gov). Medicare does not pay for 24-hour care at home, meal delivery, or homemaker and personal care services when those are the only services needed.

Medicare Advantage, Texas Medicaid and commercial plans set their own rules, such as prior authorization and network limits. Our intake team verifies coverage before care starts and tells you what we find.

Patients covered by Medicare have the right to choose a home health agency. When a hospital or physician recommends home health, you or your family can ask the case manager to send the referral to the agency you prefer. Hospitals are expected to respect patient preferences in discharge planning.

Every case is decided individually, but some situations commonly meet the requirements:

• After a joint replacement. A patient who uses a walker, needs help with stairs and needs physical therapy to regain strength and range of motion.
• After a hospital stay for heart failure or COPD. A patient who becomes short of breath walking short distances and needs nursing to monitor symptoms, weight and medications.
• A new or worsening wound. A patient with a surgical or pressure wound who needs skilled wound care and has trouble leaving home.
• After a stroke. A patient who needs physical, occupational or speech therapy and help from another person to leave home.

Situations that usually do not qualify on their own include needing only help with bathing or meals, or being able to leave home regularly without considerable effort. In those cases, home care or other community services may be a better fit.

If you think home health could help, it is reasonable to ask the doctor or the hospital case manager directly. Useful questions include:

• Does my loved one meet the requirements for home health?
• Which services would help: nursing, physical therapy, occupational therapy or speech therapy?
• Can the referral be sent to the agency we choose?
• Who should we call if we have questions after discharge?

You do not need to wait for a hospital stay. A primary care physician or specialist can order home health from the office when the requirements are met.

If you think you or a family member may qualify, talk with the physician or hospital case manager and ask for a home health referral. You can also call OceanCare and we will help coordinate with the physician's office. Please do not send health details through our website forms.