Home Health Care Eligibility

In most cases, any individual that will need part-time or “intermittent” skilled care can avail of home health care services. Most insurance plans follow Medicare guidelines but there are a few that do not. It is important to contact our intake to check your insurance eligibility and benefits. Generally, those who are eligible must have the following requirements:

• You must be under the care of a doctor, and you must be getting services under a plan of care established and reviewed regularly by a doctor.

• All Medicare beneficiaries, and with insurance that follows Medicare guidelines, who meet all of these conditions are covered:

  • You must need, and a doctor must certify that you need, one or more of these:

    • Intermittent skilled nursing care (other than just drawing blood).
    • Physical therapy, speech-language pathology, or continued occupational therapy services. These services are covered only when the services are specific, safe, and an effective treatment for your condition. The amount, frequency and time period of the services needs to be reasonable, and they need to be complex or only qualified therapists can do them safely and effectively. To be eligible, either: 1) your condition must be expected to improve in a reasonable and generally predictable period of time, or 2) you need a skilled therapist to safely and effectively make a maintenance program for your condition, or 3) you need a skilled therapist to safely and effectively do maintenance therapy for your condition.
• The home health agency caring for you must be Medicare-certified.

• You must be homebound, and a doctor must certify that you’re homebound. To be homebound means:

  • You have trouble leaving your home without help (like using a cane, wheelchair, walker, or crutches; special transportation; or help from another person) because of an illness or injury.
  • Leaving your home isn’t recommended because of your condition, and you’re normally unable to leave your home because it’s a major effort.
  • You may leave home for medical treatment or short, infrequent absences for non-medical reasons, like attending religious services. You can still get home health care if you attend adult day care.

Again, it is important to check with our intake department as there are insurance carriers that do not follow Medicare guidelines and may provide home health coverage without the homebound status requirement (for instance, you can still work while receiving home health care services).