Home health services are crucial in providing specialized medical care to homebound people. But, not everyone is eligible for these services, with criteria based on specific medical and situational factors. 

Understanding these eligibility criteria is essential when seeking the right level of care for yourself or your loved one. 

In this post, we’ll explain who qualifies for home health services, with additional useful information on the assessment process, insurance coverage options, and more.

Medical Eligibility Criteria

The No. 1 question most people have about home health care is whether they are eligible for it. Ultimately, this decision is down to a medical practitioner. But knowing the criteria you must meet to qualify is still useful.

Medicare lays out three main eligibility criteria:

  1. You Must Be Considered “Homebound.” Homebound means it’s difficult for you to leave home alone. If you do leave your home, assistive devices (e.g., a wheelchair or walker) and the help of another person are necessary. 
  2. You Require Intermittent Care by Skilled Nurses or Therapists. The type of care you require (i.e., complex wound management, IV therapy, medication management, etc.) must be performed by medically trained professionals. The required care must also be intermittent (occasional), not 24/7.
  3. Your Care Plan is Created and Supervised by a Doctor. A physician must sign off on an order for home health care. A doctor will need to evaluate your needs and decide on the type of care you require. They will also monitor the care as your condition changes.

Home health care can help those recovering from a serious illness or injury. It can also be used to manage ongoing chronic conditions, especially in older adults. To qualify for home health care with a chronic condition, services need to help maintain your ability to function or slow the worsening of your condition.

So, considering the above criteria, who qualifies for home health services?

Common medical conditions that qualify for home health care include:

  • Post-surgery recovery
  • Post-stroke recovery
  • Chronic heart failure
  • Recovery from a serious illness (e.g., pneumonia, infection, flu)
  • Chronic diseases (e.g., diabetes, COPD, arthritis, Parkinson’s, Alzheimer’s)
  • Recovery after a break or fracture

The Assessment Process

To qualify for home health care, you or your loved one must undergo a face-to-face assessment with a physician. 

A physician will conduct a thorough evaluation of your medical status. They will determine your home health care eligibility and the skilled medical services you need.

Once you’re referred to a home health provider, the agency will also conduct its own assessment. This assessment will help determine the level and frequency of care.

An agency assessment includes evaluating you or your loved one’s ability to perform activities of daily living. Does your condition prevent you from bathing or getting dressed safely without assistance? Do you need help around the house and with meal preparation while you recover?

The agency assessment helps determine if you’d benefit from personal and home care services on top of medical services. 

Types of Home Health Services

Home health care encompasses various services tailored to your unique needs. Three of the main services offered are skilled nursing care, therapy services, and home health aides.

1. Skilled Nursing Services

Skilled nursing refers to any medical services performed by or under the supervision of a licensed or certified nurse, including:

  • Wound care and dressing changes
  • Medication management and administration
  • Tube feedings and catheter changes
  • Condition observation and education

2. Skilled Therapy Services

Skilled therapy services are therapies performed by a licensed professional that help improve or prevent the worsening of your condition, including physical, occupational, or speech therapy.

3. Home Health Aide Services

A home health aide assists with non-medical personal care services that may be necessary due to your recovery or health condition, such as:

  • Bathing
  • Grooming
  • Toileting
  • Dressing
  • Mobility support
  • Meal preparation

Benefits of Home Health Services

Home health care helps adults live safely and comfortably in their homes, even when recovering from an injury or managing a chronic health condition. 

Key benefits of home health care are:

  • Comfort and Familiarity. When you’re not feeling your best, the familiarity of home can be extremely comforting. Comfort helps reduce stress or anxiety caused by your condition.
  • Improved Quality of Life and Independence. Home health care helps adults continue with their routines and everyday tasks in the safest way possible. Home care allows patients to retain their independence for as long as possible.
  • Personalized Care. Each patient receives a customized care plan and one-on-one care. This personalized care builds trust and increases effectiveness. 
  • Better Health Outcomes. Research has shown that patients who receive home health care after leaving the hospital recover faster with fewer complications.
  • Lower Risk of Hospital Readmission. Receiving specialized care at home reduces the likelihood of hospital readmission.  
  • Cost-Effectiveness Compared to Institutional Care. Intermittent skilled care is cheaper than full-time care in a nursing facility or care home.

Insurance Coverage and Payment Options

Typically, home health care is covered by Medicare, Medicaid, and most commercial insurance. Insurance may cover up to 100% of your care if you meet the eligibility criteria. 

Coverage through Medicare

To qualify for Medicare coverage, you must meet the three criteria outlined above: Being “homebound,” needing intermittent care by skilled professionals, and having a doctor’s order. 

You must also receive your care from a Medicare-certified home health agency like Providence Home Care.

Medicare covers skilled nursing care, therapies, and home health aides. Although, Medicare only covers personal care by home health aides if you also receive medical care. It does not cover this service on its own.

Coverage through Medicaid

You must meet the above medical criteria and additional financial and functional requirements to receive Medicaid coverage for home health services.

Each state has its own criteria on who qualifies for free or low-cost home health care. You should research your state’s requirements to see if you qualify.

In many states, Medicaid may also cover personal care assistance in the home, even when not receiving medical care.

Private Insurance Coverage

Many private insurance plans cover home health care to some degree. The amount and specific services covered depend on your individual plan. 

Some private insurers only cover specific types of care, like skilled nursing. Others may cover a wider range of services. In general, most private insurers don’t cover non-medical personal care alone.

Differences Between Home Health and Home Care

Distinguishing between home health and home care services is crucial when seeking the right support for yourself or your loved one. These two care types are often confused. Yet the services offered are significantly different. 

Home health care focuses on skilled medical services provided by licensed professionals, such as registered nurses or therapists. The care requires a doctor’s order and supervision.

Home care, on the other hand, focuses on assisting with activities of daily living. These activities include personal care such as bathing, grooming, dressing, meal preparation, and light housekeeping. Home care professionals also offer companionship and emotional support to homebound adults. 

Home care services are sometimes provided alongside home health care. For example, if you’re recovering from a serious injury and struggle using the toilet or bath alone. But most insurance providers don’t consider home care a vital health service and won’t cover it independently. 

Caregiver Support and Respite Services

Even when receiving home health services, caring for a loved one is hugely demanding, especially when recovering from an injury or managing an ongoing health condition. Fortunately, home health agencies also offer support for family caregivers. 

Home health aides offer relief and respite for family caregivers. Respite allows you to take some much-needed time to yourself while knowing your loved one is safe.

Trained professionals can also teach you the safest and most efficient ways to provide care for your loved one. They’ll show you how to use any assistive or medical equipment and teach you what to do in an emergency if they’re not there.

Home Health Care at Providence Home Care

Providence is a Medicare-licensed care agency offering home health services in the greater Oklahoma City area. Our passionate and highly-trained team of clinicians and caregivers can provide various healthcare services under physician and registered nurse supervision.

Our values include treating every person with dignity, respect, and compassion, operating with integrity, and serving our clients with excellence. So you can rest assured that your loved one will be in great hands, no matter what they’re going through.

Contact us today to learn more about how we can help.

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