Stringent Medicare Home Health Care Requirements

Many health care treatments that were once offered in an outpatient medical environment can now be done in your home. In general, the goal of home health care is to provide short term treatment for an illness or injury. Medicare pays for you to get certain health care services in your home if you meet specific eligibility criteria. The services must be considered reasonable and necessary for the treatment of your illness or injury. This is known as the Medicare home health benefit. If you get your Medicare benefits through a Medicare health management plan (not original Medicare) check your plan’s membership materials, and contact the plan for details about how the plan provides your Medicare covered home health benefits.

If you are covered by Medicare, you can use your home health benefits provided you are under the care of a doctor, and the services and plan of care established are reviewed regularly by a doctor. The need for intermittent skilled nursing care, physical therapy, speech-language pathology services, or continued occupational therapy must exist and be certified as necessary by your doctor.

The home health agency must be Medicare-certified. You must be “homebound,” and a doctor must certify you as such. You are considered homebound if (i) leaving your home is not recommended because of your condition, (ii) you cannot leave your home without help (such as using a wheelchair or walker, needing special transportation, or getting help from another person), and (iii) leaving home requires a considerable and taxing effort. However, a person classified as homebound may leave home for medical treatment or short, infrequent absences for non-medical reasons, such as attending religious services.

The Affordable Care Act of 2010 was enacted on March 23, 2010 establishing the requirement for a face-to-face interview by the ordering physician prior to providing home health services. The purpose of the Act is to reduce fraud, waste and abuse after the Center for Medicare and Medicaid Services (CMS) expressed concern over the significant variation in services provided to beneficiaries.

A face to face interview has to occur no more than 90 days prior to the home health care start date or within 30 days of the start of the home health care plan. The face to face interview may be performed by the treating physician, nurse practitioner, clinical nurse specialist or physicians assistant. The certification must include an explanation as to why the doctor’s findings support the need for home health care, including the patient’s home-bound status and the need for either intermittent skilled nursing services or therapy services.

Re-certification of the need for home health care must be provided at least every 60 days and must be signed and dated by the physician who reviewed the plan of care.

What all of this means is that the requirements are more stringent in cases where individuals require home health care and want the care to be covered by Medicare. It is important to seek the proper advice when considering the need for Medicare home health benefits.

1 Comment

  1. Bee Well Home Health Care

    July 24, 2015 at 7:30 am

    Many thanks for revealing about home health care, really helps a lot.

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