Who Qualifies for Home Health Care Services?

By BEN ADEL | Special to the Palisadian-Post

Home health services are those which include medical care and treatments for seniors over 65 years of age, individuals with disabilities and other eligible recipients. Qualifying for home health care comes with certain requirements.

The most significant criteria include: individuals must be under the care of a doctor, a physician approved plan of care must in place and medical care needs at home cannot be around-the-clock, 24-hour care.

It’s important to realize that home health services are very different from home care services.

Home care involves the day-to-day, non-medical tasks needed by individuals who can no longer provide it themselves. Home care may include medical appointment assistance, senior transportation and personal care assistance like grocery shopping, bathing, meal preparation, medication reminders and other caregiving duties.

Home health services, in contrast, provide for specific doctor-prescribed medical needs, calling upon healthcare professionals to administer ongoing at-home medical care.

Since Home Health services are medical in nature, they may encompass a wide range of healthcare components. The most popular home health offerings include nursing care, licensed clinical social workers, physical therapy, occupational therapy, speech therapy and certified home health aides.

All of these services can be provided in the comfort of your home, a benefit that regularly contributes to faster recovery times following hospitalization.

The first step for a potential recipient to meet eligibility requirements is an evaluation of their physical health status. Since most home health services work in partnership with agencies who assign and oversee the healthcare providers coming to your home, it’s important to really understand their health status requirements. Most reputable companies, in order to become Medicare-certified agencies, follow specific Medicare criteria.

Medicare Home Health requirements include the following eligibility items:

The patient needs to be homebound.

The patient must be under a physician’s care.

The patient must require medical services and treatment.

The home environment must not only be safe, but care must be deemed easily deliverable at the location.

Medical equipment that remains in the home must have adequate care.

The care cannot be 24-hour care: daily, weekly and month time limits typically apply.

A plan for medical emergencies must exist.

A duplication of services cannot exist.

A thorough evaluation of medical status will help determine eligibility.

The most common ways to pay for home health services in the state of California include Medi-Cal, Medicare, long-term care insurance, private health insurance, VA benefits, private pay (out of pocket, or a combination of private pay and other above sources.

While payment can be collected for home health services via all of the above methods, Medicare continues to lead as the most popular plan to cover these financial obligations.

Medicare—a federal health insurance program—requires that individual recipients are homebound (sometimes called housebound). This means they cannot, or must have great difficulty with leaving their home, even for medical appointments.

“Original Medicare,” sometimes called “Traditional Medicare,” only covers medical services and will not cover non-medical items as provided under the umbrella of “home care.” Each service, like nursing care or physical therapy, must be doctor-prescribed.

California Health Advocates notes that in addition to other detailed requirements for Medicare eligibility, you must also be a citizen of the United States or have been a legal resident for at least five years.

In the state of California, the majority of home health services are provided by agencies. Agencies typically follow into two categories: licensed home health agencies and Medicare certified home health.

Licensed home health agencies are certified by the state of California, and often work with private insurance companies and LTC insurance policies. Many agencies may also be certified to accept Medicare or Medi-Cal.

If you’re going to take advantage of Medicare, the agency you partner with must be Medicare-certified. These agencies are also licensed by the state of California.

Luxe Homecare is a home health agency that is licensed and Medicare-certified in California to provide medical services for both categories: private health insurance and Medicare. To get your important questions about Home Health eligibility answered, reach out to our team today.

Ben Adel is founder of Luxe Homecare, a Pacific Palisades-based homecare agency offering services in Los Angeles, Orange County and Riverside. They offer round-the-clock support, including registered nurses (RN and LVN) and rehabilitation services. Contact the Luxe team at 310-459-3535 or visit luxehomecare.com.