Key Takeaways
- Eligibility requirements for home health care coverage
- Answers to common questions about how to qualify for Home Health Care under Medicare, Medicaid, and VA programs.
- Practical guidance on how to initiate the qualification process for home health care.
What is Home Health Care?
Home health care refers to a range of medical and health-related services provided in an individual’s home to help manage illness, injury, or chronic conditions. This care supports patients by delivering medical services at home when leaving the house would be too challenging or burdensome due to their condition. Services may include wound care, physical therapy, occupational therapy, injections, and other types of skilled care.
Home Care vs. Home Health Care
Home care provides non-medical assistance, such as help with activities of daily living, including bathing, dressing, toileting, ambulating, feeding and transferring, while home health care includes skilled medical services such as nursing and therapy.
Who Qualifies for Home Health Care Services
To qualify for home health care coverage, individuals must meet specific requirements.
- Homebound Status
- Necessity of Therapy or Skilled Nursing Services
- Care is Provided by an Approved Home Health Agency
Homebound Status
Patients must be considered homebound, meaning they have difficulty leaving home without assistance from another person or medical equipment. A doctor may also deem a person homebound if he or she believes the individual’s condition will worsen as a result of needing to leave their home.
Necessity of Therapy or Skilled Nursing Services
A doctor must certify that the patient needs nursing or therapy services in their home, performed by or under the supervision of a skilled professional. Only temporary services are eligible. They must be predictable and finite–for a set period of time at predetermined intervals.
Care is Provided by an Approved Home Health Agency
Medicare, Medicaid, and VA programs require that services be provided by an approved home health agency, though in some cases, Medicaid funding will cover a family caregiver or friend to provide non-medical in-home care.
Common Qualifying Conditions
- Post-surgical recovery
- Stroke rehabilitation
- Severe mobility limitations
Learn more about home care eligibility
How to Qualify for Home Health Care Under Medicare
Medicare covers home health care under Part A and Part B if:
- A doctor certifies the need for home health care.
- Services are provided by a Medicare-approved home health agency.
- The patient is homebound and requires skilled nursing care.
How Long Will Medicare Pay for Home Health Care?
Medicare covers home health care for as long as the patient meets eligibility requirements, but services must be reviewed and recertified by a physician every 60 days. However, Medicare does not cover long-term, full-time home health care.
How to Qualify for Home Health Care Through Medicaid
Medicaid coverage varies by state but generally includes home health care and home care services for eligible low-income individuals. Patients may need to:
- Meet income and asset requirements.
- Require medical necessity certification.
- Apply for state-specific Medicaid home care programs or waivers.
How Long Will Medicaid Pay for Home Health Care?
Coverage duration depends on state-specific Medicaid programs and the patient's medical condition. Medicaid may cover long-term care if deemed necessary, but each state sets its own limits. Unlike Medicare, Medicaid will sometimes cover costs related to daily living activities if it allows a senior to remain in their own home rather than move into a Medicaid-approved assisted living facility or nursing home. In some cases, the care allowance can go toward paying a relative or friend for providing the care.
How to Qualify for VA Home Health Care Benefits
VA benefits provide home health care to eligible veterans through programs like:
- Homemaker and Home Health Aide Care – This is home care to assist with daily activities to help a veteran maintain independence in his or her home.
- Skilled Home Health Care Services – This program provides coverage for temporary skilled nursing or therapy needs.
- Home-Based Primary Care – Coverage for a primary care provider who comes to patients’ homes for medical appointments.
How to Apply
Senior Helpers of Orlando can assist veterans with the process of applying for VA benefits. Or veterans can contact their local VA office to connect with a social worker. Additional services may be available depending on the veteran’s level of disability and service-connected conditions.
How Long Will VA Pay for Home Health Care?
Coverage varies based on eligibility, medical needs, and VA funding. Some veterans may qualify for indefinite home health services, while others may have limitations.
Overcoming Common Challenges in Qualifying
- Denied coverage due to insufficient documentation – Ensure physician orders are clear and complete.
- Difficulty finding an approved provider – Contact local agencies certified by Medicare, Medicaid, or VA.
- Navigating insurance requirements – Work with a case manager or healthcare advocate.
- Understanding plan limitations – Verify coverage before beginning services.
Paying for Home Health Care: Key Options
- Medicare – Covers eligible services under strict criteria.
- Medicaid – Varies by state, often more comprehensive for long-term care.
- VA Benefits – Covers services for eligible veterans.
- Private Insurance Companies – Coverage varies by provider and policy.
- Out-of-Pocket Expenses – May be necessary for non-covered services.
- Long-Term Care Insurance – May cover extended care needs.
FAQs About Qualifying for Home Health Care
What is the most common diagnosis for home health care?
Common conditions include post-surgical recovery, chronic illness management, stroke rehabilitation, and mobility impairment.
What are the steps to appeal a denied claim?
Before you can successfully appeal a denied claim, it’s essential to understand why it was denied in the first place.
- Review the denial notice and reason.
- Submit additional documentation.
- File an appeal with Medicare, Medicaid, or private insurance.
- Seek assistance from an advocate if needed.
Does Medicare pay for a home assistant?
Medicare does not cover non-medical home assistants but may cover personal care services when provided as part of a home health care plan. However, some Medicare Advantage plans include limited benefits for non-medical home care.
Partnering with Senior Helpers for Home Health Care Services
Senior Helpers (www.seniorhelpers.com/fl/orlando) provides non-medical home care services that allow seniors to remain independent at home. But we also provide expert guidance on eligibility for home health care services such as therapy and nursing. Our trained professionals assist families in navigating the qualification process.
Schedule a free in-home care assessment today!