Frequently Asked Questions about Home Health Eligibility
Qualifying for Home and Community Based Services
Qualifying for Hospice Services
Frequently Asked Questions About Home Health Services
While the conditions outlined in this Q&A pertain specifically to Medicare, they can be used as a general guide to determining an individuals eligibility for home health care services under most insurance plans. In many instances, if the patient does not meet the Medicare conditions, home health services will likely not be covered by their insurance carrier. As in any case, however, all insurance companies have different requirements.
Q1. How do I obtain home health services. What is the procedure?
A1. To qualify for home health care coverage, you must have your doctor certify that you meet the following conditions:
1. You need medical care in your home.
2. The care you need includes intermittent (not full time) skilled nursing care, physical therapy, or speech language pathology services;
3. You are homebound; and
4. The Medicare program has approved (certified) the home health agency serving you.
The home health agency has the additional burden of assessing the patient status and environment of care. The information is then evaluated to determine the type of home health services that would best meet the your needs. The home health agency should then contact your doctor with these recommendations to assist him/her with the development of a Plan of Care.
Q3. When is an individual homebound?
A3. An individual does not have to be bedridden to be considered homebound. However, the condition of these patients should be such that there exists a normal inability to leave home and, consequently, leaving home would require a considerable and taxing effort.
Generally speaking, patients are considered homebound if they have a condition (due to an illness or injury) that restricts their ability to leave their place of residence, except with the aid of a supportive device such as crutches, canes, wheelchairs, and walkers, the use of special transportation, the assistance of another person or if leaving home is medically contraindicated. In most circumstances, if a patient drives, they would not be considered homebound.
Please note that the homebound criteria are not met when: (1) frequent absences from the home are for social reasons, for shopping or business purposes; or (2) the patient attends adult day care for non-medical reasons.
Q4. What are some examples of homebound patients?
A4. Some examples of homebound patients that illustrate the factors used to determine whether a homebound condition exists include:
1. A patient recently paralyzed from a stroke who is confined to a wheelchair or requires the aid of crutches in order to walk;
2. A patient who is blind or senile and requires the assistance of another person to leave his/her residence;
3. A patient who has lost the use of their upper extremities and, therefore, is unable to open doors, use handrails on stairways, etc., and requires the assistance of another individual to leave their residence;
4. A patient who has just returned from a hospital stay involving surgery suffering from resultant weakness and pain and, therefore, their actions may be restricted by their physician to certain specified and limited activities such as getting out of bed only for a specified period of time, walking stairs only once a day, etc.;
5. A patient with arteriosclerotic heart disease of such severity that they must avoid all stress and physical activity; and
6. A patient with a psychiatric problem if the illness is manifested in part by a refusal to leave home or is of such a nature that it would not be considered safe to leave home unattended, even if they have no physical limitations.
Q5. What if the patient is able to leave the home?
A5. If the patient does in fact leave the home, the patient may still be considered homebound if the absences from the home are infrequent or for periods of relatively short duration, or are attributable to the need to receive medical treatment. Occasional absences from the home for non-medical purposes, e.g., an occasional trip to the barber, a walk around the block or a drive, would not necessitate a finding that the patient is not homebound if the absences are undertaken on an infrequent basis or are of relatively short duration and do not indicate that the patient has the capacity to obtain health care outside the home.
Q6. What is considered the patient's place of residence?
A6. A patient's residence is wherever the makes their home. This may be their own dwelling, an apartment, a relative's home, a home for the aged, or some other type of institution. However, a hospital, skilled nursing facility (SNF), or intermediate care facility (ICF) are not considered the patient's home.
Q7. What about elderly or feeble patients who are afraid to leave the home?
A7. The aged person who does not often travel from home because of feebleness and insecurity brought on by advanced age would not be considered confined to the home for purposes of receiving home health services unless they meet the conditions outlined in Question #1 above.
Q8. Who makes the homebound determination?
A8. Determinations concerning medical necessity or homebound status are the responsibility of the medical professionals treating the patient. The home health agency can assist the medical professional in making eligibility determinations and in understanding the standards governing home health coverage criteria in order to ensure that the claims meet all legal requirements. The home health agency is accountable for the appropriate and timely submission of claims. Inappropriate claims could result in de-certification of the home health agency.
Q9. What should I do qualify for home health care coverage?
A9. The ultimate responsibility still remains with the physician who has certified and signed the patient's plan of care. Most home health agencies have quality processes in place to monitor the appropriateness of care.
Q10. I heard that the government is planning to change the Medicare definition of the term "homebound." What is the status of this proposed change?
A10. In a report issued on April 29, 1999, the Department of Health and Human Services has recommended to Congress that no changes be made to the current definition of "homebound. HHS has concluded that, until additional information is available to more accurately determine home health eligibility, the current definition should remain in place.
Qualifying for Home and Community Based Services
Home and Community Based Services (HCBS) is a Medicaid program that pays for help in the home, adult day care, and assisted living, and respite care. It serves elderly and blind or disabled individuals who require Long-term care services. The intent is to serve this population in a home or appropriate community setting that is more cost effective than a nursing home. The individual must have the same medical level of need as one who requires nursing home care.
Services are arranged by the Single Entry Point (SEP) agency that assigns a case manager to coordinate and monitor services. HCBS does not provide 24-hour help. The cost of all combined services must be less than Medicaid’s payment for nursing home care. There is a yearly cap on the amount the state spends on an individual, usually a third of comparable nursing home costs.
SERVICES AVAILABLE UNDER HCBS
Once accepted for HCBS, the following services are paid for by Medicaid to the extent they are part of the individual’s care plan:
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Home health care as defined under the Medicaid Home Health Program, including services of medical personnel if needed. |
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Personal care services such as hands-on assistance with activities of daily living (ADLs). This includes help with bathing, dressing, shampooing hair, ambulating, transfers, medication reminders, etc. |
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Homemaker services, such as light housecleaning, meal preparation, laundry, grocery shopping, etc. |
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Adult Day Care, offering protective oversight in a structured environment including activities, meals, and medication administration. |
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Transportation to Adult Day services, grocery store, dental and vision appointments, support groups, and visits to a spouse in a nursing home. |
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Respite care in a Medicaid-certified protective setting, such as a nursing home or assisted living facility, when the primary caregiver in unavailable. Maximum 30 days benefit per calendar year. |
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Home modification such as a wheel chair ramp, widening doorways, bathroom grab bars, etc. |
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Electronic monitoring or Lifeline emergency response system hookup, to signal a provider agency in an emergency. |
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Prescription medications, not covered by Medicare. |
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Assisted Living in an Alternate Care Facility (ACF). This means it is a licensed Medicaid facility. |
NOTE: Assisted living costs are only covered by Medicaid if the individual is in a Medicaid licensed Alternate Care Facility (ACF). This may be a small personal board and care home or a larger assisted living facility. Individuals who live in a non-Medicaid assisted living facility, are not eligible for HCBS benefits. The individual must move to a Medicaid assisted living facility in order to make an application for Medicaid.
ELIGIBILITY REQUIREMENTS
Three requirements must be met for an individual to be eligible for Home and Community Based Services. The individual must be eligible in all three categories:
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Medical need for care |
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Income below a certain amount |
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Resources (savings, stocks, life insurance) below a certain amount |
An individual applying for HCBS must be a citizen of the United States either by birth or naturalization or a legal alien living in the United States prior to August 22, 1996. An applicant must be a resident of Utah. There is no length of state residency requirement. The individual can apply for Medicaid the first day in Utah, provided there is the intent to remain in Utah. The application process cannot begin before the individual arrives in Utah.
MEDICAL NEED
As for nursing home Medicaid, the Single Entry Point agency performs an assessment of the individual’s activities of daily living using the UTLC-100.2 assessment tool. This is used to determine that the individual qualifies for nursing home care, which also entitles him/her to HCBS services. The assessment may be done in the hospital, nursing home, or in the individual’s own home.
INCOME
The gross income of the applicant must be below $1,809 a month (2006). If the income is over this amount, an Income Trust must be set up. The rules for an Income Trust for an individual on HCBS are different than those for an individual on nursing home Medicaid. This is discussed under Income Trusts.
RESOURCES
The non-exempt resources of the applicant must be below $2,000. After July 1, 1999 a couple is allowed the same Community Spouse Resource Allowance (CSRA) as that for nursing home applicants. That figure for 2006 is $99,540.
WHERE TO APPLY
All applications for Home and Community Based Services are made through the Single Entry Point
If the individual is at home
an application for Home and Community Based Services is made through the Single Entry Point (SEP) agency in the county where the home is located.
If the individual is in the hospital
an application for Home and Community Based Services is made through the Single Entry Point agency in the county where the individual normally resides, although the hospital may be in a different county. Hospitalization does not cause an individual to lose his/her county of residence.
If the individual is in an assisted living facility
, having paid private pay until funds are depleted, the application is made in the county where the assisted living is located.
A listing of Single Entry Point agencies is found in Appendix V.
APPLICATION PROCESS
The application for Home and Community Based Services begins with the Single Entry Point Agency (SEP). The referral can be made to the SEP by a family member, social worker, hospital discharge planner, or anyone involved in the care of the applicant. Once the referral is made, the SEP will see that Part I and Part II of the application is sent to the applicant or the family.
The ULTC-100.2 is done at this time using information obtained from the applicant, family members, or hospital personnel. A family member should be present at this appointment to supplement any information about the applicant’s condition.
Once the applicant is approved by the SEP as needing nursing home level of care, Part II of the Medicaid application will be processed by the county Department of Human Services. An appointment may be set up with an eligibility technician at the county department for financial eligibility. The application process can take two to three months before approval. Services cannot begin until the application is approved.
Many assisted living facilities require 6 months to a year of private pay before they will accept a resident on Medicaid. In many cases it is prudent to find an assisted living facility that accepts Medicaid and pay private pay while funds are available to obtain a Medicaid bed when funds run out.
