Medicare Guidelines for Home Health Orders Explained

Many patients who need home health care have Medicare insurance. However, agencies must follow specific Medicare guidelines for home health orders to receive approval and payment. Here’s what you need to know.

Understanding Medicare Guidelines 

The Medicare guidelines for home health agencies are specific. Only patients who meet certain criteria are eligible for select services. Maintaining your records can help you stay compliant with these requirements. 

Certification of Eligibility for Home Health Benefits

Before your patient can receive benefits, a physician must certify that home health is a necessary part of their health plan and order the services. The certification must occur via a face-to-face encounter 90 days before or within 30 days after the start of care. 

The physician or other allowed practitioner must certify that the patient:

  • Is housebound
  • Needs medically necessary intermittent skilled nursing care, or
  • Needs certain types of therapy

Medicare-Covered Home Health Services

Medicare covers specific services and a home health aide for qualifying patients. Your agency will receive payments for all eligible services provided to patients in 30 days. 

Medicare guidelines for home health are as follows:

  • Skilled nursing services for less than 8 hours per day or 28 hours per week
  • Medical social services to help patients find counseling or other community resources
  • Speech-language, occupational, or physical therapy to treat an illness or injury or maintain your health
  • Medical supplies for use at home
  • Certain durable medical equipment

Medicare only covers services certified as part of a care plan. For example, durable medical equipment is only eligible if it’s medically necessary and prescribed for use at home. The device must only be for someone who is sick or injured. 

While patients must be homebound, they are still eligible if they leave home for short, occasional nonmedical reasons, like religious services or other outings. Patients who attend adult day care are also eligible. 

Excluded Services

Some types of home health care aren’t eligible for Medicare coverage. As a general rule, non-skilled care isn’t covered, which means Medicare won’t pay for:

  • 24-hour home care
  • Personal care services, like bathing, toileting, dressing, or other daily living activities
  • Meal deliveries
  • Home health aide services not related to the care plan, like shopping, laundry, or cooking

Establishing a Plan of Care

Each patient receives a unique care plan based on their medical conditions, need for skilled care or therapy, and individual eligibility. You aren’t required to use any specific forms, but Medicare needs to see a plan that proves your patient needs home health care.

The plan should cover a variety of data points:

  • Diagnoses
  • Medications 
  • Mental, psychosocial, and cognitive status
  • Type of home health services and equipment required
  • Nutritional requirements
  • Functional limitations
  • Activities permitted
  • Need for therapy
  • Frequency and duration of visits required
  • Prognosis 
  • Medical records
  • Labs, imaging, vitals
  • Measurable goals and outcomes

Why Home Health Agencies Trust Our Solutions

Coordinating home health care across multiple patients and teams is complex. Our fully automated software solution streamlines communication between physicians, care teams, and patients. 

With WorldView, you can manage referrals, update records, and maintain documents for Medicare certification requirements. The result is better compliance management and better patient care. Save time and simplify your home healthcare with WorldView. Schedule a demo today. 

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