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Carnegie Healthcare
On October 28, 2020

Guide to Qualifying for Home Care Services

If caring for a loved one at home has become too much for you, then home health care services may be an alternate solution to consider. These services allow your loved one to continue living in the safety and comfort of their own home, while providing some relief to you and your family.

However, the cost of home care services is always a concern. This is when Medicare’s home health benefit comes in. For those requiring care, Medicare coverage can help reduce out-of-pocket costs, allowing you to get the best care possible for your loved one without worrying about finances. To help you easily navigate Medicare, here is a breakdown to see if your loved one qualifies for home health services:

1. Services that are eligible

Both Medicare Part A (hospital insurance) and Medicare Part B (medical insurance)—or sometimes both together—will cover these home health services:

  • Skilled nursing care that is part-time or "intermittent"
  • Physical therapy in the home
  • Occupational therapy in the home
  • Speech-language pathology services in the home
  • Medical social services, such as counseling
  • Part-time or intermittent home health aide service (personal hands-on care)

2. Services that are not eligible

There are certain services that are not eligible under the program. Medicare will not pay for:

  • Around-the-clock care at home
  • Meals delivered to the home
  • Routine homemaker services (such as cleaning, laundry, or shopping) – if this is the only type of care needed
  • Personal care (such as using the bathroom or dressing) – if this is the only type of care needed

In general, Medicare limits its coverage to medical and health care services. The individual must have identifiable medical needs, rather than a broad need for "care.”

3. A doctor's certification of eligibility for care

If your loved one’s needs are medical (as specified above), then he or she is potentially eligible. But what more is required? A doctor must confirm:

  • The services are needed;
  • The type of medical services needed; and
  • The reasons for requiring health care at home.

These three requirements are called "certification of eligibility," a crucial step in obtaining services. Let’s take a closer look at these requirements to understand what they mean.

The individual must be under a doctor's care and the services that are requested must be part of the doctor's treatment plan. This plan must also be reviewed regularly by the doctor (or other health care professional), and must include documentation that the individual has had a face-to-face doctor's visit regarding the need for home health care services within a specified time frame.

One piece of good news is that Medicare covers all services in the aftermath of an acute medical emergency such as hospitalization. Of course, your loved one still must establish the need for skilled health care services at home, but income does not impact eligibility for these home care services.

4. A little more detail on requirements

When you are considering the home health care services that are needed, there are a few more things to keep in mind. These are matters that will be handled by your doctor, as well as Carnegie Healthcare or another agency, but it helps to understand them:

  • The services that are eligible for Medicare coverage must prove to be "specific, safe, and effective" treatment for the condition in question.
  • The services must meet the test of being “reasonable” by these criteria:
    • The number of services rendered;
    • Frequency of services rendered; and
    • The time period of services rendered.
  • They must be services that only a qualified therapist can perform safely and effectively.
  • Your loved one’s medical condition must be expected to improve in a reasonable and predictable period of time.
  • A doctor must certify that your loved one is homebound.

Let's take a moment to look at the reasons for these rules and requirements. Medicare will already make reasonable expenditures to allow your relative to remain at home if, to do so, he or she requires part-time or "intermittent" skilled-nursing care. However, home health care is far more expensive than care in a long-term care facility, which is why there are limits set by Medicare.

It is also important to note that there is some leeway. For example, it is still acceptable if a "homebound" individual travels for medical treatment or for occasional non-medical reasons, such as attending religious services. For example, your loved one can continue to qualify if he or she attends adult day care.

5. The role of a Medicare-certified home health agency

So - how can your family start the process of establishing eligibility for these services, getting a doctor's certification, and getting a health care plan in place? Carnegie Healthcare is here to help guide you every step of the way.

We will accept your loved one’s Medicare benefits for complete home health care. Doctors and other medical care professionals will be there to help determine your eligibility, obtain the "certification of eligibility," and provide the care.

Carnegie Healthcare

At Carnegie Healthcare, we specialize in providing comprehensive care to individuals from all walks of life tailored to his/her unique needs. We can supplement your medical care needs that are covered by Medicare and aid by delivering a comprehensive package of services for your loved one, so they can live at home safely and comfortably. If you're looking for home health care services for a loved one in New Jersey, or need guidance to see if they qualify for home care, please contact us today for a free consultation.


Published by Carnegie Healthcare October 28, 2020
Carnegie Healthcare