Home Health Care Services - Medical Necessity Criteria

Criteria for documenting medical necessity of home health care services, including the services of a home health aide

Contents:

When is someone considered homebound or confined to the home?
Medical necessity criteria for home health care
Is home health covered by Medicare?
What home health care is covered by Medicare?
What are the Medicare guidelines for home health?
Does insurance cover a home health aide?
Documentation to submit
Health plan criteria for home health and other references

When is someone considered homebound or confined to the home?

A person is considered homebound, or confined to the home, when he/she meets the following criteria:

The patient must have either:
- A need for any of the following because of illness or injury:
  - The assistance of another person to leave his/her place of residence
  - The aid of supportive devices such as canes, crutches, walkers, or wheelchairs
  - The use of special transportation
- A condition such that it is medically contraindicated for them to leave their home.
The patient must be unable to leave home under normal circumstances and it would take considerable and taxing effort for them to do so.

A person can still be considered homebound even if they, at times, do leave the home if such absences from home:

are either:
- infrequent or only for a relatively short duration, such as for a funeral, religious service, or graduation, or
- due to needed health care treatment, such as outpatient kidney dialysis, chemotherapy, or radiation therapy; and
do not indicate that the patient is able to obtain the requested home health care service outside rather than in the home.

Medical necessity criteria for home health care

Home health services are considered medically necessary when all of the following criteria are met:

The patient is considered homebound.
The service is prescribed by the patient’s attending physician, primary care physician, or other licensed health care provider practicing within the scope of license as part of a written plan of care.
The service can only be safely and effectively performed by qualified technical or professional health personnel.

Most health plans require that the patient’s treatment plan be reviewed regularly — usually once every 30 days — to assess if skilled interventions are still needed.

Home health services are considered NOT medically necessary in any of the following situations:

The services are:
- not clinically appropriate,
- custodial in nature, such as assistance with activities of daily living — like eating, bathing, dressing, and ambulating — when these are the only services needed by the patient,
- provided for the convenience or comfort of the patient or his/her family, or
- more costly than an alternative health service.
The patient’s treatment plan does not show a continued need for skilled intervention.
The goals in the patient’s plan of care have been achieved.

Is home health covered by Medicare?

Yes, eligible home health care services are covered by Medicare Part A and Part B.

What home health care is covered by Medicare?

Home health services covered by Medicare when medical necessity criteria are met include:

Part-time or intermittent skilled nursing care
Part-time or intermittent home health aide services
Physical therapy
Occupational therapy
Speech-language pathology services
Medical social services

Services that are NOT covered by Medicare include:

24-hour home care
Meals delivered to the home
The following services when they are the only care needed:
- Personal or custodial such as using the bathroom, bathing, or dressing
- Homemaker services such as laundry, cleaning, and shopping

What are the Medicare guidelines for home health?

The guidelines governing Medicare coverage of home health services can be found in the Medicare Benefit Policy Manual. The manual includes information such as when a person would be considered confined to the home, services may be covered under a home health plan of care, and what items and services are excluded from coverage.

Does insurance cover a home health aide?

Generally, the services of a home health aide may be considered medically necessary and covered by insurance when they are done together with, and in support of, skilled home health care services* provided by licensed professionals. Covered home health aide services include but are not limited to:

Assistance with:
- activities of daily living
- a prescribed exercise regimen
Health monitoring activities such as taking blood pressure
Changing dressings that are non-sterile and do not require a licensed nurse
Supervising intake of prescribed medications and/or special diets
Routine care of orthotic and prosthetic devices

* The intermittent skilled home health care services should be provided by licensed professionals such as:

a registered nurse
a physical therapist
an occupational therapist
a speech therapist

However, coverage and medical necessity criteria may vary between health insurance companies and individual health plans so be sure to check the patient’s benefit plan document.

Documentation to Submit

These are the things you can prepare documentation of in order to support your statement that home health care services are medically necessary. Submit only those that apply.

Documentation that the patient is confined to the home (see definition above)

Documentation that the home health service is prescribed as part of a written plan of care by the patient's attending physician, primary care physician, or other health care provider practicing within their scope of license

Documentation that the home health service is complex enough that it can only be safely and effectively provided by a home health professional

Documentation that the treatment plan will be reviewed at least once and the continued need for skilled intervention will be assessed every 30 days by the patient's attending physician, primary care physician, or other health care provider practicing within their scope of license

Documentation that the home health service is not more costly than an alternative health service

For home health aide:

Documentation that the services to be provided by the home health aide are being rendered in conjunction with intermittent skilled home health care services being provided by qualified professionals

Documentation that the services to be provided by the home health aide directly support skilled home health care services

Health plan criteria for home health and other references

Aetna Criteria for Home Health Aides
Anthem Blue Cross Criteria for Home Health
CGS Medicare Home Health Coverage Guidelines
Florida Medicaid Home Health Visit Services Coverage Policy
Harvard Pilgrim Health Care Medical Policy on Home Health Care
Indiana Health Coverage Programs on Home Health Services
LifeWise Health Plan of Oregon Utilization Management Guideline on Skilled Home Health Care Services
MassHealth Guidelines for Medical Necessity Determination for Home Health Services
Medicare.gov Coverage of Home Health Services
Medicare Benefit Policy Manual for Home Health Services
TRICARE Coverage of Home Health Care
Tufts Health Plan Medical Necessity Guidelines on Home Health Care Services
UnitedHealthcare Criteria for Home Health Care
University Health Alliance (UHA) Payment Policy on Home Health Care