Does Medicare Need Certifications for Home Health Care?

Yes, Medicare requires certifications for home health care. This documentation verifies the medical necessity of these services and meets Medicare's eligibility criteria. Understanding these requirements can help you or your loved one navigate the process of obtaining Medicare-covered home health care services.

Medicare requires a physician's certification to establish the medical necessity of home health care services. This process involves several components:

• Physician's Order: A physician must order home health care services, certifying the patient needs intermittent skilled nursing care, physical therapy, speech-language pathology services or continued occupational therapy.
• Face-to-Face Encounter: The physician or a qualified health care practitioner must have a face-to-face encounter with the patient within 90 days before starting home health care services or within 30 days following the start of care. This encounter ensures the physician personally evaluates the individual's condition.
• Homebound Status: The patient must remain homebound, meaning that leaving the house requires considerable and taxing effort or the assistance of another person.

As an important distinction, homebound doesn't mean the patient remains bedridden. Medicare permits occasional absences from home for individuals to receive medical treatments or short, infrequent trips for nonmedical reasons.

The certification process for Medicare home health care involves several key steps to ensure compliance with the established requirements.  In addition to a patient's medical records and a clinical note or discharge summary that certifies a face-to-face encounter has occurred, Medicare requires:

• Initial Assessment: A home health agency evaluates the patient's needs and coordinates with a physician to develop a plan of care.
• Plan of Care: An individual's physicians must approve and sign a detailed plan of care, which outlines the types of services needed, the frequency of those services and the duration of care.
• Ongoing Certification: For continued home health care services, the physician must regularly review and recertify the patient's plan of care and update Medicare on any changes in their condition. This certification must occur at least every 60 days. 

Certifications ensure an individual requires home health care services and that the services they receive effectively cover their specific needs. It also verifies that only eligible patients receive coverage for home health care, preventing the misuse of Medicare funds. Local Aging and Disability Resource Centers help connect seniors and their loved ones with trained benefits professionals who can guide them through the intricacies of Medicare benefits.

When arranging Medicare coverage for home health care, it's crucial to choose the right service provider. Medicare requires that covered services come from a program-certified home health care agency. This requirement ensures the quality of care an individual receives and minimizes the occurrence of Medicare fraud. A search tool can help you find home health agencies near you.