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What Role Do Primary Care Physicians Play in Medicare Home Health Care?
Date Updated: December 13, 2024
Written by:
Ashlee Shefer is a freelance copywriter, content writer, and digital marketer who specializes in senior care, mental health, health care, and other wellness-related topics. She has one year of experience writing both short- and long-form content related to senior resources, assisted living, nursing homes, and home care, including blog posts, research-based articles, resource guides, product reviews, facility blurbs, finances, and care costs.
Reviewed by:
Gene Altaffer has a Masters in Gerontology from the University of Southern California and has worked in many avenues along the continuum of long-term care, assisting thousands of clients and their families since 1995. He also sold long-term care insurance from numerous carriers while also assisting families with retirement planning. Gene helps seniors navigate their Medicare plans, ensuring they understand their benefits and options.
The role primary care physicians play in Medicare home health care involves verifying the patient's need for services and developing a care plan. Medicare only covers medically necessary part-time or intermittent home health care for homebound individuals. A primary care physician ensures their patient meets eligibility requirements and a Medicare-approved agency coordinates the appropriate services.
How Do Primary Care Physicians Determine Eligibility for Medicare Home Health Care?
Medicare home health care serves individuals recovering from an illness or injury. A primary care physician assesses the individual, ensuring their situation aligns with Medicare's eligibility requirements. These requirements state a person must be homebound, meaning:
- Due to their condition, they have trouble leaving home without help from another person or an assistive device, such as a walker, wheelchair or cane.
- A doctor recommends they stay home due to their condition.
- They can't leave home because it presents a major effort.
The physician must meet with their patient in person and order home health services from a Medicare-approved agency. Additionally, they verify that the individual needs part-time or intermittent skilled nursing care. Medicare doesn't cover full-time or 24-hour care or personal care when the patient doesn't need other services. Home care better serves those who don't need skilled nursing care.
Understanding a Primary Care Physician's Responsibilities in Coordinating Medicare Home Health Care
After a primary care physician deems home health care medically necessary, they develop an individualized care plan. This document informs home health agencies about what services, health care professionals and durable medical equipment the individual needs. Although the agency coordinates these services with providers, it maintains communication with the patient's physician throughout care.
If agency staff notices changes in a person's condition, they must report it to the physician to adjust the care plan. Only physicians can update the plan or order additional services. They also maintain communication with their patients to ensure continuous access to appropriate support, provide educational resources and offer assistance in navigating the health care system. Additionally, the physician must review care plans at least once every 60 days, confirming alignment with the patient's condition and current needs.