People sometimes use the term home health as a general category of service, but under federal regulations, home health means one very specific type of provider. For consumers, knowing the difference can mean the difference between thousands of dollars in out-of-pocket expenses, or zero out-of-pocket expenses. Knowing can also make a big difference in how well tailored your medical services are for your particular situation. As a quick summary, home health is a skilled medical provider that sends nurses and therapists to the homes of patients. Most such agencies maintain Medicare certification, but not all. Let’s take a moment to explore the differences and see what cases home health fits best.
Defining Home Health
People often use the term home health in the general sense to refer to any healthcare provider that sends people, equipment, or supplies to a person’s home. Non-home health businesses that may get referred to generally as home health include hospice, home medical equipment providers, non-medical home care, companion care, home infusion pharmacies, etc. These businesses may even use the term home health in their company names.
However, the Code of Federal Regulations (CFR), Title 42, Section 484 provides a very specific definition of home health that excludes every type of provider we just named. To summarize those 22 pages of federal regulations, a home health agency is a provider that sends more than one type of clinician for intermittent home visits to homebound patients for the primary purpose of delivering skilled medical care such as teaching, medication administration, wound care, and rehabilitation.
Medicare Certified Home Health – Medicare Pays 100%
Most agencies fitting the federal definition of home health maintain Medicare certification, but not all. Traditional Medicare pays certified agencies 100% of allowable charges for all services delivered to qualified patients and even for the supplies used during visits. Patients have no co-pays. Medicare waives any deductibles. There are no out-of-pocket expenses to speak of when Medicare beneficiaries qualify for home health.
Case managers often use the term Medicare-certified home health to differentiate from home health as a general term. On the other hand, there are several home health agencies that conform to federal regulations without having Medicare certification. These agencies are not reimbursed directly by Medicare. They may be working up to Medicare certification, which can be a long process. Home health agencies without Medicare certification may work with private insurance, the VA, or Medicaid.
Key Components of Home Health
Here are the differentiating factors of home health agencies versus other types of providers who offer healthcare services at home.
Under federal regulations, a home health agency must employ at least two types of clinicians from a list of six.
- Registered nurses
- Physical therapists
- Occupational therapists
- Speech therapists
- Home health aides
- Medical social workers
Commonly a home health agency will have at least nurses, aides, and physical therapists available, because these are the clinicians most essential to the bulk of cases home health handles. Agencies may use other disciplines, but they will have at least two of these six.
Home health services defined this way are primarily for skilled medical care. Skilled care means the services require the training and licensure of a nurse or therapist. This will also mean that services must be ordered by and delivered under the general supervision of a doctor. Home health services tend to be triggered by some change in illness or injury status.
Medicare uses the skilled need criterion to differentiate home health from what it calls attendant services. Don’t put too fine a point on it, though. Home health agencies are allowed to offer home health aides to patients as long as the skilled need is valid.
When to Choose Home Health
Here are the situations in which home health will be a better choice than other health care providers offering home services.
- When being discharged from a hospital, skilled nursing facility, or inpatient rehab to home.
- When there is a need for rehabilitation such as physical therapy, but using a center or outpatient practice is not a good fit for the patient’s situation.
- When patients or their families are managing wound care at home.
- When there is a chronic disease that is flaring up or at risk of flaring up.
- When there is a risk of hospitalization or emergency department care that can be reduced through proactive care at home.
When Home Health is Not the Best Choice
- When patients qualify for hospice.
- When people need visits lasting longer than 30 minutes or more frequently than a few times per week.
- When people need services long-term. There are some situations where home health can be authorized to provide intermittent services long-term, but these are the minority.
- When patients need physical therapy but can travel to outpatient services without risk or unusual burden.
Exceptions to The Guidelines
The guidelines above will help families choose home health in the right situations, most of the time. There are a few more exceptions we should acknowledge.
Medicaid Home Health
Medicaid does not require homebound status like Medicare does. Medicaid only requires that the home be the best location for the prescribed treatments. The same agency that may require homebound status for a Medicare beneficiary may use a different set of considerations for a Medicaid beneficiary.
Multiple Licenses in One Agency
Home health agencies are not limited to one type of license. Some provide home health, hospice, non-medical home care, and/or private-duty nursing.
Some states, notably Florida, use the term home health specifically to license non-medical home care providers. This is the exact opposite of what federal regulations do. These types of discrepancies make it difficult to ask a business if it is a home health agency and know what the answer “yes” really means. This is where the term “Medicare-certified home health agency” becomes useful. Only agencies adhering to the federal definition of home health services achieve Medicare certification.
Nursing and Aide Agencies
There are a growing number of agencies that are not home health agencies under federal regulations but that legally provide both skilled nursing and non-medical home care. In Maryland, certain levels of “Residential Service Agencies” operate this way. This is a very useful combination for many situations. These agencies tend to focus on less acute, less complex cases. They fill an important gap in that they serve well in situations where the need is primarily for attendant care and/or when the need is long term. The nurses may perform basic wound care, medication management, disease teaching, etc. These agencies are less likely to provide full-fledged rehabilitation or post-acute care, but there is overlap in what these two agency types can do.
It’s helpful for consumers to know that home health actually refers to a very specific type of health care provider, not just a category of businesses. The home health agency is set up to be the ideal choice for intermittent, skilled medical care at home for patients who would be better off not traveling around. With nurses, therapists, and aides all making visits under a physician-supervised plan of care, home health can accomplish a number of care plans that are also delivered in hospitals and nursing facilities. Finally, for qualified patients, Medicare pays 100% of the costs related to home health care. It pays to know the difference.