If you have MEDICARE , you can use your home health benefits if you meet all the following conditions:
- You must be under the care of a doctor, and you must be getting services under a plan of care established and reviewed regularly by a doctor.
- You must need, and a doctor must certify that you need, one or more of the following.
- Intermittent skilled nursing care
- Physical therapy
- Speech-language pathology services
- Continued occupational therapy The home health agency caring for you must be approved by Medicare (Medicare-certified).
- You must be . Home bound, and a doctor must certify that you’re home bound. To be home bound means the following: Leaving your home isn’t recommended because of your condition.
- Your condition keeps you from leaving home without help (such as using a wheelchair or walker, needing special transportation, or getting help from another person)leaving home takes a considerable and taxing effort.
A person may leave home for medical treatment or short, infrequent absences for non-medical reasons, such as attending religious services. You can still get home health care if you attend adult day care, but you would get the home care services in your home.
What isn't covered
- 24-hour-a-day care at home.
- Meals delivered to your home.
- Homemaker services like shopping, cleaning, and laundry , and when these services aren’t related to your plan of care.
- Personal care given by home health aides like bathing, dressing, and using the bathroom.
MEDICAID : cover 24-hour-a-day care.
Individual must be:
- Self-directing or have someone able to direct
their care. 92 ADM-49 clarifies that the person directing care does not
need to reside with the consumer but must have "substantial daily
contact." http://onlineresources.wnylc.net/pb/docs/92_adm-49.pdf
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The patient’s condition must be stable, meaning
that it may be may be chronic and degenerative but is not expected to
exhibit sudden deterioration or improvement; AND does not require
skilled professional or frequent medical or nursing judgment to
determine changes to the plan of care. 18 NYCRR 505.14(a)(4)(i).
A common basis for denial of eligibility is that the consumer
allegedly needs a "higher level of care" than personal care. If the
two above criteria are met, and the consumer does not need the aide to
perform tasks beyond the personal care scope of tasks , then eligibility should be established --
