MEDICARE (T-18)

MEDICAID (T-19)

Who is eligible for home care services?

Clients must be Medicare eligible. Medicare Part A required for 100% coverage

Clients must meet income requirements. Cards issued monthly.

What are the qualifying conditions for home care?

Clients must have a skilled and medically necessary need, be homebound, require skilled care on an intermittent basis and be under the care of a physician.

Clients must be homebound for skilled services. Non-skilled and private duty services do not require home-bound status.

What is meant by "homebound"?

A recipient is considered homebound if a considerable and taxing effort is required to leave home. If absences are infrequent and of short duration a recipient may still be considered homebound.

Same as Medicare, unless the services could not reasonably be obtained from another provider.

What types of services are covered?

Skilled professional services (i.e., skilled nursing; physical and speech therapies) required in order to qualify for occupational therapy, social worker or home health aide services. Skilled services can include "hands- on" care as well as assessment, observation and teaching. Medication set-up, when it is the only skilled need, is not covered. Services must be provided on an intermittent basis. Private duty services are not covered.

Skilled services covered as in Medicare. A recipient may qualify for personal care worker or home health aide services without being homebound and without a skilled need. In addition, services can be provided in certain instances up to 24 hours per day, 7 days a week, e.g., ventilator dependent clients with a prior authorization. Medical social worker and teaching (when it is the only skilled need) are not covered. Medication set-up is covered when there is no other alternative.

What are the limits to the provision of services?

Care is "physician-driven" and requires a doctor's order to initiate and recertify care every 60 days. Qualifying conditions must be met.

Each client has a "bank" of 30 home health visits (to include all types of services) and 50 hours of personal care worker services per calendar year. Any additional services and all private duty require prior authorization.

What about coverage for medical equipment?

Medical supplies and equipment are covered according to Medicare guidelines based on diagnosis and criteria. IV medications administered at home are generally not covered except for a few specific agents that are given as prolonged infusions.

Disposable, consumable, expandable or nondurable medically necessary supplies are covered if necessary to carry out the plan of care. Prior authorization is required for certain items. A co-payment may be required to be paid by the recipient based on the established Medicaid guideline fee schedule.

When is it appropriate for a client to receive hospice services?

Hospice is appropriate for clients who are no longer receiving active treatment for a life limiting illness. A physician must verify that the client has a life expectancy of no more than six months.

Same as Medicare

What if the client requires care before the next scheduled visit?

The Nurse Case Manager makes contact with physician for approval and follows up with a written physician order. A nurse is always on call at Horizon Home Care & Hospice, Inc.

Same as Medicare, and additional Medicaid stipulations. A nurse is always on call at Horizon Home Care & Hospice, Inc.