Medicare Criteria for Home Care: What does "Homebound" and "Skilled Need" mean?
Medicare requires that a patient be "homebound" and have aÂ "skilled need" to qualify under Medicare for home health nursing and therapy services. Here are some tips to help you decide if your patient meets Medicare requirements:
"Homebound" does NOT mean that a patient has to be "bed bound" to qualify. The patient is considered "homebound" under Medicare if the patient cannot leave home without "considerable and taxing effort".
Most patients have an injury or illness that makes it difficult to leave home; for example, if the patient:
- Requires the aid of supportive devices (wheelchair or walker)
- Requires the use of special transportation
- Needs the assistance of another person
- Has a condition that leaving the home is medically contraindicated
- Symptoms of the disease process (such as pain, SOB or confusion) worsen when leaving the home
The patient can leave home for medical treatment (such as chemotherapy or dialysis) or for receiving therapeutic and psychosocial treatment (such as through a certified adult day care program).
The patient cannot be disqualified from services if they leave home for a non-medical absence as long as the absence is "infrequent and short in duration". Some examples include attending a religious service, a trip to the barber, special family event or a walk around the block.
The patient must have a "skilled need" that requires the skills of a licensed nurse, speech therapist or physical therapist to perform.
- Once a skilled need is established, a secondary discipline such as medical social worker, home health aide or occupational therapist may be involved in providing patient services.
- Medicare will NOT pay for personal care services in the absence of a skilled need.
Our admission staff is trained in assisting referral sources to determine Medicare and other insurance requirements and is a resource to you.
For more information or to make a referral, please call 800-924-2273.
Download a printable version – HHS for Professionals – Medicare Homebound Criteria