Skilled Needs and Homebound Status: What You Need to Know

Wondering whether your home health care will be covered by insurance? Here’s a clue: Do you have a skilled need and are you homebound? “Skilled need” and “homebound” are two words that go hand-in-hand when an insurance company is considering home health care coverage. Many insurance companies follow Medicare guidelines when it comes to coverage for home care. For that reason, we have found that understanding Medicare’s definitions is a great help in understanding how the majority of insurance companies define certain terms.

What is a Skilled Need?

A skilled need refers to something that someone with a license is required to provide. For most purposes, this means a Registered Nurse or a Physical Therapist. Some examples of skilled needs include: 

• Intravenous or intramuscular injections and intravenous feeding 
• Wound care
• PEG tube care
• Medication management, administration and education
• Physical therapy, due to a fall or post-surgery rehab, for example 

Once a skilled need has been identified and approved, then services from a speech therapist, occupational therapist, social worker and home health aide can be provided. If you don’t have a skilled need, then most insurance companies, including Medicare, will not provide coverage for these services (occupational therapy, social work, or home health aide) on their own.

What is Homebound?

By Medicare’s guidelines, you are homebound if: 

1. You need the help of another person OR medical equipment to leave your home. This could include a wheelchair, walker, or crutches. 
2. Your doctor believes that your health or illness could get worse if you leave your home.
3. You typically cannot leave your home OR it’s difficult for you to leave your home (requires taxing effort)

The MedicareIntertactive.org site continues to further explain homebound status:

“Your doctor is the final say in whether you are homebound. Even if you are homebound, you can still leave your home for medical treatment, religious services, and/or to attend a licensed or accredited adult day care center without putting your homebound status at risk. Leaving home for short periods of time or for special non-medical events, such as a family reunion, funeral, or graduation, should also not affect your homebound status. You may also take occasional trips to the barber or beauty parlor.”

Home Care Visits: What to Expect

So you have the skilled need, the homebound status, and the doctor’s order for home care services. What can you expect next? At your first visit, the nurse or therapist will review your information, the doctor’s orders and the plan of care. They’ll review your medications, talk with you about your goals, and discuss the role of any family members who may be part of your care.  After these introductory steps have been completed, the visit will follow the protocol of a “normal visit”–a check of your blood pressure, temperature, heart rate and breathing and of course, the therapy or nursing care that has been prescribed. Education is also part of the visit, so you and/or your caregiver will be taught how to perform exercises, care for a wound, or how to control symptoms of your ailments.

All insurance policies limit the number of home care visits they will cover in a given year, so check with your insurance company for the specifics of your plan. When coverage ends or if the coverage provided isn’t enough, you may want to opt for out-of-pocket coverage. Silver Lining Home Healthcare is very uniquely positioned for any gaps in care that insurance doesn’t cover. As a skilled home health agency, Silver Lining Home Healthcare can provide care for patients who have skilled needs AND non-skilled needs, regardless of homebound status. Two companies can’t be billing insurance at the same time; since Silver Lining Home Healthcare focuses on private home care, we can actually be present in the home at the same time as an insurance-covered option. We can also continue care after discharge from another program, offering clients the comfort of familiar faces and uninterrupted care.

*Note: Silver Lining Home Healthcare provides private home care and charges a fee for our services. We are not affiliated with any government programs. We do not accept Medicare or Medicaid.

Resources: 

Home Health Basics – Medicare Interactive

The Homebound Requirement – Medicare Interactive 

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