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Eligibility Criteria for Home Health Care

Service Limitations & Considerations:

Geographic Boundaries

Home health services are generally limited to Frederick County. For patients discharged directly from Frederick Health Hospital, services may be provided up to 5 miles outside the county line if staffing allows. Referrals beyond these boundaries may be declined. Service availability in outlying areas is subject to staffing and the ability to meet patient needs safely and in a timely manner.

Staffing Capacity

Referrals may be declined if the agency does not have adequate qualified staff available to provide safe, timely, and effective care without compromising services for existing patients.

Insurance and Authorization

Each referral is screened to confirm coverage criteria, including insurance verification and any required pre-authorization. Referrals may be declined if the agency is not in the patient’s insurance network or if authorization is denied by the payer.

Age Considerations

The agency does not routinely provide care for patients under the age of 18, and any referrals for patients <18 will be reviewed case by case prior to acceptance to assure we can safely and effectively meet the needs of the patient. Agency will require the parent or legal guardian to always be present during the visit. If this agreement cannot be assured, the Agency will decline the referral.

Psychiatric, Behavioral, and Substance Abuse Referrals

Agency does not provide psychiatric, behavioral health, or substance abuse services as the sole reason for services.

Caregiver Support Requirement

The agency cannot provide service to certain conditions, when their isn't a caregiver support within the home.

Ventilator-Dependent Care

The agency cannot accept patients who require ventilator support, unless the ventilator is being cared for by another provider.

Custodial and Extended Care

The agency does not provide custodial care, extended-hour care, or 24-hour services.

Visit Frequency and Daily Care

Capacity for daily wound care or infusion visits is extremely limited due to geography and staffing. When appropriate, the agency will teach a household caregiver to provide daily care or IV therapy.

Patient and Environmental Safety

If safety concerns arise during the referral process, the referral may be designated high risk. The agency may require additional measures, such as a second staff member or law enforcement accompaniment for visits. If these measures are declined by the patient or family, or the agency cannot support joint visits due to capacity constraints, the referral may not be accepted.

History of Non-Compliance and Behavioral Safety Risks

Patients with a documented history of non-compliance or behavioral concerns who have previously been discharged for causing safety risks to staff may be refused service. If discharge occurred due to a specific event involving safety concerns, the agency reserves the right to refuse future referrals for patients deemed not safe for staff.

Medicare Guidelines for Home Health Care

Medicare will pay for health care services provided in a patient’s residence only if all of these conditions are met:

  • Patient is eligible for Medicare benefits
  • Patient needs intermittent skilled nursing or physical therapy or occupational or speech therapy
  • Patient must meet homebound criteria (see definition below)

Homebound Status Defined

A homebound person is defined as one who requires considerable effort and assistance to leave home and needs care on an intermittent basis.

Patients may be considered homebound if absences from the home are:

  • Infrequent
  • For periods of relatively short duration, or
  • Attributable to the need to receive medical treatment including attendance at a psychosocial or medical day treatment program accredited, licensed or certified by the state

Patients with a psychiatric disease or condition may be considered homebound even if their physical ability is unimpaired, when certain conditions are met.

Generally a beneficiary will be considered to be homebound if he/she has a condition:

  • Due to an illness or injury which restricts the ability to leave home except with the aid of supportive devices (crutch, cane, wheelchair, walker) special transportation, or another person
  • That is such that leaving his/her home is medically contraindicated

Patient is under the care of a doctor who:

  • Determines the need for home care is medically necessary and medically reasonable
  • Sets up and periodically reviews a home health agency plan of care
  • The home health agency serving the patient is approved for payment by the Medicare program

When in doubt about homebound status, call our intake staff and they will be able to assist you!

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