Role and Services
Home health agencies are a type of home care organization. These agencies provide nursing care and certain other health care services that an individual can have in their home for the treatment of an illness or injury. The term home health agency often indicates that a home care provider is Medicare certified.
Individuals requiring skilled home care services often receive their care from a Home Health Agency. Services provided by these agencies are highly supervised and controlled, because of strict regulatory requirements. While some Home Health Agencies limit their services to nursing and one or two other specialties, other agencies may deliver through:
- Social Workers,
- Homemakers and Home Care Aides (HCA's),
- Durable medical equipment and Supply Dealers, and
For cases in which an individual requires care from more than one specialist, Home Health Agencies coordinate a care giving team to administer services that are comprehensive and efficient. Personnel are assigned according to the needs of each patient. Home Health Agencies recruit and supervise their personnel; as a result, they assume liability for all care.
Licensing and Credentialing
All home health agencies in Virginia are licensed by the Virginia Department of Health. An agency may choose to be exempt from state licensure through certification in one of the four ways:
- The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) Certification;
- Community Health Accreditation Program (CHAP) Certification;
- Medicaid Personal Care Certification;
- Medicaid/Medicare Certification.
When trying to find a home health agency, ask for their license number. Be specific in asking for the license number issued by the Virginia Department of Health, and not the number for their license to operate a business.
If the agency is licensure exempt they should have a letter stating their exemption based on one of the four reasons listed above. Ask for a copy of their letter. A home health agency should provide the proper documents and information at your request. If you have any difficulty or feel uncertain about a particular agency, or would like to receive a referral to an home health agency in your area, contact The Office of Licensure and Certification (OLC), Virginia Department of Health, 9960 Mayland Drive, Richmond, Virginia 23233; Phone: (804) 367-2102; the complaint hotline: 1-800-955-1819; Fax: (804) 367-2149. The OLC inspects and licenses medical care facilities and services, certifies Managed Care Health Insurance Plans (MCHIPs), conducts Medicare/Medicaid surveys for federal certification, and investigates complaints. The complaint hotline is 1-800-955-1819.
Cost and CoverageSelf-pay
Home care services that fail to meet the criteria of third-party payers must be paid for "out of pocket" by the patient or other party. The patient and home care provider negotiate the fees.
Medicare (Original Plan)
In order to receive Medicare coverage for home health care services the following are necessary:
- The referring physician must authorize and periodically review the patient's plan of care,
- The patient must need intermittent (and not full time) skilled nursing care, or physical therapy ,or speech language pathology services,
- The patient must be homebound, and
- The agency caring for the patient must be Medicare-approved.
If all conditions are met, Medicare will cover part-time or intermittent skilled nursing care, part-time or intermittent home health aide services, physical and occupational therapy, speech language pathology services, medical social services, medical supplies (not drugs or biological), and durable medical equipment. You pay nothing for home health care services under Medicare. You may be responsible for paying 20% of the approved amount for durable medical equipment. For more information concerning Medicare coverage, call 1-800-Medicare (1-800-633-4227).
Medicare (Managed Care Plan)
Medicare managed care plans must provide the full range of Medicare-covered home health services available in a particular geographic area. It is very important to remember that if you have this care plan, your choice of home health agencies is limited to agencies that work with the managed care plan. Call your managed care plan if you have questions about the plan's home health care rules.
The Virginia Department of Medical Assistance Services (DMAS) administers Medicaid coverage for home health services. Home health services are covered by Medicaid when provided by an authorized Home Health Agency under a plan of treatment prescribed by your doctor up to a specified number of visits. The visits of a Nurse and a Home Health Aide are limited to 32 visits of each type annually. Any visits after 32 for Nurses must be pre-authorized. Visits by a Physical Therapist, Occupational Therapist, and Speech and Language Therapist have to be pre-authorized after 24 visits. There is a $3.00 co-payment per day of service.
Under Medicaid coverage, home health services must include part-time Nursing, HCA services, and medical supplies and equipment. At the state's option, Medicaid also may cover audiology; physical, occupational, and speech therapies; and medical social services. Hospice is a Medicaid-covered benefit in 38 states. The Medicaid hospice benefit covers the same range of services that Medicare does.
A Home Health Agency may offer Medicaid waivered services available to specific targeted populations that are not available to all Medicaid recipients. Ask the Home Health Agency to explain these waivered services, if any. Medicaid also has Medicare-related coverage that pays for some or all of Medicare's premiums and may also pay Medicare deductibles and coinsurance for certain people who are entitled to Medicare and have low income.
Veterans who are at least 50% disabled due to a service-related condition are eligible for home health care coverage provided by the Veterans Administration (VA). A physician must authorize these services, which must be delivered through the VA's network of hospital-based home care units. The VA does not cover non-medical services provided by HCAs.
Preventative Health and Health Services Block Grant (PHHS)
Depending on funding, each year states receive federal health services block grants for state-identified service needs. The government allocates these funds on the basis of the state's population and within a federal limit. Portions of the funding sometimes are directed into programs providing Home Care Aide and homemaker or chore worker services. For additional information on PHHS block grants, visit http://www.cdc.gov/nccdphp/blockgrant/
Some Community Organizations grant funds for home health and supportive care. Depending on an individual's eligibility and financial circumstances, these organizations may help pay for all or a portion of the needed services. Hospital Discharge Planners, Social Workers, local offices on aging, and non-profit organizations such as, the Alzheimer's Association. Some Alzheimer's Association chapters offer scholarships of up to $500 of respite services for those who have no other means of paying for this service.
Choosing a Home Health Agency
Here are some important questions to ask when choosing a Home Healthcare Agency:
- How are they regulated?
- Are they certified by Medicare?
- Are they licensed by the state or accredited by an accrediting agency?
- Does this agency give the services I need?
- Is this agency's staff on duty 24 hours a day, seven days a week?
- Does the agency publish a fee schedule?
- How long has the agency been serving the community?
- What will I be charged for services/supplies?
- How are emergencies handled?
- Can my family and I help decide my plan of care?
- Does the agency educate family members about the type of care being given?
- Who makes sure the home health care plan is being followed? Does the supervisor make regular visits to the home?
- Who can I call if I have questions or complaints?
- What happens if a Home Health Agency Staff person does not come when scheduled?
- Will the agency be in regular contact with my doctor?
- For additional information on home health care refer to LeBoeuf's Home Health Care Handbook: All you need to become a caregiver in your home (Eldercare Edition). This is a very helpful guide for navigating through the resources available in your community.
- It is important, when considering an agency, to check that they are qualified, certified, trustworthy and registered either with Medicare and/or the state. Registration serves two purposes: 1)Reimbursement, if covered by Medicare or Medicaid for services provided by the agency, and 2)Assurance that the person providing the service is appropriately trained.
- The Virginia Association of Home Care (VAHC) offers information to consumers about home health and other forms of home care. To request a free brochure or to find answers to your questions about home care call the VAHC at 804.285.8636 or 1.800.755.8636.
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