Patients and families are choosing the option of home care more frequently – and thanks to an aging population, the increasing prevalence of chronic disease and increasing hospital costs, home health care is the fastest-growing expense in the Medicare program. So how does it work; who qualifies; and what services are covered by the US Original Medicare Plan?

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Who is eligible and what are the Medicare regulations and services?

Many health care treatments that used to be done only in a hospital can now be done in your home. Health care given in the home is usually less expensive, more convenient, and just as effective as care you get in a hospital or skilled nursing facility. If you are eligible, Medicare pays for you to get certain health care services in your home. This is known as the Medicare home health benefit.

Home health care is the fastest-growing expense in the Medicare program because of the aging population, the increasing prevalence of chronic disease and increasing hospital costs. Patients and families are choosing the option of home care more frequently. Medicare's regulations are often considered the standard of care for all home health agency interactions, even when a patient does not have Medicare insurance. These regulations require patients who receive home health care services to be under the care of a physician and to be homebound. The patient must have a documented need for skilled nursing care or physical, occupational or speech therapy. The care must be part time (28 hours or less per week, 8 hours or less per day) and occur at least every 60 days except in special cases. A detailed referral and specific care plan maximize the care to the patient and the reimbursement received by the physician.

Exactly how much has this industry grown? According to the Bureau of Economic Analysis, from 2000 to 2007, the broadly defined Home Health Care Services ranked 41st among the 491 industries that make up the NAICS. Amazingly, since the beginning of 2008 it has moved up that chart and to be in the top 15, with the likes of information services and petroleum refineries.

Home health care is a formal, regulated program of care delivered by a variety of health care professionals in the patient's home. It is also a Medicare benefit, provided certain requirements are met. For many reasons, the need for home health care has grown rapidly in the past decade, with the number of patients receiving Medicare-sponsored home care and the number of agencies delivering that care increasing at rapid rates – coupled with a significant growth in home hospice care.

Medicare's regulations are frequently considered the "standard of care" for all home health agency (HHA) interactions. The Medicare criteria for home health care entitlement are:

• Patient is under the care of a physician.
• Patient requires skilled nursing, occupational therapy, physical therapy or speech therapy on an intermittent basis.
• Patient qualifies for Medicare.
• Care is medically reasonable and necessary.
• Patient is homebound.
• Patient's needs can be met on an intermittent or part-time basis.
• Patient resides in a home or facility that does not perform skilled care (eg. not in a nursing home or hospital).
• A plan of care is rendered under the guidance of a physician.

A patient must be homebound to receive HHA services. "Homebound" implies that the patient is unable to leave home or that leaving home requires a considerable and taxing effort. Patients may be considered homebound if absences from the residence are infrequent, are of relatively short duration or are for the purpose of receiving medical treatment (eg. medical appointments or trips to a medical-model adult day care agency). Attending ceremonies of a religious nature does not generally disqualify a patient from being considered homebound. A patient who is unable to leave home without the help of assistive devices such as canes or walkers or who has a mental illness that may preclude leaving the home would also be considered homebound.

A home health care patient also must have a "reasonable and necessary" need for skilled care from a nurse, therapist (physical or occupational), speech/language pathologist or social worker. Intravenous therapy and wound care are considered skilled needs, as well as monitoring for pain control or "teaching and training activities which require skilled nursing personnel to teach (the patient) or caregivers how to manage the treatment regimen." Medicare covers occupational or physical therapy or speech/language pathology assessment and treatment when ordered after an acute episode of illness or a surgery. A therapist may perform the initial assessment, and a nurse need not be involved. A home safety evaluation for patients who are physically challenged is a potentially significant and useful skilled need assessment that is often overlooked.

There are no statutory or regulatory limits to the length of time for which coverage is available. Home care must be "part time," defined as no more than 28 hours per week or 8 hours in any given day. In some cases, this definition may be extended to 35 hours a week, but only with Medicare fiscal intermediary review and acceptance.

Care is to be "intermittent," occurring at least every 60 days, although less frequent medical indications (such as a catheter change every 90 days) will usually qualify. Skilled care that is given less than 4 days per week may be ordered for an unspecified time period. When skilled care is needed more than 4 days per week, the home health care nurse must specify a projected end point. There are, however, state-by-state exceptions that are related to state budget funding for homebound patients. Local home health care agencies should be able to provide this specific information.

We ask Medicare – who can get Medicare-covered home health care, and what services does Medicare cover?

If you have Medicare, home health care services are covered if you meet all the following conditions:

1. Your doctor must decide that you need medical care at home, and make a plan for your care at home.
2. You must need intermittent skilled nursing care, physical therapy, speech-language therapy, or to continue occupational therapy. 
3. The home health agency caring for you must be approved by the Medicare program (Medicare-certified).
4. You must be homebound, or normally unable to leave home without help. To be homebound means that leaving home takes considerable and taxing effort. You can be homebound and still leave home for medical treatment or short, infrequent absences for non-medical reasons, such as trips to a barber or church. A need for adult day care doesn't keep you from getting home health care.

If you meet all four of the conditions above, Medicare will cover the following types of home health care:

Skilled nursing care on a part-time or intermittent basis. Skilled nursing care includes services and care that can only be performed safely and correctly by a licensed nurse (either a registered nurse or a licensed practical nurse).

Home health aide services on a part-time or intermittent basis. A home health aide doesn't have a nursing license, but supports the nurse by providing services such as help with bathing, using the bathroom, dressing, or other personal care. These types of services don't need the skills of a licensed nurse. Medicare doesn't cover home health aide services unless you are also getting skilled care such as nursing care or other therapy. The home health aide services must be part of the home care for your illness or injury.

Physical therapy, speech-language therapy, and occupational therapy for as long as your doctor says you need it.

• Physical therapy includes exercise to regain movement and strength in a body area, and training on how to use special equipment or do daily activities, like how to get in and out of a wheelchair or bathtub. 
• Speech-language therapy (pathology services) includes exercise to regain and strengthen speech skills.
• Occupational therapy includes exercise to help you do usual daily activities by yourself. You might learn new ways to eat, put on clothes, comb your hair, and perform other usual daily activities. You may continue to receive occupational therapy if ordered by your doctor even if you no longer need other skilled care.

Medical social services to help you with social and emotional concerns related to your illness. This might include counseling or help in finding resources in your community.

Certain medical supplies, like wound dressings (but not prescription drugs or biologicals).

Durable medical equipment, such as a wheelchair or walker.

Food and Drug Administration (FDA)-approved injectable osteoporosis drugs in certain circumstances.

Currently, Medicare does not cover (does not pay) for any of the following:

• 24-hour-a-day care at home;
• Meals delivered to your home;
• Homemaker services like shopping, cleaning, and laundry; and
• Personal care given by home health aides like bathing, dressing, and using the bathroom when this is the only care you need.

Most of the time, your doctor, a social worker, or a hospital discharge planner will help arrange for Medicare-covered home health care. However, you have a say in which home health care agency you use.