How to Qualify for Home Health Care: Everything You Need to Know

Key takeaways

• Home health care is designed for individuals recovering from an illness, injury, or surgery, those managing a chronic condition, or people needing consistent medical attention without the need for hospitalization.
• Qualifying for home health care requires a physician’s order certifying that the patient is homebound and in need of skilled care.
• Home health aides and personal care assistants can help with basic daily tasks like bathing, dressing, using the toilet, and meal planning and preparation, and may be included as part of a home health care strategy.

 

Many people assume that home health care is only available for seniors or those leaving the hospital after surgery or treatment. However, other people can qualify for home health care, including individuals with disabilities, chronic health conditions, some functional limitations, and those with fall risks. Qualification requirements will vary depending on the type of care being sought, and eligibility depends on your health needs, your physician’s recommendations, and your insurance or Medicaid requirements.

In this article we’re going to help clarify what is needed to qualify for home health care, and provide helpful resources and information to assist people in getting the help they need.

What Is Home Health Care?

Home health care refers to a wide range of medical and support services delivered directly in a patient’s home. It is designed for individuals recovering from an illness or surgery, managing a chronic condition, or needing consistent medical attention without the need for hospitalization, and may include:

• Skilled Nursing: Licensed registered nurses (RNs) deliver expert care such as administering medications, wound care, IV therapy, and monitoring chronic disease. They ensure accurate medical treatment and act as the first line of medical support at home.
• Therapy Services: Physical, occupational, or speech therapists help patients regain strength, improve mobility, and restore daily functions. 
• Medical Social Services: Medical social workers can assist with counseling, connect patients to community resources, and help families navigate the emotional and practical challenges associated with medical conditions or functional/mobility limitations.
• Personal Care Under Medical Plans: Home health aides and personal care assistants help with daily tasks like bathing, dressing, using the toilet, and meal planning and preparation. Working under medical supervision, they help patients maintain healthy hygiene, mobility, and dignity while providing essential support for overall patient well-being.
• Provider Coordination: Care teams coordinate with physicians, therapists, specialists, and family caregivers to ensure seamless communication and cohesive treatment plans, improving patient satisfaction and outcomes.

It’s important to understand the difference between home health care and non-medical home care in order to choose the right level of care for yourself or a loved one. While both support individuals at home, home health care is focused on providing medical treatment via licensed professionals such as nurses and therapists, while home care generally refers to non-medical assistance like help with meals, hygiene, companionship, and well-being. 

Who Qualifies for Home Health Care?

Let’s go over the general categories of people who can qualify for home health care. There may be other situations that qualify a person for home health care in certain locations or under specific conditions, but in general, the following are the main groups who can qualify.

Seniors Who Need Assistance at Home

We said above that seniors aren’t the only demographic that can qualify for home health care, but they are certainly the largest category. Around 85% of home health care patients are aged 65 or older. They may qualify for home health care due to age-related mobility limitations, chronic health conditions, or due to a risk of falling, in addition to other disabilities or medical conditions which we’ll discuss below.

Individuals With Disabilities

People with permanent physical disabilities, developmental disabilities, and long-term functional limitations can qualify. These may include spinal injury, traumatic brain injury (TBI), autism spectrum disorder (ASD), down syndrome, cerebral palsy, epilepsy, and intellectual disabilities.

People Recovering From Illness, Injury, or Surgery

Those with temporary physical disabilities due to injury or surgery, or those recovering from serious illness can qualify for home health care after they are discharged from the hospital. Home health care includes rehabilitation support, temporary care needs, and other physician-directed services during the recovery period.

Individuals With Chronic Medical Conditions

People with chronic medical conditions can qualify for home health care. These may include (but are not limited to):

• Cardiovascular diseases such as heart failure, coronary artery disease, and hypertension
• Parkinson’s disease
• Respiratory conditions like chronic obstructive pulmonary disease (COPD) and other progressive lung diseases
• Chronic kidney disease
• Cancer
• Multiple sclerosis
• Stroke 
• Dementia
• Alzheimer’s disease
• Muscular dystrophy
• Severe arthritis
• Spina bifida
• Diabetes (Type 1 or 2, especially for insulin administration and blood sugar monitoring)
• Non-healing wounds
• Other qualifying conditions

What Requirements Must Be Met to Qualify for Home Health Care?

Medical Need Assessment

The most important requirement that must be met to qualify for home health care is a physician’s order certifying that you are homebound and require skilled care due to functional limitations. Under Medicare, this requires a face-to-face evaluation/assessment within 90 days before or 30 days after the start of care. Under other health care plans, the requirements for a face-to-face doctor’s evaluation may differ, and you’ll need to check with your individual provider. 

The physician’s documentation will typically include specific orders, establish an ongoing treatment/care plan, and a doctor will periodically review the necessity of your home health services (typically at least once every 60 days, in the case of Medicare-provided home health care).

Evaluation of Ability to Perform Activities of Daily Living (ADLs)

ADLs or “activities of daily living” is the medical/social services term for the basic tasks you typically do every day that are essential to your physical survival and well-being. They’re sometimes called physical activities of daily living because they relate to your body’s needs. Common ADLs include:

• Bathing
• Dressing
• Grooming and hygiene
• Mobility (ability to move from bed or from room to room)
• Using the toilet and dealing with continence
• Meal preparation and eating

If you or your loved one has difficulty with one or more ADLs you may qualify for home health care or home health aide assistance, but you’ll need to discuss this with your care provider. Some providers such as Medicare will provide part-time or intermittent home health aide care to help with ADLs only if you’re also getting skilled nursing care, physical therapy, speech-language pathology services, or occupational therapy at the same time.

When and how often healthcare providers assess a person’s ability to perform ADLs depends on their medical history and current situation. In general, nurses or occupational therapists assess how well you can perform ADLs when you’re hospitalized, returning home from the hospital, recovering from an event such as surgery, injury, TBI, or stroke, or have a neurodegenerative disorder, intellectual disability, or mental health disorder.

Home Safety and Care Needs Evaluation

Either as part of or separately from the medical needs and ADL assessment, there will also need to be a home safety and care needs evaluation that will determine the extent of the subject’s needs at home, the hours of care provided, and any safety issues related to the physical or mental limitations. These will also need to be reviewed at regular intervals, which will be determined by the caregiver working in concert with the physician or social services organization.

How to Qualify for Home Health Care Through Medicaid

Medicaid Eligibility Requirements

Health/care requirements evaluation: To obtain home health care via Medicaid, you must be evaluated by a healthcare provider who certifies that you need one or more of the following: Intermittent (not continuous) skilled nursing care, physical or speech therapy, ongoing occupational therapy, and/or help with daily activities (e.g., bathing, dressing, medication management).

Additionally, if you don’t already have Medicaid, you must first apply through your local or state agency. A good way to find out how is to Google “How to apply for Medicaid in [your state].” That should take you to the appropriate resource. In New York, you can apply via the New York State of Health marketplace or your local social services office. Info is also available at the New York Medicaid website.

Medicaid also requires that you meet your state’s strict low-income and asset limits. Again, this will vary by state. For long-term care and waiver programs, the general rule of thumb is a monthly income cap of around $2,900 and a countable asset limit of roughly $2,000 for a single applicant. 

If you live in New York and already have Medicaid, you can get helpful information and schedule the state assessment to qualify for home health care at the New York Independent Assessor Program website. The assessment helps determine the type and amount of home care services you may receive. For other states, please consult your state’s government health services website for more details.

How to Apply for Home Health Care Services

Step 1: Speak With Your Doctor

The first requirement in getting set up for home health care is to speak to your doctor, who will perform the medical assessment required to determine whether you are eligible to apply for home health services, and (if you meet the requirements) write the order specifying the type and length of services.

Step 2: Verify Insurance or Medicaid Coverage

After you have obtained the physician’s assessment and documentation (or even before), verify that your insurance or Medicaid coverage is in force and will cover home health care services.

Step 3: Choose a Home Care Agency

Your physician, health care provider, or HMO may be affiliated with one or more home health organizations, and depending on your state, you may or may not have a lot of choices here. Choose the one that works with your insurance plan/coverage and meets your physical needs.

Step 4: Complete Required Assessments

There may be additional home safety, physical capability, or other assessments required as part of the approval process, to help you and your health care provider determine the most effective uses of home health care services in your specific case. As noted earlier, for Medicaid, there will also be a financial eligibility assessment to ensure that you meet the requirements for coverage.

Step 5: Develop a Personalized Care Plan

Working with your health care provider, you and your home health services team will develop a personalized care/treatment plan that will address your needs most effectively. This plan will be regularly reviewed to ensure that it is meeting your requirements.

What If You Don’t Qualify Right Away?

If you don’t immediately qualify for home health care, you have several options:

Request a reassessment or appeal

If your health condition changes or you believe your care needs were not fully or accurately evaluated, you may be able to request a new assessment or appeal the decision. Additional medical documentation from your healthcare provider can help support your case.

Use Medicare home health benefits

If you have been trying to obtain home health services via your private insurance but you qualify for Medicare, it may cover short-term home health services, including skilled nursing, therapy, and limited home health aide care for eligible medical conditions. Learn more at the official Medicare website.

Consider private home care

Private home care agencies provide services such as personal care, companionship, and household assistance. Depending on your situation, these services may be paid for out of pocket or through long-term care insurance or other private coverage.

Explore community-based programs

Many communities offer support services for older adults and individuals with disabilities, including meal delivery, transportation, adult day programs, caregiver support, and homemaker services. Your local Area Agency on Aging can help identify available resources. Find your local agency through the U.S. Administration for Community Living.

Work with your healthcare team

Your doctor, hospital discharge planner, or social worker can help connect you with temporary care options and local assistance programs while you pursue long-term home care services.

Review your Medicaid eligibility regularly

If you have been denied home health care because you don’t qualify for Medicaid, be sure to check back regularly. Home care requirements vary by state, and eligibility may change if your financial or medical circumstances change.

How Amazing Home Care Can Support You

Amazing Home Care provides experienced, HHA (home health aide) and PCA (personal care assistant) services, and can help you understand the eligibility requirements and guide you through the assessment process. We have service areas throughout New York, and are happy to assist you with Medicaid-related questions as you determine the right course of action for you or your loved one. Schedule a consultation or speak with a care coordinator today.

 

Compliance Disclaimer:

Amazing Home Care is a licensed New York home care services agency providing non-medical assistance. Our caregivers do not provide medical diagnosis, treatment, or therapy. Any exercise, medication, or health-related activities are performed only as directed by a licensed healthcare provider and according to an approved care plan.

 

Frequently Asked Questions (FAQs)

How do you qualify for home health care?

Eligibility typically depends on medical need. A healthcare provider must determine that home-based services are necessary and that the individual meets program or insurance requirements.

Does Medicaid cover home health care in New York?

Yes. New York Medicaid may cover home health care and personal care services for eligible individuals who meet financial and medical criteria and require care at home.

What medical conditions qualify for home health care?

Many conditions may qualify, including recovery from surgery, chronic illnesses, disabilities, injuries, stroke, heart disease, diabetes, and other conditions requiring skilled care or assistance with daily activities.

Do you need a doctor’s referral for home health care?

Yes. A physician or other authorized healthcare provider must write an order certifying that the patient is homebound and that home health care services are medically necessary.

Can family members provide home care services?

Some Medicaid programs allow eligible family members to serve as paid caregivers, though rules vary by state and program. Specific training or enrollment requirements may apply.

How long does it take to get approved for home health care?

Approval times vary depending on the program, insurance provider, and required assessments. Some cases are processed within days, while others may take several weeks.

What is the difference between home health care and home care?

Home health care provides skilled medical services such as nursing and therapy under a healthcare treatment plan. Home care focuses on non-medical assistance with daily activities like bathing, dressing, meal preparation, and housekeeping.

Can you receive home health care if you are not a senior?

Yes. Home health care is available to eligible adults and children of any age who have a qualifying medical condition or disability and meet the requirements of their insurance or assistance program.