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Home health care: Who qualifies and what's required for coverage?
March 21, 2025

This article is for:

  • Providers who refer patients for home health care services
  • Home health care providers caring for our members

We offer a comprehensive network of home health care providers that help support our members’ care needs and activities of daily living to allow them to safely stay in their homes.

Home health care may include the following services provided by a certified home health care agency:

  • Skilled nursing (for medical or psychiatric conditions)
  • Rehabilitation services, such as physical, occupational, or speech therapy
  • Social work services
  • Home health aide care to support activities of daily living

These services help meet the needs of people with acute, chronic, and terminal illnesses or disabilities who, without this support, might otherwise require services in an acute care, psychiatric care, or residential facility.

Eligibility

Commercial1 and Medicare Advantage members may be eligible for these services when they:

  • Have a plan of care that’s ordered and supervised by a doctor or other health care professional.
  • Need intermittent care from skilled professionals.
  • Are homebound.
    • This means the member’s illness is manifested in part by a refusal to leave the home or, due to their clinical circumstances, it wouldn’t be considered safe for them to leave home unattended.
    • We also take into consideration members who may not be appropriate for treatment in a group or outpatient setting, such as an immune system or mental health condition, since it may not be safe to be treated in a public setting.
  • Are at a high risk of admission or readmission to inpatient care.
  • Have significant barriers to independently access care in the community.

Our coverage

Below, we describe our coverage. Federal Employee Program members have limited coverage for home health care services. Please check fepblue.org for details.

Referral

Not required.

  • The PCP or authorized specialist2 will continue to provide orders for the home health care service (see signed orders section below).

Authorization3

Not required for in-network care.
This means no initial authorization and no authorization is required throughout the episode of care.

Clinical criteria for coverage

Commercial members (HMO/POS, EPO/PPO, indemnity)
InterQual®''

Medicare Advantage members
Medicare Benefit Policy Manual
Chapter 7: Home Health Services

Functional therapy assessment

Upon admission to the home health care agency, a functional assessment should be performed if rehabilitation services have been ordered. The treating physical, occupational, or speech therapist will make the assessment at the initial visit.

Sometimes a home safety evaluation is ordered by the PCP or specialist to determine any barriers at home that may need to be addressed (for example, grab bars, raised toilet seat).

Signed orders

The home health care provider should get orders from the PCP or authorized specialist before initiating care and maintain a copy of those written orders in case you’re asked to substantiate them.

The written orders also provide any limitations, such as weight bearing or avoid resistance, which the treating clinician needs to follow. This includes a home health aide who may be assisting a member with activities of daily living.

The ordering PCP or specialist should review the plan of care at least every 60 days, and sign and date that it’s been reviewed.

Medication assistance
  • Education and teaching
  • Medication management
  • Administer injections or infusions as needed

Mental health support
  • Psychiatric nursing evaluations
  • Physical assessments to manage medical issues
  • Help managing symptoms
  • Monitoring progress and response to treatment
  • Education for patients and family members about behavioral symptoms, medications, and management
  • In-home LICSW services
  • Medication management
  • Administer injections, if needed
  • Coordinating care with the patient’s healthcare providers and the home health team
  • Referrals to helpful community resources

 

Resources

To access InterQual criteria, go to InterQual Criteria and SmartSheets. Then click Go Now.

To access InterQual criteria, log in and go to Clinical Resources>Coverage Criteria & Guidelines>InterQual Criteria and SmartSheets. Then click Go Now.


1. Commercial includes HMO/POS, EPO/PPO, and indemnity plans. It does not include Federal Employee Program members.

2. An authorized specialist is in the same referral circle as the PCP. If the specialist is not in the same referral circle as the PCP, then they need to get a referral from the PCP to request home health care services. For HMO or EPO members using out-of-network benefits for home health care, it must be authorized. For New England Health Plan members, referral and authorization requirements are determined by the state in which the PCP participates.

3. Authorization is required for private duty nursing (commercial members only who have this benefit) and for home infusion therapy.
Note: Please remember that Medex members are covered for home health care services through Medicare. Send claims to Medicare directly.

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