Medicaid Requirements for In-Home Care

Medicaid is an insurance program administered by federal and state governments. You might qualify for Medicaid if you are a child under 18, pregnant, or a low-income earner.

Medicare is a different, similar program that targets senior citizens. Some people, such as disabled children and seniors, can also receive in-home care free of charge through Medicaid. Registered nurses, certified medical assistants and speech pathologists are examples of home health care workers who travel to a patient's home and administer treatment under this program.

Medicaid Eligibility

• You must obtain regular Medicaid coverage to receive in-home care. While rules differ by state, Medicaid generally is available for U.S. citizens and lawful permanent residents. Some women receive emergency Medicaid when delivering a child without insurance, but they will not qualify for long-term home health care. States have some discretion on Medicaid coverage, like the ability to waive parental income so that a child can receive in-home care.

Physician Diagnosis

• Schedule a visit with your primary care physician, who must prescribe home health care based on the patient's condition, be it a physical disability, mental illness or developmental disability. Recommendations for Medicaid in-home care should not come from emergency care physicians or dentists. If the physician's request is denied, submit a timely appeal to Medicaid. Each state establishes its own appeals process. Most states require that you send a written appeal (explanation of why you disagree) within 30 or 60 days to an address included in the decision notice. You might receive an appeal hearing before a panel or a panel might review your case based on available information (medical records, prescriptions).

Coverage

• Home health care might involve physical or speech therapy, or care by a nurse. Home health care recipients typically cannot travel outside of the home because of their condition. You still might be eligible for in-home care even if you are not bedridden -- meaning that you can walk or leave your home for brief time periods, such as to attend doctors' appointments, but not to work 25 hours a week.

Benefits

• In-home care creates several advantages for the patient, particularly in that you can stay at home instead of residing at a state-run institution or nursing home facility. For example, an in-home nurse might help you bathe, dress and eat. You also might qualify for free medical equipment, such as a wheelchair.

Considerations

• In-home care is not permanent. Medicaid officials review cases periodically and can stop home health care when a patient's condition improves.

  Be aware that home health agencies have committed fraud, such as billing for treatments or services that were never rendered. You should receive regular Medicaid statements by mail that describe the services that the in-home agency has charged. You will not be liable for the fraudulent charges, unless you intentionally, knowingly or willingly commit fraud with the agency.