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Medicare Plan of Care Requirements

Home health care is a highly sought after benefit for older adults and those with disabilities. Medicare, the federally administered health care program for these populations, offers a home health benefit for those who meet certain requirements. One of the key requirements for home health care under Medicare is a plan of care.

  1. Home Health Agency Requirements

    • Medicare only requires a plan of care if a recipient tries to get a home health care benefit. To qualify for the benefit, the patient must be homebound and require skilled nursing care, which includes physical, occupational, or speech therapy. Next is the drafting of a doctor-approved plan of care. The plan is a document specifying how much and what types of home health care the doctor believes the patient requires.

    Hospital Requirements

    • If the beneficiary is in the hospital, the hospital's social worker or discharge planner will arrange for a Medicare-certified home health agency to visit the beneficiary. This person will assess the health condition of the beneficiary and determine whether she qualifies for home health care. From here, they will draft the plan of care, and a doctor must approve it.

    Home Requirements

    • If the Medicare beneficiary is at home and not in a hospital, she will need to speak with her doctor about home health needs. The doctor contacts the home health agency and explains the needs of the patient. From here, the agency will send a nurse to evaluate the patient, and the nurse will draw up the plan of care. The doctor must approve it.

    Reissuing and Re-evaluation Requirements

    • The prepared plan of care is for 60 days, known as an "episode of care." After 60 days, there is a re-evaluation of patient needs. If she still meets the requirements, there can be a new plan of care issued, or a renewal of the previous plan. This can happen as often as necessary as long as the patient qualifies.

    Switching Home Health Agency Requirements

    • If the home health agency can no longer provide care according to the plan of care requirements, or if the patient needs to transfer to another home health agency for any reason, the doctor and the new home health agency must issue a new plan of care.

    Discharge Requirements

    • If a home health agency has discharged a patient who later needs additional care, this also requires the drafting of a new plan of care.

    Changing a Plan of Care Requirements

    • Sometimes, a plan of care needs a re-evaluation during the 60-day episode of care if a patient has significantly improved or worsened health conditions. A home health agency must have the doctor's permission before changing a plan of care.

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