Eligibility for home care certification: what clinicians should know.

Abstract

In order for patients to receive home care that is reimbursable by Medicare, the Health Care Financing Administration (HCFA) has ruled that a physician must certify the need for services at home and establish the plan of care.1 This gate-keeping role may be appropriate for primary care physicians in many cases. However, nurses, therapists, or social workers may sometimes be better suited to determine home care eligibility because of the nature of the patient's condition or because, unlike physicians, they routinely make house calls.2 Before 1989, coverage of home care services by Medicare was intended exclusively to provide short-term care after an acute illness or medical event. Since 1989, as a result of a lawsuit brought against the federal government by the National Association of Home Care on behalf of a patient (Duggan v Bowen), Medicare beneficiaries can receive in-home, long-term care so long as eligibility criteria continue to be met.1, 3