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Medicaid Prior Authorization Services
Home health services are available to Indiana Health Coverage Program (IHCP), also known as Medicaid, members who are medically confined to home when services are ordered by the member’s physician. IHCP members who, because of illness or injury, are unable to leave home without the assistance of another person or of an assistive device, such as a wheelchair or walker, or for whom leaving the home is contrary to medical advice, are considered to be medically confined to home.
Home health services may be utilized for care and treatment of acute or chronic conditions, rehabilitation, education regarding care, coordination of community services, or to avoid prolonged or repeated hospitalizations and/or higher and more costly levels of care.
Who is eligible for services?
One of the following indicators from each category must be present to be eligible for home health services:
Category I: Individual
- Individual is considered at risk of respiratory failure, severe deterioration, or hospitalization without constant monitoring.
- Individual requires total care – monitoring 24 hours per day.
- Individual desires to stay in the home, rather than in a LTC facility.
- The medical condition of the individual has deteriorated, creating the need for more intense short-term care (physician’s statement required).
- Individual does not have a primary caregiver or access to other care.
Category II: Caregiver
- Primary caregiver is employed and absent from the home, or is unable to provide the necessary care.
- Primary caregiver has additional child care responsibilities, disallowing the time needed to care for the member (three or more children under six years of age, or four or more children under the age of 10).
- Primary caregiver also has additional children with special needs to care for (one or more children with special healthcare needs requiring extensive medical and physical care).
- Major illness or injury of caregivers, with expectation of recovery (physician’s statement required)
- Temporary but significant change in the availability of caregiver – for example, military service (commanding officer, other military representative, or employer’s statement required).
- Significant permanent change in caregiver’s status – for example, death or divorce with loss of one caregiver (physician’s statement required).
What activities can the Prior Authorization services provide?
Prior-Authorized (PA) Home health services may consist of the following:
- Skilled nursing services provided by an RN or LPN
- Home health aide services
- Physical Therapy
- Occupational Therapy
- Speech Therapy
What activities are not allowed?
The following services are non-covered home health services, except as specified under the applicable IHCP Waiver Service programs:
- Transportation to and from grocery stores, drug stores, banks, etc.
- Homemaker services, including shopping, laundry, cleaning, meal preparation, etc.
- Companion or sitter services, including escort services, activity planning, etc.
- Chores, including picking up prescriptions, household supplies and/or groceries, etc.
- Respite care
Still need help?
Fill out our contact form or call 765-447-7683 for assistance.
Medicare Coverage of Home Health Care
The goal of home health care is to provide treatment for an illness or injury. Where possible, home health care helps you get better, regain your independence, and become as self-sufficient as possible. Home health care may also help you maintain your current condition or level of function, or to slow decline.
Medicare pays for you to get health care services in your home if you meet certain eligibility criteria and if the services are considered reasonable and necessary for the treatment of your illness or injury.
Who is eligible?
If you have Medicare, you can use your home health benefits if:
- You’re under the care of a doctor, and you’re getting services under a plan of care established and reviewed regularly by a doctor.
- You need, and a doctor certifies that you need, one or more of these:
- Intermittent skilled nursing care (other than drawing blood)
- Physical therapy
- Speech-language pathology services
- Continued occupational therapy
- The home health agency caring for you is approved by Medicare (Medicare certified).
- You are homebound, and a doctor certifies that you are homebound. To be homebound means:
- You have trouble leaving your home without help (like using a cane, wheelchair, walker, or crutches; special transportation; or help from another person) because of an illness or injury, or leaving your home isn’t recommended because of your condition.
- You’re normally unable to leave your home, but if you do it requires a major effort.
You may leave home for medical treatment or short, infrequent absences for non-medical reasons, like an occasional trip to the barber, a walk around the block or a drive, or attendance at a family reunion, funeral, graduation, or other infrequent or unique event. You can still get home health care if you attend adult day care or religious services.
- As part of your certification of eligibility, a doctor, or certain health care professionals who work with a doctor (like a nurse practitioner), must document that they’ve had a face-to-face encounter with you (like an appointment with your primary care doctor) within required timeframes and that the encounter was related to the reason you need home health care.
If you only need skilled nursing care, but you need more than “intermittent” skilled nursing care, you don’t qualify for home health services. To determine if you’re eligible for home health care based on a medically predictable recurring need for skilled nursing,
Medicare defines “intermittent” as skilled nursing care that’s needed or given either:
- Fewer than 7 days each week.
- Daily for less than 8 hours each day for up to 21 days. Medicare may extend the three week limit in exceptional circumstances if your doctor can predict when your need for daily skilled nursing care will end.
If you’re expected to need full-time skilled nursing care over an extended period of time, you wouldn’t usually qualify for home health benefits.
Still need help?
Fill out our contact form or call 765-447-7683 for assistance.
Options Counseling
What is Options Counseling?
Options counseling is a person-centered service for seniors, individuals with disabilities, or their caregivers. When you call our Aging and Disability Resource Center or make a referral online, our friendly and knowledgeable staff will listen to your concerns.
We may inquire about health, physical limitations, living arrangements, and transportation needs, or explore the possibility of a meal service or medical alert device. We may also discuss your financial situation to determine eligibility for publicly-funded programs. Then, we can provide personalized recommendations to help you achieve your goals. This conversation is free for everyone, regardless of income or financial assets.
If you are eligible for subsidized services, your information is transferred to an Assessment and Transitions Specialist, who will schedule an in-home visit within 10 business days. At your home, the initial assessment takes about two hours. During this time, we will talk with you and other family members about your long-term care needs and identify providers. The Assessment and Transitions Specialist then completes all necessary paperwork and submits it to Indiana’s Division of Aging for approval, which typically takes 20 days.
If you already have a Medicaid number, services can begin almost immediately following approval. If you don’t have Medicaid, your Assessment and Transitions Specialist will guide you through the application process. After submission, confirmation can take an additional 90 days.
Through it all, Area IV Agency’s dedicated staff will provide the support and practical assistance you need to help you achieve the greatest possible independence, dignity, and quality of life.
Still need help?
Fill out our contact form or call 765-447-7683 for assistance.