What does ''homebound'' mean?

A beneficiary must be homebound to qualify for the Medicare Home Health Benefit. An individual would be considered homebound if he/she experiences:

• a normal inability to leave home
• a considerable and taxing effort to leave their home
• absences from the home are infrequent, of short duration, or are to receive medical care.

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Do I have to have a physician's order to get personal care services?

To initiate personal care services, a physician's order is not required. However, if the recipient of personal care services has NC Medicaid insurance (blue card), the physician will have to sign the plan of care developed by the RN who completes the initial assessment.

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What are the criteria to get home health care?

To receive home health care services under Medicare, a patient must meet the following criteria:

• homebound
• be under a physician's care- all home health services must be ordered by a physician
• reasonable and necessary- treatment provided at home must fall within the accepted standards of medical practice and be appropriate for the patient
• skilled services-the patient must have a medical need that requires the skill of a licensed nurse, physical therapist or a speech therapist. Once the skilled need is established a secondary discipline such as medical social worker, occupational therapist or home health aide may be involved in providing patient services
• part time and intermittent-home visits are made to provide a needed service and not extended hours of care. The patient must also have a medically predictable, recurring need for skilled care. One time visits are not allowable under Medicare guidelines.

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• delivered by Certified Nursing Assistants
• preventative in nature and are provided over a longer period of time
• paid for by the NC Medicaid program or paid for privately. Medicare does not pay for personal care services
• designed to maintain a medically stable individual.

Home Health services are:

• delivered by Registered Nurses and/or Licensed Therapists
• rehabilitative or restorative in nature and are delivered over a relatively short period of time
• paid for by Medicare and some private insurances. Home health services can also be paid for privately if the patient does not meet the Medicare criteria
• designed to promote recovery following an acute medical crisis.

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Who pays for home care services?

Personal care services can be paid for privately. Some long-term care insurance policies and a few private insurances have benefits that cover personal care services. However, most personal care services are paid for by Medicaid. Medicare does not pay for personal care services. Home health services are paid for by Medicare, Medicaid, private insurance, and privately.

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Will long-term care insurance pay for home care services?

Due to high nursing home cost and a desire to remain at home, many people are now exploring the value of long-term care insurance. These policies vary from company to company and many policies can be written to meet the prospective clients' specific desires regarding where and how they would like to receive care in their senior years. lf it is your desire to stay at home, be sure to specifically ask your long-term care insurance agent about personal care and home health.

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How do I select the right home care provider?

Consumers today are very savvy and for good reason. When employing a home care agency it is very important to do some research. The National Association for Home Care has a wonderful website with helpful information on how to select the right home care provider. Their site is www.nahc.org. The "Consumers" page under the "General Information" heading will provide you with a wealth of helpful information.

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Is PCS and MR-PCS the same thing?  Can it be provided by a CNA?

Personal Care Services or PCS is a Medicaid service while MR-PCS is a service under the Community Alternatives Program (CAP). PCS is assistance in the home with activities of daily living, i.e., bathing, dressing, meal preparation. MR-PCS is personal care services (as described above) provided as a support service to a person with mental retardation/developmental disabilities. To be eligible for MR-PCS services, the individual must have received a slot for the CAP- funded services. Typically MR-PCS is done in combination with a variety of other habilitation and supportive services. MR-PCS can be provided by a CNA who has met all the necessary educational training and competencies criteria for the behavioral health program.

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How can I get Behavioral Health services?

The first step is to be in the system of an area program that provides MH/DD/SA (Mental Health/Developmental Disability/Substance Abuse Services). Depending on the type of difficulty a person is experiencing and/or the type of disability they have, the person will need to have an assessment by the appropriate department. You can learn each department's specific process by  calling your Area Program.

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Do I have to use the Behavioral Health provider agency that someone recommends or do I have choice?

Each person eligible to receive services has the freedom to choose any qualified agency as their provider. The agency should be ''endorsed'' with your area LME. Endorsed agencies and their staff meet certain qualifications that are required by the area program. Endorsed agencies are subject to periodic audits by the area program to ensure that they are complying with specifications. Each person receiving support services has the right to ''provider choice'' and should be shown or given a list of all agencies when they are deciding which agency to choose. No one should dictate your choice. It is recommended that families ask to conduct interviews with several agencies in order to make an informed selection.

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