As we’ve seen, there is a wide range of what health plans cover. It’s important to check your policy, and if necessary call for clarification.
You may want to document all phone calls to your insurer that include the name of the representative you spoke to. If possible, when clarification is obtained, ask to have a written copy mailed, faxed, or emailed.
Additionally, even with state and federally funded healthcare plans such as Medicare, Medicaid, and state assistance, there is great variability at the state level and even within states of what services can be accessed and reimbursed.
One thing to remember is that most insurance plans, including Medicare and Medicaid, require all services to be under a physician’s order. So if in-home services are needed, a doctor will have to consider them “medically necessary” and write for them.
Many in-home health agencies will have behavioral health specialists, typically nurses. Some of the kinds of services they can provide include assistance with medication management (up to multiple visits a day), psycho education, and some minimal counseling.
Another important consideration is that all in-home services need to meet criteria for “medical necessity,” a term that is defined in different ways by different insurers. For Medicare, “medical necessity” requires that there be specific achievable goals. Using in-home services to maintain the status quo will not cut it in most instances for Medicare. Medicare also requires that a person meet their definition of “homebound” in order to qualify for in-home services. This may not hold true for Medicaid, but the rules vary from state to state.