Homecare for the Special Needs Child
The question most often asked by families of special needs children is whether it is possible to obtain help at home for the care of their child. The level of care some children require in order to support their ability to stay at home and lead as “normal” a life as possible often leaves families tired and exhausted. Many require around the clock medical care in order to experience as high a quality of life as possible, and mothers and fathers too often find themselves filling the role of nurse and medical caregiver rather than parents.
In Pennsylvania, most children with special needs are eligible for medical assistance; such medical assistance provides additional services and coverage above and beyond any primary insurance a family may have. One of those state medical assistance benefits is coverage for private duty in-home care nursing and home health aide services to children under the age of 21 years (although special programs do exist for those over the age of 21.) These benefits include that of in-home nursing and home health aide care.
As with any insurance coverage, certain criteria must be met to be considered for this in-home care benefit within medical assistance. Many children qualify for this coverage, and simply ensuring that families, medical providers and support programs are aware of the criteria necessary to obtain such coverage ensures the benefit reaches as many children and families as possible.
First and foremost, it is required that a child have medical assistance coverage in order to be eligible for these in-home care services. As noted, many children with special medical and physical needs do qualify for medical assistance support regardless of family income. In most cases, simply taking the time to complete the necessary paperwork aimed at presenting information about the child’s specific special needs serves to get one evaluated and entered into the medical assistance system. The child’s social worker, medial provider or any home health agency can help with the process and ensure the paperwork is completed properly and submitted appropriately
Once the child has obtained medical assistance coverage, it is important to ask the question “Is there a medical necessity for in-home care?” Medical assistance will ask when determining whether to authorize in-home care. It is the “bench mark” used state-wide, and serves to ensure that care is awarded to those families where there is specialized care taking place in the home that requires the skill of a trained individual.
The determination of this necessity for care is best done by a licensed home health agency who understands in-home care policies and can advise families on whether this “bench mark” has been met. Many home health agencies can begin to help with determining the presence of medical necessity via an initial phone consultation evaluation. Once a medical necessity for care has been determined, the child’s physician will compile a letter that speaks to the medical and safety needs of the child. This letter will be submitted with the request to medical assistance for the in-home care.
Next, it is important to examine the other factors that will impact the decision by medical assistance to authorize in-home care. Specifically, family work schedules, the schedule for the child’s care, the level of care that is required by the child, the child’s attendance at school and the number of parents in the home – these factors all come into play when evaluating any given request for care. This information will be submitted to medical assistance as part of the initial request for in-home care, and is often compiled and submitted by a licensed home health agency.
Finally, it is critical to seek out a home health agency in the area that can guide families through the process of submission for in-home care. A request for in-home care ideally should come from either a hospital or physician’s office or a licensed home health agency. These individuals and organizations understand the process of requesting in-home care and can ensure that all necessary documents and criteria have been obtained.
While there is no guarantee that in-home care will be approved, it is prudent to evaluate the medical necessity for care, the specific care and schedule for care the child requires and the general status and makeup of the family when considering the in-home care option. Licensed home health agencies are a great resource for guidance through this process and should be sought out as soon as the need for in-home care is considered. The earlier their involvement in the process, the better the overall process will be.