MEDICARE: Conditions To Be Met For Coverage Of Home Health Services

Basic conditions:

  • Patient is an eligible Medicare beneficiary
  • Home Health Agency has valid agreement to participate in Medicare Program
  • Beneficiary qualifies for coverage
  • Services billed are covered Medicare home health services
  • Medicare is the appropriate payer
  • The services billed are not excluded from payment

Additional criteria:

  • The service must be ordered by physician
  • Service must be reasonable and medically necessary to treat illness or injury.
  • Beneficiary must be homebound
  • Beneficiary must need a skilled primary service
  • Skilled nursing must be provided on an intermittent or part-time basis

** When all the above conditions and criteria are met, medicare will reimburse for an unlimited number of visits.

What are “reasonable and necessary services?”

  • Determined by plan of care and medical record documentation: progress or lack thereof, medical condition, functional losses and treatment goals
  • Based upon objective clinical evidence
  • Length of services is determined by individual needs

When is a beneficiary considered homebound?

  • When there is a normal inability to leave home, and leaving home requires a considerable and taxing effort (documentation must indicate this).
  • Cognitive impairments that require constant supervision for safety

Allowed absences from the home include:

  • Receiving health care treatment
  • Attending religious service
  • Other infrequent or unique event: reunion, funeral, graduation…
  • Using supportive devices does not automatically make the beneficiary homebound

What if I am not homebound?

  • These services can be subject to co-pays and/or deductibles. Call our office for more info about your plan and what it covers.
  • Once a patient is no longer homebound, billing for services under the Part A Medicare home health benefit must stop immediately because the patient is no longer eligible for home care (see theHealth Insurance Manual for Home Health Agencies 203 Conditions to Be Met for Coverage of Home Health Services and §204 Conditions the Patient Must Meet to Qualify for Coverage of Home Health Services).
  • If there is still a need for skilled therapy services, the patient is eligible for Part B outpatient therapy services which may be obtained in the setting of the patient’s choice (i.e., an outpatient clinic, a hospital department or even the patient’s home). Any agency that is Medicare certified is eligible to provide and bill for outpatient therapy services under Part B of the Medicare program.

What is the impact of other available caregivers?

  • Eligibility is not affected by the fact that the beneficiary may qualify for care in another setting (e.g. hospital, skilled nursing facility)
  • Caregiver availability usually does not affect the eligibility for Medicare covered home health services. One exception is when services are to provide normally self-injected medications (e.g. insulin or calcitonin). This applies only if the beneficiary is either physically or mentally unable to self-inject the medication, and there is no other person willing and able to give the medication.

When does a beneficiary qualify for intermittent skilled nursing care?

  • Applies to skilled nursing visits only
  • Skilled nurse visits must be at least once every 60-90 days
  • Skilled nurse visits seven days per week are not to exceed 21 days without a finite and predictable end point to daily skilled nurse care.

How does a beneficiary’s place of residence affect coverage?

The beneficiary cannot be a resident of an institution that meets the basic definition of a hospital or a skilled nursing facility (Social Security Act 1861(e) or 1819(a) facilities)

What if a beneficiary resides in an assisted living facility?

If it is determined that the assisted living facility (also called personal care homes, group homes etc) in which the beneficiaries reside are not primarily engaged in providing:

  • Diagnostic and therapeutic services for medical diagnosis, treatment, care of disabled or sick persons
  • Care or related services for patients who require medical or nursing care
  • Rehabilitation services for the rehabilitation of injured, sick, or disabled persons then Medicare will cover reasonable and necessary home health care to these individuals.