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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

WHAT IS THE IMPACT OF OTHER AVAILABLE CAREGIVERS?
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.
Eligibility is not affected by the fact that the beneficiary may qualify for care in another setting (e.g. hospital, skilled nursing facility).

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

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.

WHEN DOES A BENEFICIARY QUALIFY FOR DAILY SKILLED NURSE VISITS (SEVEN DAYS A WEEK)?
When the physician orders daily skilled nursing services for more than three weeks, the home health agency must document the medical necessity of the additional services.
An endpoint statement is required: must be reasonable for the medical condition, and must identify a predictable and finite period of time daily skilled nursing visits will be needed
Only exception is the coverage of daily skilled nursing visits to administer insulin injection to a homebound beneficiary who is physically or mentally incapable of self-injection and who has no willing or able caregiver available.

WHEN DOES A BENEFICIARY QUALIFY FOR ONE-TIME SKILLED NURSE VISITS?
When initially there appears to be a need for medically necessary, intermittent skilled nursing visits, but after the first visit the need for additional visits in not necessary (e.g. beneficiary is institutionalized, dies)

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