- Avoid Processing Delays by Following Proper Submission Guidelines
- Medicare Beneficiary Eligibility Checklist
- Acceptable Electronic Signatures Reminder
- Capable Recipients for the Advance Beneficiary Notice of Noncoverage
- Hospital-Issued Notices of Noncoverage
- Medicare Advance Written Notices of Noncoverage Booklet
- Primary Care Exception Guidelines
- Ordering DMEPOS Items
- Appropriate Use Criteria Program
- Assistant at Surgery Billing Documentation Reminder
- Avoid Return to Provider and Claim Rejections-Enhancing the Beneficiary Eligibility Verification Process
- Checking Eligibility and Knowing Your Point of Contact
- Cloned Documentation Could Result in Medicare Denials for Payment
- Documentation Reminder: Psychiatry and Psychology Services
- Documentation Required for Home Visits
- Electrical Stimulation Therapy: Important Coverage and Documentation Reminders
- Go Paperless Today - Protect Your Bottom Line
- Hospital Acquired Conditions and Present on Admission Resource for Physicians
- Inpatient Admission Prior to Medicare Entitlement Job Aid
- MDS Calendar
- Medicare Home Health Collaboration with Other Provider Types
- Part A Claims for High Cost Items and Certain Drugs Requiring Additional Information
- Manual Review of Claims for Replacement of Supplies and Accessories used with External Ventricular Assist Device
- Referring, Monitoring and Certifying Home Health Services
- Scribing Medical Record Documentation
- Skilled Nursing Facility Medicare Part A Benefit Quick Reference Fact Sheet
- Submit Medical Record Documentation Electronically
- Submitting Electronic Medical Records via CD-ROM
- Using the Medicare Part B PWK Fax-Mail-esMD Cover Sheet
Medicare Home Health Collaboration with Other Provider Types
Table of Contents
- The Medicare Home Health Benefit
- Therapy Providers and the Home Health Benefit
- Durable Medical Equipment Suppliers and the Home Health Benefit
- Hospice and the Home Health Benefit
- Medicare Advantage Organizations and the HH Benefit
- Related Content
The Medicare Home Health Benefit
HH care is a Medicare benefit for beneficiaries who are confined to their home and entitled to Part A and/or Part B coverage. A beneficiary receiving HH care must receive services from a Medicare-certified HHA. The beneficiary must be under the care of a physician or allowed practitioner who certifies that he/she meets all five eligibility criteria as follows:
- Confined to the home
- Has a need for skilled care in the home
- The physician or allowed practitioner has agreed to monitor HH services, or has identified in writing, the name of a physician or allowed practitioner who has agreed to do so
- There is a plan of care in place for services in the home
- Had a face-to-face encounter with a physician or allowed practitioner 90 days prior to or within 30 days following the initial start of care date by the HHA
All home care services provided to the Medicare beneficiary must be provided directly by, or under arrangements made by, the certified HHA for a period of up to 60 days. HH services under a plan of care are paid in two 30-day periods of care based on a 60-day certification. An HH beneficiary may be eligible for an unlimited number of 60-day certifications as long as they remain eligible for HH care and the certifying physician or allowed practitioner monitoring the plan of care re-certifies that the beneficiary continues to meet all eligibility criteria.
When a beneficiary is under the care of a HHA, that agency is paid under the HH prospective payment system and must bill Medicare for all HH services provided to the beneficiary. Services provided to a Medicare beneficiary receiving HH care fall under the HH consolidated billing guidelines. These services may include:
- Part-time or intermittent skilled nursing services
- Part-time or intermittent HH aide services
- Physical therapy
- Speech-language pathology
- Occupational therapy
- Medical social services
- Routine and non-routine medical supplies
- Covered osteoporosis drugs
- HH services provided under arrangement at hospitals, skilled nursing facilities or rehabilitation center involving equipment too cumbersome to utilize within the beneficiaries home
Therapy Providers and the Home Health Benefit
It is the responsibility of every Medicare contracted provider to verify eligibility for Medicare covered services prior to rendering care to the beneficiary. If a therapy provider (e.g., outpatient rehabilitation center, nursing facility, outpatient hospital) begins providing services with a beneficiary who is receiving home health services, the therapy provider must contact the HHA prior to rendering services in an effort to contract with the HHA for any services subject to HH consolidated billing. The HHA has no financial liability for therapy services arranged and provided outside of their agency if they did not approve or have prior knowledge of the services rendered. Providers must verify HH services by
- Talking with the beneficiary and/or,
- Checking any eligibility system such as the IVR system, NGSConnex, or HETS
Upon verification of eligibility, HH certification will be identified and include information regarding start and end dates (or projected end dates) of the HH period.
HH guidelines state that HH services must be provided within the place of residence (e.g., their dwelling/house, an apartment, assisted living facility or some other type of institution). Some institutions may have therapy staff; however, any therapy services written within a HH plan of care must be provided by HHA staff or a therapy provider that has contracted with the HHA.
Durable Medical Equipment Suppliers and the Home Health Benefit
The HHA is not responsible for providing DME, even when it is included within the plan of care. Supplies covered as DME are paid on a fee schedule separately from the HH prospective payment system rate and are excluded from the HH consolidated billing requirement; the determining factor is the medical classification of the supply, not the diagnosis. DME supplies may be provided by a DME supplier or by a HHA, but only one provider may bill for the DME.
HHAs that are located in an area where DME is subject to a competitive bidding program must have a contract to supply DME. If the HHA does not have a contract to supply DME, they must use a contracted supplier to furnish DME and their claims must be submitted to the DME MAC.
Hospice and the Home Health Benefit
Once a Medicare beneficiary elects the hospice benefit, the hospice agency is responsible for all care related to the terminal illness. A beneficiary may have an open HH episode at the same time as a hospice election period; however, any services not related to the terminal illness provided by the HHA should be billed on the HH period of care claim utilizing condition code "07."
If a beneficiary is transferred out of HH services the same date that they are admitted to a hospice agency, there may be a home health visit on the same date. In such circumstances, the HHA will discharge the beneficiary to hospice care during the last HH visit and the hospice agency will admit to their services.
Medicare Advantage Organizations and the HH Benefit
When a Medicare beneficiary is also enrolled in an MA plan, all HH services that fall within the MA organization’s enrollment dates must be sent to the MA plan.
If a Medicare beneficiary begins HH care under an MA plan and switches back to traditional Medicare within the HH period, the HHA will open a HH period once the first billable traditional Medicare service is delivered. If a Medicare beneficiary begins HH care under traditional Medicare and then switches to an MA plan, the HHA will bill up to the date of the last billable visit under traditional Medicare and the remainder of the services provided should be submitted to the MA plan according to the MA plan guidelines.
Related Content
- CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 10, Section 40.2
- CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 7
Revised 11/6/2023