- Section 1 Introduction
- Introduction
- Federal Government Administration
- Fundamentals of Medicare: State Responsibilities
- Fundamentals of Medicare: Participating Providers
- Voluntary and Involuntary Termination of Provider Agreement
- Disclosure of Health Insurance Information
- Privacy Act
- National Provider Identifier
- Legacy Provider Numbers/Provider Transaction Access Numbers (PTANs)
- Medicare Administrative Contractors
- Fundamentals of Medicare: Information References
- Acronyms
- Fundamentals of Medicare: Glossary of Terms
- Section 2 Medicare Basics
- The History of Medicare
- What Is the Medicare Program and How Is It Funded?
- Medicare Eligibility and Premiums
- The Social Security Administration and Medicare Enrollment
- The Medicare Card
- Medicare Part A
- Inpatient Hospital Care
- Skilled Nursing Facility Inpatient Care
- Home Health Care Benefit
- The Hospice Benefit
- Medicare Part B Medical Insurance
- Fundamentals of Medicare - Medicare Program Exclusions
- Medicare Advantage Organizations
- Medicare Secondary Payer
- Supplemental Insurance
- Coordination of Benefits Trading Partners
- Section 3 Fraud and Abuse
- Section 4 Getting Ready to Bill Medicare
Section 2: Medicare Basics
Home Health Care Benefit
Table of contents
- Home Health Care Benefit
- Responsibilities of Hospitals Discharging Medicare Beneficiaries
- Home Health Prospective Payment System
- Responsibilities of Providers Subject to Consolidated Billing
- Requirements for Coverage
- Home Health Benefit Days and Costs
- Covered Home Health Services
- Noncovered Home Health Services
Home Health Care Benefit
The home health benefit may be a natural progression of care from a hospital to SNF to home. It is possible for a beneficiary to go directly into home health care without having a prior hospitalization.
Responsibilities of Hospitals Discharging Medicare Beneficiaries
A hospital discharging a Medicare beneficiary to home health care can also play an important role in alerting the beneficiary to their potential liability under home health consolidated billing. Under the Medicare conditions of participation for hospitals, discharge planning (42CFR, Section 482.43 [b][3] and [6]), hospitals must have in effect a discharge planning process that applies to all patients and the discharge planning evaluation must include an evaluation of the likelihood of a patient needing post-hospital services and of the availability of the services. The hospital must include the discharge planning evaluation in the patient’s medical record for use in establishing an appropriate discharge plan and the hospital must discuss the results of the evaluation with the patient or individual acting on his or her behalf.
Home Health Prospective Payment System
Effective for all services provided on or after 10/1/2000, all services under the home health plan of care are included in the home health prospective payment system (HH PPS). Rehabilitation services and nonroutine supplies are subject to the home health CB. The payment for these services will be made directly to the primary HHA. No payment will be made to an outside provider of service, unless the primary HHA make arrangements for an outside provider to render these services.
Responsibilities of Providers Subject to Consolidated Billing
Since Medicare payment for services subject to home health consolidated billing is made to the primary HHA, providers of these services must be aware that separate Medicare payment will not be made to them. Therefore before they provide services to a beneficiary, provider need to determine whether or not a home health episode of care exists for that beneficiary. This information is available by checking the CWF. Providers should ask the beneficiary or his/her representative if he/she is presently receiving home health services under a home health plan of care. If a provider learns of a home health episode from any of these sources, or if they believe they don’t have reliable information, they should advise the beneficiary that if the beneficiary decides not to have the services provided by the primary HHA and the beneficiary is in an HH episode, the beneficiary will be liable for payment for the services. Beneficiaries should be notified of their potential liability before the services are provided.
Requirements for Coverage
To be considered for coverage, four conditions must be met:
- The care must include intermittent skilled nursing care, physical, occupational, or speech therapy.
- A physician must establish a plan of care for the beneficiary and have a recurring role in the treatment plan. The physician has the responsibility to create, certify, and recertify the treatment plan.
- The patient’s care must be provided by a Medicare-certified HHA.
- These agencies can contract with other providers to render certain services. However, please note that primary home health agencies are not liable to reimburse other providers for services denied due to Home Health Consolidated Billing unless:
- The provider is providing a service called for on the home health plan of care, and
- The provider has a subcontracting agreement with the HHA.
- These agencies can contract with other providers to render certain services. However, please note that primary home health agencies are not liable to reimburse other providers for services denied due to Home Health Consolidated Billing unless:
- The patient must be considered homebound.
- An individual does not have to be bedridden to be considered homebound, or confined to the home. However, the condition of these patients should be such that there exists a normal inability to leave home and, consequently, leaving home would require a considerable and taxing effort.
If the patient does leave home, it must be to get medical care, or for short, infrequent, nonmedical reasons (such as a trip to get a haircut), or to attend religious services or adult day care. If the patient does leave the home, it has to be with the aid of a wheelchair, walker, crutches, canes, or the assistance of another person. If that patient were not confined to home, they would be able to seek treatment under the outpatient hospital benefit and the home health program would not be necessary.
- An individual does not have to be bedridden to be considered homebound, or confined to the home. However, the condition of these patients should be such that there exists a normal inability to leave home and, consequently, leaving home would require a considerable and taxing effort.
Home Health Benefit Days and Costs
The Balanced Budget Act of 1997 modified the home health program in the area of payment. Beginning in 1999, any beneficiary starting home health care following a hospital/SNF stay will have the first 100 visits paid for under Medicare Part A. Subsequent visits would be paid under Part B. If the patient does not have a prior hospital stay, they are still qualified to receive home health visits. There is no limit to the number of visits under Part B, but there has to be a medical necessity for the visits. Coinsurance and deductible are applied to these visits.
Covered Home Health Services
Some covered services under the home health benefit include, but are not limited to:
- Skilled nursing care on a part-time or intermittent basis. Skilled nursing care includes services and care that can only be performed safely and correctly by a licensed nurse (either a registered nurse or a licensed practical nurse).
- Home health aide services on a part-time or intermittent basis. A home health aide does not have a nursing license. The aide provides services that give additional support to the nurse. These services include help with personal care such as bathing, using the toilet or dressing. Medicare does not cover home health aide services unless the patient is also getting skilled care such as nursing care or other therapy. The home health aide services must be part of the home care for the patient’s injury or illness.
- Physical therapy, speech-language pathology, and occupational therapy for as long as a doctor determines it continue to be necessary.
- Medical social services to help the patient with social and emotional concerns related to the illness. This might include counseling or help in finding resources in the community.
- Certain medical supplies, like wound dressings, but not prescription drugs.
- Certain medical equipment, such as a wheelchair or walker. Medicare usually pays 80 percent of the approved amount for some medical equipment.
Noncovered Home Health Services
Some noncovered services under the home health benefit include, but are not limited to:
- 24-hour day care at home
- Meals delivered to the home
- Homemaker services such as cleaning, laundry, and shopping
- Personal care given by home health aides (bathing, getting dressed) when this is the only care needed
Revised 1/2021