The law states that patient’s are entitled to have the cost of “reasonable and necessary” services reimbursed regardless of whether the patient has a caregiver. CMS does state “where a family member or other person is or will be providing services that adequately meet the patient’s needs, it would not be reasonable and necessary for HHA personnel to furnish such services.” There is a presumption that there is no ‘willing and able’ caregiver in the home to provide services being performed by the HHA unless the patient or family state otherwise.
(OASIS items M1100 and M2100 are where CMS looks to determine assistance the patient has in the home and whether they need additional assistance. Always ensure you are responding to these OASIS items appropriately to reflect the level of care a patient has in their home so you don’t miss out of reimbursement for unnecessary care in the home setting. — NOT IN BENEFITS MANUAL)
There are a couple of examples given in the Medicare Benefits Manual:
A patient who lives with an adult daughter and otherwise qualifies for Medicare coverage of home health services, requires the assistance of a home health aide for bathing and assistance with an exercise program to improve endurance. The daughter is unwilling to bathe her elderly father and assist him with the exercise program. HHA services would be reasonable and necessary. Similarly, a patient is entitled to have the costs of reasonable and necessary home health services reimbursed by Medicare even if the patient would quality for institutional care.
A patient who is being discharged from a hospital with a diagnosis of osteomyelitis and requires continuation of the IV antibiotic therapy was found to meet the criteria for Medicare coverage of skilled nursing facility services. If the patient also meets the qualifying criteria for coverage of home health services, payment may be made for the reasonable and necessary HHA the patient needs. Medicare payment should be made for reasonable and necessary home ehatlh services where the patient is also receiving supplemental services that do not meet Medicare’s definition of skilled nursing care or home health aide services.
A patient who needs skilled nursing care on an intermittent basis also hires a licensed practical (vocational) nurse to provide nighttime assistance while family members sleep. The care provided by the nurse, as respite to the family members, does not require the skills of a licensed nurse (as defined in 40.1) and therefore has no impact on the beneficiary’s eligibility for Medicare payment of home health services even though another third party insurer may pay for that nursing care.”
CMS Benefits Policy Manual 20.2 – Impact of Other Available Caregivers and Other Available Coverage on Medicare Coverage of Home Health Services. (REV. 1, 10-01-13) A3-3116.2, HHA-203.2.