Patient’s must meet conditions for Medicare coverage of Home Health Services

Medicare will cover Home Health services, but only when the following criteria have been met:

1. The person to whom the services are provided is an eligible Medicare Beneficiary;

2. The HHA that is providing the services to the beneficiary has in effect a VALID agreement to participate in the Medicare program;

3. The beneficiary qualifies for coverage of home health services;

4. The services for which payment is claimed are covered;

5. Medicare is the appropriate payer; and

6. The services for which payment is claimed are not otherwise excluded from payment.

How is coverage determined?

The decision of whether care is reasonable and necessary is based on information found in the home health plan of care, the OASIS, or a medical record of the individual patient.  Medicare doesn’t deny coverage soley on the reviewer’s general inferences about patients with similar diagnoses or on data related to utilization generally, but bases it upon objective clinical evidence regarding the patient’s individual need for care.

Coverage of skilled nursing care or therapy to perform a maintenance program does not turn on the Presence or Absence of a patient’s potential for improvement from the nursing care or therapy, but rather on the patient’s need for skilled care.  Skilled care MAY be necessary to improve a patient’s current condition, to maintain the patient’s current condition, or to prevent or slow further deterioration of the patient’s condition.

CMS Benefits Policy Manual. 20; 20.1.2 – (Rev. 179, Issued: 01-14-14; Effective: 01-07-14, Implementation: 01-07-14)

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