Home health - Patient Eligibility criteria - Part 1

Certifying Patients for the Medicare Home Health Benefit

This MLN Matters® SE1436 article gives Medicare-enrolled providers an overview of the Medicare home health services benefit, including patient eligibility requirements and certification/recertification requirements of covered Medicare home health services.

Key Points

To be eligible for Medicare home health services a patient must have Medicare Part A and/or Part B per Section1814(a)(2)(C) and Section 1835(a)(2)(A) of the Social Security Act (the Act):

** Be confined to the home;

** Need skilled services;

** Be under the care of a physician;

** Receive services under a plan of care established and reviewed by a physician; and

** Have had a face-to-face encounter with a physician or allowed Non-Physician Practitioner (NPP).

Care must be furnished by or under arrangements made by a Medicare-participating Home Health Agency (HHA).

Patient Eligibility—Confined to Home

Section 1814(a) and Section 1835(a) of the Act specify that an individual is considered “confined to the home” (homebound) if the following two criteria are met:

First Criteria  

 One of the Following must be met:
1. Because of illness or injury, the individual needs  the aid of supportive devices such as crutches, canes, wheelchairs, and walkers; the use of special transportation;  or the assistance of another person to leave their place of residence.

2. Have a condition such that leaving his or her home is medically contraindicated.

Second Criteria

Both of the following must be met:

1. There must exist a normal inability to leave home.

2. Leaving home must require a considerable and taxing effort.

The patient may be considered homebound (that is, confined to the home) if absences from the home are:

** Infrequent;

** For periods of relatively short duration;

** For the need to receive health care treatment;

** For religious services;

** To attend adult daycare programs; or

** For other unique or infrequent events (for example, funeral, graduation, trip to the barber).

Some examples of persons confined to the home are:

** A patient who is blind or senile and requires the assistance of another person in leaving their place of residence;

** A patient who has just returned from a hospital stay involving surgery, who may be suffering from resultant weakness and pain and therefore their actions may be restricted by their physician to certain specified and limited activities such as getting out of bed only for a specified period of time or walking stairs only once a day; and

** A patient with a psychiatric illness that is manifested, in part, by a refusal to leave home or is of such a nature that it would not be considered safe for the patient to leave home unattended, even if they have no physical limitations.

Patient Eligibility—Need Skilled Services

According to Section 1814(a)(2)(C) and Section1835(a)(2)(A) of the Act, the patient must be in need of one of the following services:

Skilled nursing care on an intermittent basis (furnished or needed on fewer than 7 days each week or less than 8 hours each day for periods of 21 days or less, with extensions in exceptional circumstances when the need for additional care is finite and predictable per Section 1861(m) of the Act);

** Physical Therapy (PT);

** Speech-Language Pathology (SLP) services; or

** Continuing Occupational Therapy (OT).

Patient Eligibility—Under the Care of a Physician and Receiving Services Under a Plan of Care

Section 1814(a)(2)(C) and Section 1835(a)(2)(A) of the Act require that the patient must be under the care of a Medicare-enrolled physician, defined at 42 CFR 424.22(a)(1)(iii) as follows:

** Doctor of Medicine;

** Doctor of Osteopathy; or

** Doctor of Podiatric Medicine (may perform only plan of treatment functions that are consistent with the functions he or she is authorized to perform under State law).
According to Section 1814(a)(2)(C) and Section 1835(a)(2)(A) of the Act, the patient must receive home health services under a plan of care established and periodically reviewed by a physician. Based on 42 CFR 424.22(d)(1) a plan of care may not be established and reviewed by any physician who has a financial relationship with the HHA.

Physician Certification of Patient Eligibility

As a condition for payment, according to the regulations at 42 CFR 424.22(a)(1):
** A physician must certify that a patient is eligible for Medicare home health services according to 42 CFR 424.22(a)(1)(i)(v); and

** The physician who establishes the plan of care must sign and date the certification.

The Centers for Medicare & Medicaid Services (CMS) does not require a specific form or format for the certification as long as a physician certifies that the following five requirements, outlined in 42 CFR Section 424.22(a)(1), are met:

1. The patient needs intermittent SN care, PT, and/or SLP services;

2. The patient is confined to the home (that is, homebound);

3. A plan of care has been established and will be periodically reviewed by a physician;

4. Services will be furnished while the individual was or is under the care of a physician; and

5. A face-to-face encounter:

a. Occurred no more than 90 days prior to the home health start of care date or within 30 days of the start of the home health care;

b. Was related to the primary reason the patient requires home health services; and

c. Was performed by a physician or allowed Non-Physician Practitioner.

Note: The certifying physician must also document the date of the face-to-face encounter.

According to the regulations at 42 CFR 424.22(a)(2) physicians should complete the certification when the plan of care is established or as soon as possible thereafter. The certification must be complete prior to when an HHA bills Medicare for reimbursement.

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