TN 7 (10-22)

HI 00601.310 HHA Coverage—Discussion Guidelines

In any discussion about home health services it is important not to create the impression that a beneficiary's entitlement to have payment made for visits made to their home by HHA personnel depends solely on whether they are eligible for Medicare benefits.

On the contrary, in discussing home health services with a beneficiary, stress that the law does not cover all types and levels of care provided in the home. Point out that the home health benefit is limited by statute to individuals who are under a physician's care, confined to their homes, and in need of skilled nursing care on an intermittent basis,or physical or speech therapy, or effective July 1, through November 30, 1981, occupational therapy, which is reasonable and necessary to the treatment of their illness. Effective December 1, 1981, occupational therapy is eliminated as a basis for entitlement to home health services. However, if a person has otherwise qualified for home health services because of the need for skilled nursing care, physical therapy or speech therapy, the patient's eligibility for homehealth services may be extended solely on the basis of the continuing need for occupational therapy. If these conditions are, met, Medicare will pay for any of the covered home health services required by the individual providing they are furnished directly or under arrangement by a participating HHA. As a further emphasis of the limitations applicable to the home health benefit, point out that when an individual's only need is for assistance in meeting their activities of daily living, e.g., assistance in bathing, toileting, etc. and performing simple household tasks, the care required would not be reimbursable under Medicare since it would constitute custodial care which is specifically excluded from coverage.

Skilled nursing care under Medicare has been defined as those services which must be performed by, or under the direct supervision of, a licensed nurse if the safety of the patient is to be assured and the medically desired result achieved. Stress that a service is not considered a skilled nursing service merely because it is performed by or under the supervision of a licensed nurse. That is, when the nature of the service is such that it can be safely and effectively performed (or self-administered) by the average nonmedical person without the direct supervision of a licensed nurse, the service cannot be regarded as a skilled nursing service even if a nurse renders the service (see HI 00601.340).

Physical therapy has been defined for Medicare purposes as those services prescribed by a physician which because of their complexity or the condition of the patient, require the judgment, knowledge, and skills of a qualified physical therapist and, are in fact, performed by such a therapist or under their direct supervision.

In addition, make it clear that the DO can furnish general information only and that whether home health visits furnished an individual are reimbursable is a decision which must be made by the intermediary with advice from its medical staff based on the facts in the particular case.

If the beneficiary is dissatisfied with the explanation of the denial of home health services, provide any necessary assistance in completing a request for reconsideration.