HI 00601.300 Home Health Services
Act—Sec. 1861(m), (n)
Regulation No. 5—Sec. 405.170
A patient may be eligible for home health services under both hospital insurance and SMI. (HI 00610.390 for home health services under Part B.) All services furnished by an HHA, whether provided directly by the HHA or under arrangements (see HI 00401.285) with others, must be furnished by or under the supervision of qualified personnel.
B. Requirements for coverage under HI and SMI
1. Patient must be under care of a physician
Items and services must be furnished to an individual who is under the care of a physician. This physician may be the patient's private physician, or physician on the staff of the HHA, or a physician working under an arrangement with the institution which is the patient's residence, or if the agency is hospital-based, a physician on the hospital or agency staff. The attending physician establishes the plan of treatment and also certifies to the necessity for home health services.
Effective July 1, 1981, a physician is prohibited from establishing a plan of treatment, certifying or recertifying for home health services if the physician has a significant ownership interest in, or a significant financial or contractual relationship with such home health agency other than government owned.
2. Services must be furnished under a plan
Items and services must be furnished under a plan established and periodically reviewed by a physician and which relates the items and services to the patient's condition. The plan must either be put into writing by the physician and made available to the HHA which has accepted the patient as a client or the HHA itself may make a written record of the physician's oral orders.
3. Patient must be confined to his home
An individual does not have to be bedridden to be considered as confined to his home. The patient's condition must be such that there exists a normal inability to leave home and, consequently, leaving his home would require a considerable and taxing effort.Generally, a beneficiary is considered to be homebound if he has a condition, due to an illness or injury which restricts his ability to leave his place of residence except with the aid of supportive devices such as crutches, canes, wheelchairs, and walkers, the use of special transportation, or the assistance of another person or if he has a condition so that leaving his home is medically contraindicated.
A patient's residence is wherever he makes his home. This may be his own dwelling, an apartment, a relative's home, a home for the aged, or some other type of institution. However, an institution may not be considered a patient's residence if it:
Meets at least the basic requirement in the definition of a hospital; i.e., it is primarily engaged in providing by or under the supervision of physicians, to inpatients, diagnostic and therapeutic services for medical diagnosis, treatment, and care of injured, disabled, and sick persons, or rehabilitation services for the rehabilitation of injured, disabled, or sick persons or
Meets at least the basic requirement in the definition of a skilled nursing facility; i.e., it is primarily engaged in providing to inpatients skilled nursing care and related services for patients who require medical or nursing care, or rehabilitation services for the rehabilitation of injured, disabled, or sick persons. Thus, if an individual is a patient in an institution or distinct part of an institution which provides the services described in items a. or b. above, he is not entitled to have payment made for home health services under either Part A or Part B since such an institution may not be considered his residence.When a patient remains in a participating SNF following his discharge from active care, the facility may not be considered his residence for purposes of home health coverage.