HI 00601.470 Special Conditions for Coverage of Home Health Services Under Hospital Insurance (Part A)
In addition to the conditions listed in HI 00601.300 B, the following conditions must be met for coverage under HI for services furnished prior to July 1, 1981.
A. The benefit period provision and inpatient stay requirement
Coverage of home health visits under HI is subject to a spell of illness provision and a prior inpatient stay requirement.
1. Effect of benefit period on
HI coverage extends only to home health visits (100 or less) furnished after the beginning of one benefit period (see HI 00401.340) and before the beginning of the next.
The controlling event is the beginning of the benefit period and it is immaterial whether the patient is either in a benefit period, or has ended a benefit period and not begun a new one. A series of visits ends with the beginning of a new benefit period.
For purposes of qualifying for posthospital home health benefits, a benefit period begins with a stay in a hospital accredited by the Joint Commission on Accreditation of Hospitals (JCAH), or the American Osteopathic Association (AOA), even though the hospital does not participate in the Medicare program. This rule applies regardless of whether the hospital is within the United States or in a foreign country or whether the services are emergency or nonemergency.
2. Prior inpatient stay
In addition to the benefit period requirement, the law specifies that the home health visits must take place in the year following the most recent discharge from a covered SNF stay of any duration or from a medically necessary stay of at least three consecutive days in:
A participating general, psychiatric or tuberculosis hospital; or
a participating distinct part of a psychiatric or tuberculosis hospital, or
a nonparticipating general, psychiatric, or tuberculosis hospital which meets at least the conditions of participation for a hospital, i.e., an emergency services hospital.
A nonparticipating psychiatric or tuberculosis hospital need not meet the special requirements applicable to psychiatric and tuberculosis hospitals. Federal hospitals need not be licensed under State or local laws to meet the prior stay hospital definition. Stays in Christian Science Sanatoriums are excluded for the purpose of satisfying the prior inpatient stay requirement.
The three consecutive calendar days requirement can be met by stays totalling three consecutive days in one or more hospitals. In determining whether the requirement has been met, the day of admission, but not the day of discharge is counted as a hospital inpatient day. There must be an actual discharge of the patient from the hospital or SNF to his residence. See HI 00601.300 for conditions under which an institution may not be considered the patient's residence.
The discharge from the hospital which is required to qualify home health services for payment under HI must have occurred on or after the first day of the month in which the patient attained age 65.
B. Three-day prior hospitalization—foreign hospital
A stay of three or more days in a hospital outside the United States may satisfy the prior inpatient stay requirement for posthospital home health services within the United States if the foreign hospital is qualified as an “emergency hospital.”
NOTE: Effective July 1, 1981, the visit limitation, the prior inpatient stay, and the spell of illness requirements are eliminated.