Prior to July 1, 1981, a Part B enrollee is entitled to 100 covered home health visits
under SMI in a calendar year. The visits are reimbursed by the Part A intermediary
for whichever is lower; the provider's customary charge or the reasonable cost of
the covered services.
See HI 00601.300-HI 00601.440 for a discussion of covered home health services.
See HI 00601.450 for the definition of and counting of visits.
See HI 00601.300 B. for coverage requirements which apply to both Part A and Part B services.
For home health benefits to be covered under SMI, the patient must be currently enrolled
in SMI and, where the home health services could be covered under Part A, not be eligible
to receive such services under Part A. Where a patient is eligible for home health
services under both programs the services are chargeable under Part A. When the benefits
under Part A are exhausted or the requirements otherwise no longer met, he may then
use the benefits available under Part B. A plan covering services under SMI must be
established in writing before the agency bills for the services. A physician must
certify that the patient is homebound and in need of intermittent skilled nursing
care or physical or speech therapy. Effective July 1 through November 30, 1981, a
person may also qualify for home health benefits based on his or her need for occupational
therapy. 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 home health services may be extended
solely on the basis of the continuing need for occupational therapy.
A prior inpatient hospital or SNF stay is not a requirement, nor need the condition
being treated be related to one for which inpatient care was received. Effective July
1, 1981, the prior inpatient stay and related condition requirements for services
under Part A are eliminated, as well as the 100 visit limitation under both Parts
A and B.
Effective with services provided after 12/31/72, the 20% coinsurance requirement for
home health benefits was eliminated.