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 his home
by HHA personnel depends solely on whether he is 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 his 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
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 his 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.