Southern Home Care Orientation to HCFA (Medicare) Regulations for Home Health Agencies


II. CONDITIONS TO BE MET FOR COVERAGE OF HOME HEALTH SERVICES Reference: Medicare Home Health Agency Manual, Transmittal 277

    A. The person to whom the services are provided is an eligible Medicare beneficiary.

    B. The home health agency (HHA) that is provid- ing the services to the beneficiary has in effect a valid agreement to participate in the Medicare program.

    C. The beneficiary qualifies for coverage of home health services as described in S204

    1. The patient is confined to the home. (204.1, p. 13.6)

    a. Handout: Homebound Status

    2. Services are provided under a plan of care established and approved by a physician. (204.2, p. 14)

    3. The patient needs skilled nursing care on an intermittent basis or physical therapy or speech-language pathology services or has a continued need for occupational therapy. (204.4, p. 14.3)

    D. The services for which payment is claimed are covered as described in SS205 and 206, and are reasonable and necessary (205.1, p. 14.4)

    1. Decision Tree

    2. Handouts

    E. Skilled Nursing Services

    1. Observation and Assessment (205.1, p. 14.7)

    2. Management and Evaluation of a patient care plan (p. 14.8)

    a. Handout

    3. Teaching and Training (p. 14.9)

    4. Administration of Medications (p. 14.12)

    5. Treatments and Procedures (p. 14.14)

    6. Student nurse visits (p. 14.18)

    7. Psychiatric Nursing Care (p. 14.18)

    a. Handout: Admission Criteria

    F. Skilled Therapy Services

    1. Physical Therapy (205.2, p. 15)

    2. Speech-Language Pathology services (p. 15.4)

    3. Occupational Therapy (p. 15.4)

    a. Rehab Admission Criteria

    b. OT: Non-qualifying Service

    G. Coverage of Other Home Health Services

    1. Home health aide services (206.2, p. 15.6)

    a. Handout: Referral Criteria

    2. Personal Care (p. 15.7)

    3. Medical Social Services (206.3, p. 15.9)

    a. Handout: Referral Criteria

    4. Medical supplies (206.4, p. 15.12)

    a. Routine Supplies

    b. Non-routine supplies

    5. Part-time or intermittent home health aide and skilled nursing services (206.7, p. 15.15)

    H. Medicare is the appropriate payer

    I. The services for which payment is claimed are not otherwise excluded from payment

    1. Drugs and Biologicals (230 A)

    2. End Stage Renal Disease Programs (230 E)

    3. Respiratory Care (230 H)

    4. Dietary/Nutrition Personnel (230 I)