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The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.
The rules say that Medicare pays for home health care services under a prospective payment system (HH PPS). Home health services under a plan of care are paid based on a 60-day episode of care. Payment for home health care episodes is usually made in two parts. To receive the first part of the HH PPS split payment, the home health agency must submit a Request for Anticipated Payment (RAP). Specific data elements are required to submit a RAP. The home health agency must enter the claim - Outcome and Assessment Information Set (OASIS) matching key output by the Grouper software. This is known as the Treatment Authorization Code. You can find this rule, a list of the data elements, and instructions for the Treatment Authorization Code in the Centers for Medicare and Medicaid Services, Internet Only Manual, Medicare Claims Processing Manual, Chapter 10, Section 40.1. The rules say that after a RAP has been paid and a 60-day episode has been completed or the enrollee has been discharged, the home health agency must submit a claim to receive the rest of payment due for the episode. You can find this rule and detailed instructions for the claim in the Centers for Medicare and Medicaid Services, Internet Only Manual, Medicare Claims Processing Manual, Chapter 10, Section 40.2. To report HH visits, the HHA reports one of the following HCPCS codes to represent a visit by each HH care discipline: Physical Therapy (revenue code 042x) G0151 Services performed by a qualified physical therapist in the home health or hospice setting, each 15 minutes. G0157 Services performed by a qualified physical therapist assistant in the home health or hospice setting, each 15 minutes.
G0159 Services performed by a qualified physical therapist, in the home health setting, in the establishment or delivery of a safe and effective physical therapy maintenance program, each 15 minutes. G2168 Services performed by a physical therapist assistant in the home health setting in the delivery of a safe and effective physical therapy maintenance program, each 15 minutes. Occupational Therapy (revenue code 043x) G0152 Services performed by a qualified occupational therapist in the home health or hospice setting, each 15 minutes. G0158 Services performed by a qualified occupational therapist assistant in the home health or hospice setting, each 15 minutes. G0160 Services performed by a qualified occupational therapist, in the home health setting, in the establishment or delivery of a safe and effective occupational therapy maintenance program, each 15 minutes. G2169Services performed by an occupational therapist assistant in the home health setting in the delivery of a safe and effective occupational therapy maintenance program, each 15 minutes. Speech-Language Pathology (revenue code 044x) G0153 Services performed by a qualified speech-language pathologist in the home health or hospice setting, each 15 minutes. G0161 Services performed by a qualified speech-language pathologist, in the home health setting, in the establishment or delivery of a safe and effective speech-language pathology maintenance program, each 15 minutes. Note that modifiers indicating services delivered under a therapy plan of care (modifiers GN, GO or GP) are not required on HH PPS claims. Skilled Nursing (revenue code 055x) General skilled nursing: G0299Direct skilled nursing services of a registered nurse (RN) in the home health or hospice setting G0300Direct skilled nursing of a licensed practical nurse (LPN) in the home health or hospice setting. Care plan oversight: G0162 Skilled services by a licensed nurse (RN only) for management and evaluation of the plan of care, each 15 minutes (the patient's underlying condition or complication requires an RN to ensure that essential non-skilled care achieves its purpose in the home health or hospice setting). G0493 Skilled services of a registered nurse (RN) for the observation and assessment of the patient's condition, each 15 minutes (the change in the patient's condition requires skilled nursing personnel to identify and evaluate the patient's need for possible modification of treatment in the home health or hospice setting). G0494 Skilled services of a licensed practical nurse (LPN) for the observation and assessment of the patient's condition, each 15 minutes (the change in the patient's condition requires skilled nursing personnel to identify and evaluate the patient's need for possible modification of treatment in the home health or hospice setting). Training: G0495 Skilled services of a registered nurse (RN), in the training and/or education of a patient or family member, in the home health or hospice setting, each 15 minutes. G0496 Skilled services of a licensed practical nurse (LPN), in the training and/or education of a patient or family member, in the home health or hospice setting, each 15 minutes. Medical Social Services (revenue code 056x) G0155 Services of a clinical social worker under a home health plan of care, each 15 minutes. Home Health Aide (revenue code 057x) G0156 Services of a home health aide under a home health plan of care, each 15 minutes. Regarding all skilled nursing and skilled therapy visits In the course of a single visit, a nurse or qualified therapist may provide more than one of the nursing or therapy services reflected in the codes above. HHAs must not report more than one G-code for each visit regardless of the variety of services provided during the visit. In cases where more than one nursing or therapy service is provided in a visit, the HHA must report the G-code which reflects the service for which the clinician spent most of his/her time. For instance, if direct skilled nursing services are provided, and the nurse also provides training/education of a patient or family member during that same visit, Medicare would expect the HHA to report the G-code which reflects the service for which most of the time was spent during that visit. Similarly, if a qualified therapist is performing a therapy service and also establishes a maintenance program during the same visit, the HHA should report the G-code that reflects the service for which most of the time was spent during that visit. In all cases, however, the number of 15-minute increments reported for the visit should reflect the total time of the visit. You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Medicare Claims Processing Manual, Chapter 10, Section 40.2. The rules also say that certain data elements are required. Any claim with incomplete, missing, or invalid information for all of these elements may be returned as unprocessable. You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Medicare Claims Processing Manual, Chapter 1, Section 80.3.1.
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.