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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 while Home Health Prospective Payment System (HH PPS) payment is now made for each 
30-day period, the home health PPS permits continuous 60-day recertifications for patients who continue to be 
eligible for the home health benefit. Medicare does not limit the number of continuous 60-day recertifications 
for beneficiaries who continue to be eligible for the home health benefit. Each 60-day certification can include 
two 30-day payment periods. 
 
Recertification is required at least every 60 days when there is a need for continuous home health care after an 
initial 60-day certification. The recertification visit can be done during the prior certification period. With some 
minor exceptions, the Medicare Conditions of Participation at 42 CFR 484.55(d)(1), require that the 
recertification assessment be done during the last 5 days of the previous certification period (for example, 
during the initial 60-day certification period, the recertification visit is required to be done on days 56-60). 
 
You can find these rules in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 
100-02, Medicare Benefit Policy Manual, Chapter 7, Section 10.3. 
 
The rules say that services are provided under a plan of care established and approved by a physician or 
allowed practitioner. The home health agency (HHA) must be acting upon a physician or allowed practitioner 
plan of care that meets the requirements of this section for HHA services to be covered. For HHA services to 
be covered, the individualized plan of care must specify the services necessary to meet the patient-specific 
needs identified in the comprehensive assessment. In addition, the plan of care must include the identification 
of the responsible discipline(s) and the frequency and duration of all visits as well as those items listed in 42 
CFR 484.60(a) that establish the need for such services. All care provided must be in accordance with the plan 
of care. You can find these rules in the Centers for Medicare and Medicaid Services, Internet Only Manual, 
Publication 100-02, Medicare Benefit Policy Manual, Chapter 7, Sections 30.2 and 30.2.2. 
 
The rules say that the plan of care must be reviewed and signed by the physician or allowed practitioner who 
established the plan of care, in consultation with HHA professional personnel, at least every 60 days. Each review of a patient's plan of care must contain the signature of the physician or allowed practitioner and the 
date of review. You can find these rules in the Centers for Medicare and Medicaid Services, Internet Only 
Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 7, Section 30.2.7. 
 
The rules say that the HHA must be acting upon a plan of care as described in section 30.2, and a physician or 
allowed practitioner certification or recertification that meets the requirements of the following sections in 
order for HHA services to be covered. 
 
The certification must be complete prior to when an HHA bills Medicare for reimbursement; however, 
physicians and allowed practitioners should complete the certification when the plan of care is established, or 
as soon as possible thereafter. This is longstanding CMS policy as reference in Pub 100-01, Medicare General 
Information, Eligibility, and Entitlement Manual, Chapter 4, Section 30.1. It is not acceptable for HHAs to wait 
until the end of a 60-day certification period to obtain a completed certification/recertification.  
 
You can find these rules in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 
100-02, Medicare Benefit Policy Manual, Chapter 7, Sections 30.5 and 30.5.1. 
 
The rules say that a the end of the 60-day certification, a decision must be made whether or not to recertify the 
patient for a subsequent 60-days. An eligible beneficiary who qualifies for a subsequent 60-day certification 
would start the subsequent 60-day certification on day 61. Under HH PPS, the plan of care must be reviewed 
and signed by the physician or allowed practitioner every 60-days unless one of the following occurs: 
 
--A beneficiary transfers to another HHA; or 
--A discharge and return to home health during the 60-day certification. 
 
You can find these rules in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 
100-02, Medicare Benefit Policy Manual, Chapter 7, Section 30.5.2. 
 
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.