(Medicare Benefit Policy Manual)

C.  Change of Ownership - Mergers   The merger of a provider corporation into another corporation constitutes a change of ownership. For information on specific procedures, refer to Pub. 100-07, State Operations Manual, chapter 2, section 2202.17.  20 - Conditions To Be Met for Coverage of Home Health Services  (Rev. 1, 10-01-03) A3-3116, HHA-203  Medicare covers HHA services when the following criteria are met:   1. The person to whom the services are provided is an eligible Medicare beneficiary;  2. The HHA that is providing the services to the beneficiary has in effect a valid agreement to participate in the Medicare program;   3. The beneficiary qualifies for coverage of home health services as described in 30;  4. The services for which payment is claimed are covered as described in 40 and 50;  5. Medicare is the appropriate payer; and   6. The services for which payment is claimed are not otherwise excluded from payment.  20.1 - Reasonable and Necessary Services  (Rev. 1, 10-01-03) A3-3116.1. HHA-203.1  20.1.1 - Background  (Rev. 10438, Issued: 11-06-20, Effective: 03-01-20, Implementation: 01- 11-21)  In enacting the Medicare program, Congress recognized that the physician or allowed practitioner would play an important role in determining utilization of services.  The law requires that payment can be made only if a physician or allowed practitioner certifies the need for services and establishes a plan of care.  The Secretary is respo nsible for ensuring that Medicare covers the claimed services, including determining whether they are "reasonable and necessary."   20.1.2 - Determination of Coverage  (Rev.  208, Issued: 04-22-15, Effective: 01 -01-15, Implementation: 05-11-15)  The Medicare contractors decision on whether care is reasonable and necessary is based on information reflected in the home health plan of care, the OASIS as required by 42 CFR 484.55 or a medical record of the individual patient.  Medicare does not deny coverage solely on the basis of the reviewer's general inferences about patients with similar diagnoses or on data related to utilization generally, but bases it upon objective clinical e vidence regarding the patient's individual need for care.  Coverage of skilled nursing care or therapy to perform a maintenance program does not turn on the presence or absence of a patients potential for improvement from the nursing care or therapy, but rather on the patients need for skilled care.  Skilled care may be necessary to improve a patients current condition, to maintain the patients current condition, to prevent or slow further deterioration of the patients condition.   20.2 - Impact of Other Available Caregivers and Other Available Coverage on Medicare Coverage of Home Health Services  (Rev.  208, Issued: 04- 22-15, Effective: 01 -01-15, Implementation: 05- 11-15)  Where the Medicare criteria for coverage of home health services are met, patients are entitled by law to coverage of reasonable and necessary home health services.  Therefore, a patient is entitled to have the costs of reasonable and necessary services reimbursed by Medicare without regard to whether there is someone available to furnish the services.  However, where a family member or other person is or will be providing services that adequately meet the patient's needs, it would not be reasonable and nec essary for HHA personnel to furnish such services.  Ordinarily it can be presumed that there is no able and willing person in the home to provide the services being rendered by the HHA unless the patient or family indicates otherwise and objects to the provision of the services by the HHA, or unless the HHA has first hand knowledge to the contrary.   Similarly, a patient is entitled to reasonable and necessary Medicare home health services even if the patient would qualify for institutional care (e.g., hospital care or skilled nursing facility care) and Medicare payment should be made for reasonable and necessary home health services where the patient is also receiving supplemental services that do not meet Medicares definition of skilled nursing care or home health aide services.   EXAMPLE 1:   A patient who lives with an adult daughter and otherwise qualifies for Medicare coverage of home health services, requires the assistance of a home health aide for bathing and assistance with an exercise program to improve endurance.  The daughter is unwil ling to bathe her elderly father and assist him with the exercise program.  Home health aide services would be reasonable and necessary.   EXAMPLE 2:   A patient who is being discharged from a hospital with a diagnosis of osteomyelitis and requires continuation of the I.V. antibiotic therapy that was begun in the hospital was found to meet the criteria for Medicare coverage of skilled nursing facility ser vices.  If the patient also meets the qualifying criteria for coverage of home health services, payment may be made for the reasonable and necessary home health services the patient needs, notwithstanding the availability of coverage in a skilled nursing f acility.   EXAMPLE 3:   A patient who needs skilled nursing care on an intermittent basis also hires a licensed practical (vocational) nurse to provide nighttime assistance while family members sleep.  The care provided by the nurse, as respite to the family members, does not require the skills of a licensed nurse (as defined in 40.1 ) and therefore has no impact on the beneficiary's eligibility for Medicare payment of home health services even though another third party insurer may pay for that nursing care.  20.3 - Use of Utilization Screens and "Rules of Thumb"  (Rev. 1, 10-01-03) A3-3116.3, HHA-203.3  Medicare recognizes that determinations of whether home health services are reasonable and necessary must be based on an assessment of each beneficiary's individual care needs.  Therefore, denial of services based on numerical utilization screens, diagnost ic screens, diagnosis or specific treatment norms is not appropriate.  30 - Conditions Patient Must Meet to Qualify for Coverage of Home Health Services  (Rev. 10438, Issued: 11-06-20, Effective: 03-01-20, Implementation: 01- 11-21)  To qualify for the Medicare home health benefit, under 1814(a)(2)(C) and 1835(a)(2)(A)  of the Act, a Medicare beneficiary must meet the following requirements:    Be confined to the home;   Under the care of a physician or allowed practitioner;   Receiving services under a plan of care established and periodically reviewed by a physician or allowed practitioner;   Be in need of skilled nursing care on an intermittent basis or physical therapy or speech -language pathology; or    Have a continuing need for occupational therapy.  For purposes of benefit eligibility, under 1814(a)(2)(C) and 1835(a)(2)(A) of the Act, "intermittent" means skilled nursing care that is either provided or needed on fewer than 7 days each week or less than 8 hours of each day for periods of 21 days or l ess (with extensions in exceptional circumstances when the need for additional care is finite and predictable).   A patient must meet each of the criteria specified in this section.  Patients who meet each of these criteria are eligible to have payment made on their behalf for services discussed in 40 and 50.  30.1 - Confined to the Home  (Rev. 1, 10-01-03) A3-3117.1, HHA-204.1  30.1.1 - Patient Confined to the Home  (Rev. 10438, Issued: 11- 06-20, Effective: 03 -01-20, Implementation: 01-  11-21)  For a patient to be eligible to receive covered home health services under both Part A and Part B, the law requires that a physician or allowed practitioner certify in all cases that the patient is confined to his/her home.  For purposes of the statute, an individual shall be considered confined to the home (homebound) if the following two criteria are met:   1. Criterion One:   The patient must either:   - Because of illness or injury, need the aid of supportive devices such as crutches, canes, wheelchairs, and walkers; the use of special transportation; or the assistance of another person in order to leave their place of residence   OR  - Have a condition such that leaving his or her home is medically contraindicated.   If the patient meets one of the criterion one conditions, then the patient must ALSO meet two additional requirements defined in criterion two below.   2. Criterion Two:   - There must exist a normal inability to leave home;  AND   - Leaving home must require a considerable and taxing effort.   To clarify, in determining whether the patient meets criterion two of the homebound definition, the clinician needs to take into account the illness or injury for which the patient met criterion one and consider the illness or injury in the context of the patients overall condition.  The clinician is not required to include standardized phrases reflecting the patients condition (e.g., repeating the words taxing effort to leave the home) in the patients chart, nor are such phrases sufficient, by themsel ves, to demonstrate that criterion two has been met.  For example, longitudinal clinical information about the patients health status is typically needed to sufficiently demonstrate a normal inability to leave the home and that leaving home requires a considerable and taxing effort.  Such clinical information about the patients overall health status may include, but is not limited to, such factors as the patients diagnosis, duration of the patients condition, clinical course (worsening or improvement), prognosis, nature and extent of functional limitations, other therapeutic interventions and results, etc.   If the patient does in fact leave the home, the patient may nevertheless be considered homebound if the absences from the home are infrequent or for periods of relatively short duration, or are attributable to the need to receive health care treatment.  Ab sences attributable to the need to receive health care treatment include, but are not limited to:    Attendance at adult day centers to receive medical care;    Ongoing receipt of outpatient kidney dialysis; or    The receipt of outpatient chemotherapy or radiation therapy.   Any absence of an individual from the home attributable to the need to receive health care treatment, including regular absences for the purpose of participating in therapeutic, psychosocial, or medical treatment in an adult day -care program that is licens ed or certified by a state, or accredited to furnish adult day- care services in a state, shall not disqualify an individual from being considered to be confined to his home.  Any other absence of an individual from the home shall not so disqualify an individual if the absence is of an infrequent or of relatively short duration.  For purposes of the preceding sentence, any absence for the purpose of attending a religious service shall be deemed to be an absence of infrequent or short duration.  It is expecte d that in most instances, absences from the home that occur will be for the purpose of receiving health care treatment.  However, occasional absences from the home for nonmedical purposes, e.g., an occasional trip to the barber, a walk around the block or a drive, attendance at a family reunion, funeral, graduation, or other infrequent or unique event would not necessitate a finding that the patient is not homebound if the absences are undertaken on an infrequent basis or are of relatively short duration and do not indicate that the patient has the capacity to obtain the health care provided outside rather than in the home.   Some examples of homebound patients that illustrate the factors used to determine whether a homebound condition exists are listed below.   A patient paralyzed from a stroke who is confined to a wheelchair or requires the aid of crutches in order to walk.   A patient who is blind or senile and requires the assistance of another person in leaving their place of residence.    A patient who has lost the use of their upper extremities and, therefore, is unable to open doors, use handrails on stairways, etc., and requires the assistance of another individual to leave their place of residence.   A patient in the late stages of ALS or neurodegenerative disabilities.  In determining whether the patient has the general inability to leave the home and leaves the home only infrequently or for periods of short duration, it is necessary (as is the case i n determining whether skilled nursing services are intermittent) to look at the patient's condition over a period of time rather than for short periods within the home health stay.  For example, a patient may leave the home (meeting both criteria listed above) more frequently during a short period when the patient has multiple appointments with health care professionals and medical tests in 1 week.  So long as the patient's overall condition and experience is such that he or she meets  these qualifications, he or she should be considered confined to the home.   A patient who has just returned from a hospital stay involving surgery, who may be suffering from resultant weakness and pain because of the surgery and; therefore, their actions may be restricted by their physician or allowed practitioner to certain speci fied and limited activities (such as getting out of bed only for a specified period of time, walking stairs only once a day, etc.).   A patient with arteriosclerotic heart disease of such severity that they must avoid all stress and physical activity.