(Medicare General Information, Eligibility, and Entitlement)

A home health agency is a public agency or private organization, or a subdivision of such an agency or organization, which meets the following requirements:    It is primarily engaged in providing skilled nursing services and other therapeutic services, such as physical therapy, occupational therapy, or speech -language pathology, medical social services, and home health aide services.  A public or voluntary nonpr ofit health agency may qualify by:   o Furnishing both skilled nursing and at least one other therapeutic service directly to patients, or   o Furnishing directly either skilled nursing services or at least one other therapeutic service and having arrangements with another public or voluntary nonprofit agency to furnish the services which it does not provide directly.   NOTE:   A proprietary agency can qualify only by providing directly both skilled nursing services and at least one other therapeutic service.    It has policies established by a professional group associated with the agency or organization (including at least one physician and at least one registered professional nurse) to govern the services, and provides for supervision of such services by a phys ician or a registered professional nurse;    It maintains clinical records on all patients;   It is licensed in accordance with State or local law or is approved by the State or local licensing agency as meeting the licensing standards (where State or local law provides for the licensing of such agencies or organizations); and    It meets other conditions found by the Secretary of the Department of Health and Human Services to be necessary for health and safety.   A private organization which is not exempt from Federal income taxation under section 501 of the Internal Revenue Code of 1954 (sometimes referred to as a "proprietary" organization) must be licensed pursuant to State law.  If the State has no licensing la w for such organizations, a proprietary agency cannot participate in the health insurance program.   For services under hospital insurance, the term "home health agency" does not include any agency or organization which is primarily for the care and treatment of mental disease.  There is no such restriction under supplementary medical insurance.   50.1 - Subdivisions of Agencies as Home Health Agencies  (Rev. 1, 09- 11-02)  When the subdivision of an agency, such as the home care department of a hospital or the nursing division of a health department, wishes to participate as a home health agency, the subdivision must meet the conditions of participation and must maintain rec ords in such a way that subdivision activities and expenditures attributable to services provided under the health insurance program are identifiable.  50.2 - Arrangements by Home Health Agencies (Rev. 19, Issued: 03- 11-05, Effective/Implementation: N/A)   A.  A home health agency (HHA) may have others furnish covered items or services through arrangements under which receipt of payment by the HHA for the services discharges the liability of the patient or any other person to pay for the services.  Whether the items and services are provided by the HHA itself or by another agency under arrangement, both must agree not to charge the patient for covered items and services and must also agree to return money incorrectly collected.  In permitting HHAs to furnish services under arrangements, it was not intended that the agency merely serve as a billing mechanism for the other party.  Accordingly, for services provided under arrangements to be covered, the agency must exercise professio nal responsibility over the arranged- for services and ensure compliance with the home health conditions of participation.   The agency's professional supervision over arranged- for services requires application of many of the same quality controls as are applied to services furnished by salaried employees.  The agency must accept the patient for treatment in accordance with its administration policies, maintain a complete and timely clinical record of the patient that includes diagnosis, medical history, physician's orders, and progress notes relating to all services received; maintain liaison with the attending physician with re gard to the progress of the patient and to assure that the required plan of treatment is periodically reviewed by the physician; secure from the physician the required certifications and recertifications; and ensure that the medical necessity of such servi ces is reviewed on a sample basis by the agency's staff or an outside review group.   There are three situations in which an HHA may have arrangements with another health organization or person to provide home health services to patients:    Where an agency or organization, in order to be approved to participate in the program, makes arrangements with another organization or individual to provide the nursing or other therapeutic services that it cannot provide directly;    Where an agency that is already approved for participation, makes arrangements with others to provide services or items it does not provide directly; and    Where an agency that is already approved for participation makes arrangements with a hospital, skilled nursing facility, or rehabilitation center for services on an outpatient basis because the services involve the use of equipment that cannot be made avai lable to the patient in his/her place of residence.   B.  If an agency's subdivision (acting in its capacity as an HHA) makes an arrangement with its parent agency for the provision of certain items or services, there need not be a contract or formal agreement.  If, however, the arrangement is made between the HH A and another provider participating in the health insurance program (hospital, skilled nursing facility, or HHA, and, in the case of physical therapy, occupational therapy, or speech -language pathology services, clinics, rehabilitation agencies, and p ublic health agencies), there must be a written statement regarding the services to be provided and the financial arrangements.   C.  If the arrangements are with an agency or organization that is not a qualified provider of services, there must be a written contract that includes all of the following:  1. A description of the services to be provided.   2. The duration of the agreement and how frequently it is to be reviewed.   3. A description of how personnel will be supervised.  4. A statement that the contracting organization will provide services in accordance with the plan of care established by the patient's physician in conjunction with the HHA's staff.   5. A description of the contracting organization's standards for personnel, including qualifications, functions, supervision, and inservice training.  6. A description of the method of determining reasonable costs and reimbursement by the HHA for the specific services to be provided by the contracting organization.   7. An assurance that the contracting organization will comply with title VI  of the Civil Rights Act.    If an HHA notifies a beneficiary of noncoverage of services that another party has been furnishing under arrangements entered into by the agency, the initial notice, in and of itself, does not negate the contract between the agency and the other party.  Unless the evidence shows that the contract has been formally terminated, the beneficiary is still considered to be the agency's patient and the other party to be the representative of the agency.  Consequently, if upon initial notice that a service is no lo nger covered the other party continues to provide services to the patient, the other party is considered to be furnishing the services under arrangements with the home health agency, absent evidence to the contrary.  Thus, if a beneficiary appeals the noncoverage of any or all of the arranged for services furnished after the notice, and a ruling is made in favor of the beneficiary, those services ruled on favorably would be reimbursable since they would constitute services furnished under arrangements by a certified HHA.  If the denial is sustained, however, the other party cannot bill the beneficiary for the denied services since the HHA, not the other party, is responsible for the care rendered.   50.3 - Arrangements with Parent Agency and Other Entities  (Rev. 1, 09- 11-02)  If an agency's subdivision (acting in its capacity as an HHA) makes an arrangement with its parent agency for the provision of certain items or services, there need not be a contract or formal agreement.  If, however, the arrangement is made between the HH A and another provider participating in the health insurance program (hospital, skilled nursing facility, or HHA, and, in the case of physical therapy, occupational therapy, or speech -language pathology services, clinics, rehabilitation agencies, and publi c health agencies), there must be a written statement regarding the services to be provided and the financial arrangements.   If the arrangements are with an agency or organization that is not a qualified provider of services, there must be a written contract that includes all of the following:   A description of the services to be provided;    The duration of the agreement and how frequently it is to be reviewed;    A description of how personnel will be supervised;    A statement that the contracting organization will provide services in accordance with the plan of care established by the patient's physician in conjunction with the HHA's staff;    A description of the contracting organization's standards for personnel, including qualifications, functions, supervision, and inservice training;    A description of the method of determining reasonable costs and reimbursement by the HHA for the specific services to be provided by the contracting organization; and    An assurance that the contracting organization will comply with title VI of the Civil Rights Act.   50.4 - Notice of Noncoverage of Services  (Rev. 1, 09- 11-02)  If an HHA notifies a beneficiary of noncoverage of services that another party has been furnishing under arrangements entered into by the agency, the initial notice, in and of itself, does not negate the contract between the agency and the other party.  Unless the evidence shows that the contract has been formally terminated, the beneficiary is still considered to be the agency's patient  and the other party to be the representative of the agency.  Consequently, if upon initial notice that a service is no longer covered the other party continues to provide services to the patient, the other party is considered to be furnishing the services  under arrangement.   50.5 - Rehabilitation Centers  (Rev. 19, Issued: 03- 11-05, Effective/Implementation: N/A)   When the services are of such a nature that they cannot be administered at the patient's residence and are administered at a rehabilitation center which is not participating in the program as a hospital, skilled nursing facility, or home health agency, the rehabilitation center must meet certain standards.  The physical plant and equipment of such a rehabilitation center must me et all applicable State and local legal requirements for construction, safety, health, and design, including safety, sanitation and fire regulations, building codes, and ordinances.  Given the statutory definition, a community mental health center is not c onsidered a rehabilitation center.   60 - Hospice Defined  (Rev. 1, 09- 11-02)  A hospice is a public agency or private organization or a subdivision of either that is primarily engaged in providing care to terminally ill individuals and meets the conditions of participation for hospices, and has a valid provider agreement.   60.1 - Subdivision of Organizations as Hospices  (Rev. 1, 09- 11-02)  When a subdivision of an organization, such as the home care department of a hospital, wishes to participate as a hospice, the subdivision must meet the hospice conditions of participation and must maintain records in such a way that activities and expendi tures attributable to services provided under the hospice program are identifiable.   60.2 - Arrangements by Hospices (Rev. 1, 09- 11-02)  Hospices are required to provide core services directly, that is, nursing services, medical social services, and counseling. Other covered services may be provided under arrangement.   70 - Physician Defined  (Rev. 1, 09- 11-02)  Physician means doctor of medicine, doctor of osteopathy (including osteopathic practitioner), doctor of dental surgery or dental medicine (within the limitations in subsection 70.2 ), doctor of podiatric medicine (within the limitations in subsection 70.3), or doctor of optometry (within the limitations of subsection 70.5 ), and, with respect to certain specified treatment, a doctor of chiropractic legally authorized to practice by a State in which he/she performs this function.  The services performed by a physician within these definitions are subject to any limitations i mposed by the State on the scope of practice.   The issuance by a State of a license to practice medicine constitutes legal authorization. Temporary State licenses also constitute legal authorization to practice medicine.  If State law authorizes local political subdivisions to establish higher standards for medical practitioners than those set by the State licensing board, the local standards determine whether a particular physician has legal authorization.  If State licensing law limits the scope of practice of a particular type of medical practitioner , only the services within the limitations are covered.   The issuance by a State of a license to practice medicine constitutes legal authorization. Temporary State licenses also constitute legal authorization to practice medicine.  If State law authorizes local political subdivisions to establish higher standards for medical practitioners than those set by the State licensing board, the local standards determine whether a particular physician has legal authorization.  If State licensing law limits the scope of practice of a particular type of medical practitioner , only the services within the limitations are covered.   NOTE:   The term physician does not include such practitioners as a Christian Science practitioner or naturopath.  70.1 - Doctors of Medicine and Osteopathy  (Rev. 1, 09-11-02)  The requirement that a doctor of medicine be legally authorized to practice medicine and surgery by the State in which he/she performs his/her services means a physician is licensed to practice medicine and surgery.   A doctor of osteopathy who is legally authorized to practice medicine and surgery by the State in which he/she performs his/her services qualifies as a physician.  In addition, a licensed osteopath or osteopathic practitioner qualifies as a physician to the extent that he/she performs services within the scope of his/her practice as defined by State law.