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Many Pennsylvania intermediate care service providers could be billing Pennsylvania’s Medical Assistance Program ( i.e. Medicaid ) for long term intermediate level nursing and related health care services ( i.e. long term institutional level care ) concerning patients who are more properly long term intermittent level nursing and related health care service ( i.e. long term residential level care) patients under Medicare’s Part A Home Health Services benefit.

In Pennsylvania, to be considered nursing facility clinically eligible as is required for both nursing facility services and home and community based Pennsylvania Department of Aging ( i.e. PDA HCB ) waiver services payment under Medical Assistance ( i.e. Medicaid), you must show that at least an intermediate level of care is medically needed by the recipient of those services . See (55 Pa. Code § 1181.22 ; see also 42 U.S.C. 1396n(c)(1) concerning PDA waiver services ( emphasis added) . A “nursing facility” often is just an intermediate care level provider, as a “nursing facility “ institution need not be an “skilled nursing facility “ institution that is primary engaged in providing skilled nursing care and related services and/or rehabilitation services to a resident. Rather, a “nursing facility” need only provide “on a regular basis, health-related care and services to individuals who because of their mental or physical condition require care and services (above the level of room and board) which can be made available to them only through institutional facilities, and is not primarily for the care and treatment of mental diseases “ ” See 42 U.S.C. 1396r (a) (1)(C).

Pennsylvania defines an intermediate level of care as “ A level of care provided by a facility that is licensed by the Department of Health to provide intermediate care. Intermediate care shall be ordered by, and provided under the direction of a physician. It is available on a continuous 24-hour basis to a person who does not require the degree of care and treatment provided in a hospital or skilled nursing facility. Because of a mental or physical disability, the person does, however, require nursing and related health and medical services in the context of a planned program of health care and management. ….. See 55 Pa Code 1181.2 Definitions. (emphasis added)

Accordingly, to be clinically eligible for Pennsylvania Medical Assistance or Medicaid , whether it be for either nursing home services or PDA HCB waiver services, one must clinically need at least regularly provided and continuously available nursing and health-related care and services that are above the level of room and board but below the level of hospital and skilled nursing facility care and services, within the context of a planned program of health care and management.

On the other hand, as I’ve detailed in prior articles, to be clinically eligible for the Medicare Home Health Services benefit under Medicare Part A , the patient must meet the following requirements:

1 Be confined to the home;
2 Under the care of a physician;
3 Receiving services under a plan of care established and periodically reviewed by a physician;
4 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. (emphasis added)

The term “part-time or intermittent” for purposes of coverage under §1861(m) of the Act means skilled nursing and home health aide services furnished any number of days per week as long as they are furnished (combined) less than 8 hours each day and 28 or fewer hours each week (or, subject to review on a case-by-case basis as to the need for care, less than 8 hours each day and 35 or fewer hours per week). See Section 40 – Covered Services Under a Qualifying Home Health Plan of Care -Medicare Benefit Policy Manual Chapter 7 – Home Health Services (Rev. 142, 04-15-11 citing (Rev. 1, 10-01-03) A3-3118, HHA-205 (emphasis added)

Medicare does not limit the number of continuous 60-day episode recertifications for beneficiaries who continue to be eligible for the home health benefit. See Section 30. 5.2 – Periodic Recertification – Medicare Benefit Policy Manual Chapter 7 – Home Health Services (Rev. 142, 04-15-11 citing (Rev. 139, Issued: 02-16-11, Effective: 01-01-11, Implementation: 03-10-11). The restoration potential of a patient is not the deciding factor in determining whether skilled services are needed. Even if full recovery or medical improvement is not possible, a patient may need skilled services to prevent further deterioration or preserve current capabilities. See 42 C.F.R. §409.32( c ) Criteria for skilled services and the need for skilled services.

A patient’s residence is wherever he or she makes his or her home. This may be his or her own dwelling, an apartment, a relative’s home, a home for the aged, or some other type of institution. However, an institution may not be considered a patient’s residence if the institution is a hospital or a skilled nursing facility, as well as most nursing facilities under Medicaid. Thus, if a patient is in an institution or distinct part of an institution identified above, the patient is not entitled to have payment made for home health services since such an institution may not be considered their residence. When a patient remains in a participating skilled nursing facility following their discharge from active care, the facility may not be considered their residence for purposes of home health coverage. See Section 30.1.2 – Patient’s Place of Residence – Medicare Benefit Policy Manual Chapter 7 – Home Health Services (Rev. 142, 04-15-11 citing(Rev. 1, 10-01-03) A3-3117.1.B, HHA-204.1.B.

Therefore, given the narrow clinical eligibility distinction between regularly provided and continuously available nursing and related health and medical services ( i.e. the Medicaid required intermediate level of care ) on the one hand , and part time or intermittent nursing and related health and medical services on the other hand ( i.e Medicare Part A’s Home Health Services Benefit ), there could be many Medicaid provided long term nursing facility patients and/or PDA waiver based home health and personal services ( i.e. institutional level of care ) patients that should rather be billed and provided services as long term Medicare Part A Home Health Services ( i.e. residential level of care ) patients.

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