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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, Such As Home Health Aide Services. Therefore, A Patient Is Entitled to Have The Costs of Reasonable and Necessary Home Health Aide Services Reimbursed by Medicare Where A Family Member Or Other Person Is or Will Be Providing Home Health Aide Services That Adequately Meet The Patient’s Home Health Aide Needs.
Ordinarily a Medicare Certified Home Health Agency ( i.e. HHA) can presume that there is no able and willing person in the home to provide the home health aide services to be rendered by that HHA unless the patient or family indicates otherwise and objects to the provision of the home health aide services ( or lack of sufficiency thereof) by the HHA, or unless the HHA has first hand knowledge to the contrary. See Medicare Benefit Policy Manual Chapter 7 – Home Health Services (Rev. 12382; Issued: 11-28-23) (Rev. 12425 Issued: 12-21-23) § 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)
However, 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, such as home health aide services. Therefore, a patient is entitled to have the costs of reasonable and necessary home health aide services reimbursed by Medicare where a family member or other person is or will be providing services that adequately meet the patient’s home health aide needs, since there is able and willing person in the home to provide the services being rendered by the Medicare Certified HHA . See Medicare Benefit Policy Manual Chapter 7 – Home Health Services Table of Contents (Rev. 12382; Issued: 11-28-23)(Rev. 12425 Issued: 12-21-23) 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)
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 aide services ( i.e by a family member providing those home health aide services) where the patient is also receiving supplemental services that do not meet Medicare’s definition of skilled nursing care or home health aide services (i.e. such the State’s Medicaid “Waiver” based and funded “personal care services” provided by a family member on behalf of an Medicaid Home Care Agency ( HCA) under a Medicaid “personal care service benefit” ) . See Medicare Benefit Policy Manual Chapter 7 – Home Health Services Table of Contents (Rev. 12382; Issued: 11-28-23) (Rev. 12425 Issued: 12-21-23) 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) ; See Also CFR § 484.80 Condition of participation: Home health aide services. (5)(i); § 440.167 Personal care services.
For payment of home health aide services provided by a family to be covered under Medicare Home Health Services and paid under arrangement by a Medicare Certified HHA, that family member must be certified as a home health aide consistent with a competency evaluation program which can be administrated by the HHA itself. See Medicare Benefit Policy Manual Chapter 7 – Home Health Services Table of Contents (Rev. 12382; Issued: 11-28-23) (Rev. 12425 Issued: 12-21-23) 50.2 – Home Health Aide Services (Rev. 10438, Issued: 11-06-20, Effective: 03-01-20, Implementation: 01- 11-21); CFR § 484.80(c) Condition of participation: Home health aide services.
If the home health agency chooses to provide home health aide services under a contractual arrangement with family member of the patient, the HHA’s responsibilities also include, but are not limited to: ensuring the overall quality of care provided by an aide; Supervising aide services and ensuring that home health aides who provide services under arrangement have met the competency evaluation requirements . See CFR § 484.80 (5) (i-iii)
The duties of a home health aide include:the provision of hands-on personal care; the performance of simple procedures as an extension of therapy or nursing services; assistance in ambulation or exercises; and assistance in administering medications ordinarily self-administered. See CFR § 484.80(3)(i-iv)
These home health aide services may include but are not limited to:
A. Personal Care
Personal care means:
- Bathing, dressing, grooming, caring for hair, nail, and oral hygiene which are needed to facilitate treatment or to prevent deterioration of the patient’s health, changing the bed linens of an incontinent patient, shaving, deodorant application,skin care with lotions and/or powder, foot care, and ear care; and
- Feeding, assistance with elimination (including enemas unless the skills of a licensed nurse are required due to the patient’s condition, routine catheter care and routine colostomy care), assistance with ambulation, changing position in bed,assistance with transfers.
B. Simple Dressing Changes That Do Not Require the Skills of a Licensed Nurse
C. Assistance With Medications Which Are Ordinarily Self-Administered and Do Not Require the Skills of a Licensed Nurse to Be Provided Safely and Effectively
D. Assistance With Activities which Are Directly Supportive of Skilled Therapy Services but Do Not Require the Skills of a Therapist to Be Safely and Effectively Performed Such as Routine Maintenance Exercises and Repetitive Practice of Functional Communication Skills to Support Speech-Language Pathology Services
E. Provision of Services Incidental to Personal Care Services not Care of Prosthetic and Orthotic Devices–When a home health aide visits a patient to provide a health related service as discussed above, the home health aide may also perform some incidental services which do not meet the definition of a home health aide service (e.g., light cleaning, preparation of a meal, taking out the trash, shopping, etc.) However, the purpose of a home health aide visit may not be to provide these incidental services since they are not health related services, but rather are necessary household tasks that must be performed by anyone to maintain a home. See Medicare Benefit Policy Manual Chapter 7 – Home Health Services Table of Contents (Rev. 12382; Issued: 11-28-23) (Rev. 12425 Issued: 12-21-23) 50.2 – Home Health Aide Services (Rev. 10438, Issued: 11-06-20, Effective: 03-01-20, Implementation: 01- 11-21)