THE FOLLOWING STUDY ARTICLE IS INTENDED FOR BASIC AWARENESS AND NOT FOR LEGAL ADVICE. IF THE READER SEEKS LEGAL ADVICE CONCERNING HIS OR HER PARTICULAR SITUATION, HE OR SHE SHOULD SEEK OUT AN ATTORNEY IN A LAWYER CLIENT RELATIONSHIP.
THE KEY ELIGIBILITY DISTINCTION BETWEEN MEDICARE’S HOME HEALTH SERVICES AND THE PA DEPARTMENT OF AGING’S MEDICAID WAIVER BASED HOME AND COMMUNITY BASED SERVICES CONCERNS WHETHER OR NOT GREATER THAN PART TIME OR INTERMITTENT SKILLED NURSING SERVICES ARE REQUIRED BY THE PATIENT .
A. MEDICAID/PENNSYLVANIA DEPARTMENT OF AGING RELATED HOME AND COMMUNITY BASED SERVICES ARE ONLY TO BE PROVIDED TO PATIENTS WHO , IF NOT FOR THEIR EXERCISE OF SUCH A WAIVER, WOULD REQUIRE THE LEVEL OF CARE TO BE PROVIDED IN A HOSPITAL, NURSING HOME OR INTERMEDIATE CARE FACILITY FOR THE MENTALLY RETARDED .
If the agency furnishes home and community-based services, as defined in § 440.180 of this subchapter, under a waiver granted under this subpart, the waiver request must— (1) Provide that the services are furnished— …. (iii) Only to recipients who the agency determines would, in the absence of these services, require the Medicaid covered level of care provided in— (A) A hospital (as defined in § 440.10 of this chapter ); (B) A NF (as defined in section 1919(a) of the Act); or (C) An ICF/MR (as defined in § 440.150 of this chapter ); See 42 CFR 441.301 (a)(3) (b) – Contents of request for a waiver for home and community based waivers.
B. ON THE OTHER HAND, MEDICARE PART A’S HOME HEALTH SERVICES BENEFIT INCLUDES ALL BUT A HOSPITAL, A NURSING FACILITY, OR CERTAIN INTERMEDIATE CARE FACILITIES FOR THE MENTALLY RETARDED IN ITS DEFINITION OF WHAT QUALIFIES AS A RECIPIENT’S PLACE OF RESIDENCE.
A recipient’s place of residence, for home health services, does not include a hospital, nursing facility, or intermediate care facility for the mentally retarded, except for home health services in an intermediate care facility for the mentally retarded that are not required to be provided by the facility under subpart I of part 483… See 42 CFR 440.70.
C. MEDICARE PART A’S HOME HEALTH SERVICES BENEFIT INCLUDES INTERMITTENT OR PART TIME SKILLED NURSING CARE, MEANING THE BENEFIT INCLUDES SKILLED NURSING CARE THAT IS NEEDED FOR FEWER THAN 7 DAYS EACH WEEK OR FOR LESS THAN 8 HOURS OF EACH DAY FOR PERIODS OF 21 DAYS OR LESS.
To qualify for the Medicare home health benefit, 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.
“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 less (with extensions in exceptional circumstances when the need for additional care is finite and predictable). See Section 30 – Conditions Patient Must Meet to Qualify for Coverage of Home Health Services Medicare Benefit Policy Manual Chapter 7 – Home Health Services (Rev. 142, 04-15-11 citing (Rev. 1, 10-01-03) A3-3118, HHA-205 (Rev. 1, 10-01-03) A3-3117, HHA-204, A-98-49
D. THE MEDICARE PART A HOME HEALTH SERVICES BENEFIT IS STILL TO BE RECEIVED BY A MEDICARE HOME HEALTH SERVICE RECIPIENT EVEN IF THE LEVEL OF SKILLED NURSING AND HOME HEALTH AIDE SERVICES COMBINED EXCEEDS THE MAXIMUM 35 HOURS PER WEEK OF COVERAGE PROVIDED BY THE HOME HEALTH SERVICES BENEFIT FOR THOSE NURSING & AIDE SERVICES , AS LONG AS THE REQUIRED SKILLED NURSING SERVICES THEMSELVES DO NOT EXCEED AN INTERMITTENT OR PART TIME LEVEL OR BASIS.
50.7.1 – Impact on Care Provided in Excess of “Intermittent” or “Part-Time” Care
(Rev. 1, 10-01-03) A3-3119.7.C, HHA-206.7.C
Home health aide and/or skilled nursing care, in excess of the amounts of care that meet the definition of part-time or intermittent, may be provided to a home care patient or purchased by other payers without bearing on whether the home health aide and skilled nursing care meets the Medicare definitions of part-time or intermittent.
EXAMPLE: A patient needs skilled nursing care monthly for a catheter change and the home health agency also renders needed daily home health aide services 24 hours per day that will be needed for a long and indefinite period of time. The HHA bills Medicare for the skilled nursing and home health aide services, which were provided before the 35th hour of service each week, and bills the beneficiary (or another payer) for the remainder of the care. If the intermediary determines that the 35 hours of care are reasonable and necessary, Medicare would cover the 35 hours of skilled nursing and home health aide visits.
50.7.2 – Application of this Policy Revision
(Rev. 1, 10-01-03) A3-3119.7.D, HHA-206.7.D
Additional care covered by other payers discussed in §50.7.1 does not affect Medicare coverage when the conditions listed below apply. A patient must meet the criteria for Medicare coverage of home health services, before this policy revision becomes applicable to skilled nursing services and/or home health aide services. The definition of “intermittent” with respect to the need for skilled nursing care where the patient qualifies for coverage based on the need for “skilled nursing care on an intermittent basis” remains unchanged. Specifically:
1. This policy revision always applies to home health aide services when the patient qualifies for coverage;
2. This policy revision applies to skilled nursing care only when the patient needs physical therapy or speech-language pathology services or continued occupational therapy, and also needs skilled nursing care; and
3. If the patient needs skilled nursing care but does not need physical therapy or speech-language pathology services or occupational therapy, the patient must still meet the longstanding and unchanged definition of “intermittent” skilled nursing care in order to qualify for coverage of any home health services.
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E. NOTE THAT A PATIENT MAY THUS HAVE SOURCES OTHER THAN PADPW HOME AND COMMUNITY BASED WAIVER SERVICES TO COVER THE COST OF HIS OR HER MEDICAL SERVICES AND CARE. THE PADPW IS TO BE THE PAYER OF LAST RESORT.
55 Pa. Code § 178.6. Third-party liability for all categories of MA.
(a) An applicant/recipient may have sources other than MA that cover the cost of his medical services and care. The third-party liability sources which are available to pay for medical services and care shall be identified and used to the fullest extent possible before payment is made by MA. The Department is the payer of last resort.
(b) Third-party resources include, but are not limited to:
(2) Health insurance benefits-Medicare
THEREFORE, IT IS VERY IMPORTANT FOR THE PATIENT TO ACQUIRE AN INDEPENDENT MEDICAL EVALUATION TO DETERMINE WHETHER OR NOT THE PRECISE LEVEL OF SKILLED NURSING CARE NEEDED BY THAT PATIENT EXCEEDS AN INTERMITTENT OR PART TIME LEVEL OF SKILLED NURSING CARE BEFORE THE PATIENT CONSIDERS OBTAINING MEDICAID/PA DEPARTMENT OF AGING WAIVER RELATED HOME AND COMMUNITY BASED SERVICES.