ATTACHMENT A

CONDITIONS THE BENEFICIARY MUST MEET
TO QUALIFY FOR MEDICARE COVERAGE OF
HOME HEALTH SERVICES

To qualify for Medicare coverage of any reimbursed Medicare home health service, the beneficiary must meet all of the criteria specified below.

Beneficiaries who meet all of the criteria are also eligible to have payments made on their behalf for supplemental services such as medical social service or home health aide.

Confined to His/Her Home (Homebound):

An individual does not have to be bedridden to be considered as confined to his/her home; however, the condition must exist that here is a normal inability and a considerable effort to leave home.
Absences from the home which are infrequent and of short duration or to receive medical care as allowable (i.e. dialysis, chemotherapy, radiation therapy or physician appointments). Short duration is generally defined as periods of time not exceeding three hours or an average of fifteen hours per month.

Patient's Place of Residence:

Wherever he/she makes his/her home (i.e. apartment, relations home, home for the aged or an institution). An institution may not be under the direct supervision of a physician, nursing care or rehabilitation services such as a nursing home.

Services are Provided Under a Plan of Care Established and Approved by a Physician:

The plan of care/medical treatment plan must indicate the type of services to be provided, who will provide them and the frequency of the services. The physician signs the initial plan of care and reviews the plan no less frequently than every two months.

Needs Skilled Nursing Care on an Intermittent Basis or Physical Therapy or Speech Therapy or Has a Continued Need for Occupational Therapy:

Skilled nursing and therapy must be reasonable and necessary. The definition of reasonable and necessary is that the complexity of the service is such that it can be performed safely and/or effectively only by or under the general supervision of a skilled nurse or therapist. There are numerous qualifying services provided by each discipline and criteria established by Medicare that must be met to assure reimbursement.