01 May Medicare Services Patient Qualification
Does My Patient Qualify for Medicare Services?
In this edition of the Alora Home Health blog, we’ll tackle a question that many agencies and caregivers must determine the answer to before any services are rendered…”How do I know if my patient qualifies for Medicare services?”
In order to receive Medicare Services, your patient must meet certain conditions for Medicare Home Care. First, they must be an eligible Medicare beneficiary and qualify for coverage. Home Health Services are provided in the patient’s place of residence. The patient is confined to the home (homebound). Medicare is the appropriate primary payer and the physician ordering Home Care is enrolled in PECOS.
Medicare Services Criteria
What is a place of residence?
A place of residence is essentially wherever a patient makes their home, whether it is permanent or temporary. It may include their own home, their child’s home, their sibling’s home, an Assisted Living Facility or Group Home, a hotel. Some patients may have more than one place of residence. Patients may not be admitted to a hospital, Skilled Nursing Facility or Rehabilitation Center.
Your patient shall be considered Homebound or confined to the home, if the following two criteria are met. Criteria one is:
- Because of Illness or injury, need the aid of supportive devices such as crutches, canes, wheelchairs and walkers; the use of special transportation; or the assistance of another person in order to leave their place of residence, OR
- Have a condition such that leaving his or her home is medically contraindicated
If the patient meets one of the above criteria, then the patient must also meet the two additional requirements as defined below:
- There must exist a normal inability to leave the home, AND
- Leaving the home must require a considerable and taxing effort
The patient cannot be homebound by choice. Being confined to the home must come as a result of a medical opinion of the physician or the result of the patient’s condition. Absences are allowed for receiving medical treatment, regardless of frequency; to acquire essential items, such as groceries or medications; or for therapeutic reasons (one example would be to attend church weekly); and other infrequent events.
Medicare requires that Skilled Care is provided and care must be necessary to improve the patient’s current condition, to maintain the patient’s current condition, to prevent or slow further deterioration of the patient’s condition. Medicare as a primary payer source requires a skilled service to be provided. This may include Nursing, Physical Therapy, Occupational Therapy, or Speech Therapy. Home Health Aide and Social Worker Services may only be provided if a skilled service (Nursing or Therapy) is provided. Medicare does not consider lab draws, medication box or prefilling insulin syringes a skilled need. Therefore, these are not considered a stand-alone reason for a visit.
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PECOS stands for Provider Enrollment, Chain and Ownership System. PECOS manages, tracks and validates all enrollment data. A Home Health Plan of Care must be signed by a physician who is enrolled in PECOS and is a doctor of medicine, osteopathy, or podiatric medicine; and the physician is not precluded from performing this function as outlined in CFR 42 Limitation of the performance of physician certification and plan of care functions. A doctor of podiatric medicine may perform only plan of treatment functions that are consistent with the functions he or she is authorized to perform under State law.
If your patient meets all of the above criteria, Qualification for Medicare Home Health Services has been met.
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