When does an absence from the home disqualify a Medicare beneficiary from receiving Medicare-covered home health care services?

Medicare covers home health services for homebound beneficiaries who need skilled nursing services on a part-time or intermittent basis or rehabilitative therapy services. One long-standing source of confusion about this benefit has been the affect of absences from the home on a beneficiary’s homebound status. The Medicare Benefits Policy Manual makes clear that CMS allows regular absences to receive medical care, and that other short or infrequent absences do not disqualify a person from receiving covered home health services. Many people think that an absence from the home must be both short and infrequent. They are mistaken. The rules allow, for example, attendance at a family reunion, which could take place over a weekend and involve a three or four day absence from home, as an infrequent absence.

Medicare Benefit Policy Manual (CMS Pub. No. 100-02), Chapter 15, Section 30.1.1, Patient Confined to the Home: Any absence of an individual from the home attributable to the need to receive health care treatment, including regular absences for the purpose of participating in therapeutic, psychosocial, or medical treatment in an adult day-care program that is licensed or certified by a State, or accredited to furnish adult day-care services in a State, shall not disqualify an individual from being considered to be confined to his home. Any other absence of an individual from the home shall not so disqualify an individual if the absence is of an infrequent or of relatively short duration. For purposes of the preceding sentence, any absence for the purpose of attending a religious service shall be deemed to be an absence of infrequent or short duration. It is expected that in most instances, absences from the home that occur will be for the purpose of receiving health care treatment. However, occasional absences from the home for nonmedical purposes, e.g., an occasional trip to the barber, a walk around the block or a drive, attendance at a family reunion, funeral, graduation, or other infrequent or unique event would not necessitate a finding that the patient is not homebound if the absences are undertaken on an infrequent basis or are of relatively short duration and do not indicate that the patient has the capacity to obtain the health care provided outside rather than in the home.

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Can Medicare cover a skilled nursing facility stay (SNF) or home health visit based on the need for physical therapy services when a person's recovery has reached a plateau?

Many people believe that when a person in need of physical therapy reaches his or her rehabilitation potential, that Medicare coverage for SNF or home health services must end. But the Medicare Benefits Policy Manual instructs Medicare's payment contractors and providers never to make skilled care determinations based only on the prognosis for the patient’s illness or condition. The manual clearly states that a person’s potential for recovery is not the deciding factor. Providers and Medicare payment contractors are to take a patient’s total condition into account.

Medicare Benefit Policy Manual (CMS Pub. No. 100-02), Chapter 8, Section 30.2.2, Principles for Determining Whether a Service is Skilled: The intermediary considers the nature of the service and the skills required for safe and effective delivery of that service in deciding whether a service is a skilled service. While a patient’s particular medical condition is a valid factor in deciding if skilled services are needed, a patient's diagnosis or prognosis should never be the sole factor in deciding that a service is not skilled.

Example: When rehabilitation services are the primary services, the key issue is whether the skills of a therapist are needed. The deciding factor is not the patient's potential for recovery, but whether the services needed require the skills of a therapist or whether they can be provided by nonskilled personnel.

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Medicare's waiver of liability protections sometimes do not apply to ambulance claims, even though the beneficiary had no way of knowing that Medicare would not cover the service. Why is that?

Waiver of liability protections may apply when Medicare denies payment on a claim because the service or item is not reasonable and necessary. The waiver protections do not apply, however, when Medicare denies payment for other reasons. When Medicare denies payment for an ambulance trip to a more distant hospital, for example, the basis for the denial is the most appropriate facility rule, and not the reasonable and necessary rule. CMS considers this a technical denial to which the waiver of liability protections do not apply.

Medicare Claims Processing Manual (CMS Pub. No. 100-04), Chapter 30, Section 20.2, Denials for Which the Limitation On Liability Provision Does Not Apply: Medicare payment under the limitation on liability provision cannot be made when Medicare coverage is denied on any basis other than one of the provisions of the law specified in §20.1.1. (See the Medicare Financial Management Manual, Chapter 3, concerning liability for overpayments arising from other causes.) There are certain claims, however, that may appear to involve a question of medical necessity, as described in §1862(a)(1) of the Act, but the actual Medicare payment denial is based on a statutory provision other than §1862(a)(1). Under these circumstances, Medicare payment under the limitation on liability provision cannot be made because the denial is not based on one of the statutory provisions specified in §20.1.1.

Section 1879(a) of the Act provides that Medicare payment will be made under the limitation on liability provision "when a determination is made that, by reason of §1862(a)(1) or (9) or by reason of a coverage denial described in subsection (g) of the Act, payment may not be made under Part A or Part B" and the conditions described in §1879(a)(2) are met. The statute thus explicitly restricts the application of the limitation on liability provision to cases that are decided on one of the statutory grounds we have specified in §20.1.1. In so providing, the Congress recognized that the issue of medical necessity of a service or item need never be reached if it were determined that the service or item would not otherwise be covered under the statute.

For example, when a Part B claim is submitted for ambulance services, the first step in processing the claim is to determine whether the services meet the requirements of §1861(s)(7) of the Act (that is, to ascertain that other methods of transportation are contraindicated) and, therefore, may be covered services under the Medicare statute. If other methods of transportation are contraindicated (and all other regulatory criteria met), only then must the Medicare contractor determine if the ambulance services are reasonable and necessary under §1862(a)(1). If other methods of transportation are not contraindicated, there is no reason for the Medicare contractor to make a medical necessity determination under §1862(a)(1) because the services have already been determined to be not otherwise covered under the Medicare statute. Therefore, when items or services are denied for any reason other than one of the specific statutory bases for denial specified in §20.1.1, limitation on liability cannot be applied.

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When must a Medicare Advantage (MA) plan cover urgently-needed care?

The Medicare Managed Care Manual defines key terms like emergency and urgently needed services and gives some helpful examples.

Medicare Managed Care Manual (CMS Pub. No. 100-16) Chapter 4, Section 130.2, Emergency and Urgently Needed Services: Urgently-needed services are covered services that:

• are not emergency services as defined in this section;
• are provided when an enrollee is temporarily absent from the MA plan’s service (or, if applicable, continuation) area (Note: Urgent care received within the service area is an extension of primary care services); and
• are medically necessary and immediately required:
  • as a result of an unforeseen illness, injury, or condition; and
  • it was not reasonable given the circumstances to obtain the services through MA plan’s participating provider network

Note that under unusual and extraordinary circumstances, services may be considered urgently-needed services when the enrollee is in the service or continuation area, but the organization’s provider network is temporarily unavailable or inaccessible. The following example is an illustration of urgently-needed services.

Example: A beneficiary has been under the care of a dermatologist for years for a chronic skin condition. However, while the member was out of the service area, the condition flared up and the beneficiary needed to see a local doctor. The required services are urgently-needed and therefore the plan is obligated to provide for them. Even though the enrollee was aware of the chronic skin condition the flare up was unforeseen. Although the flare up is not a medical emergency, it does require immediate medical attention and it was unreasonable for the enrollee to return to the service area. Therefore, the enrollee can seek medical care in a physician’s office.

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When must a Part D drug plan fill a prescription at an out-of-network pharmacy?

Part D plans must ensure that their plan members have access to prescription drugs, under certain conditions, when they are outside of the plan’s service area. The Medicare Prescription Drug Benefit Manual details those conditions and offers several examples of situations in which plans should cover drugs dispensed at out-of-network pharmacies. See the excerpt below. 

Medicare Prescription Drug Benefit Manual (CMS Pub. No. 100-18), Chapter 5, Section 60.1, Out of Network Pharmacy Access: Part D sponsors must ensure that their enrollees have adequate access to covered Part D drugs dispensed at OON pharmacies when those enrollees cannot reasonably be expected to obtain covered Part D drugs at a network pharmacy, and when such access is not routine. The coverage rules applicable to covered Part D drugs dispensed at OON pharmacies may generally mirror those applicable to covered Part D drugs dispensed at network pharmacies, to the extent that the OON pharmacy has the ability to effectuate those coverage rules. However, Part D sponsors must develop policies and procedures governing reasonable rules for appropriately limiting OON access (for example, quantity limits, purchase of maintenance medications via mail-order for extended out-of-area travel, or plan notification or authorization processes). Following are various scenarios under which CMS would expect that OON pharmacy access be guaranteed to enrollees.

Example 1: An enrollee is traveling outside his or her Part D plan’s service area; runs out of or loses his or her covered Part D drug(s) or becomes ill and needs a covered Part D drug; and cannot access a network pharmacy.
Example 2: An enrollee cannot obtain a covered Part D drug in a timely manner within his or her service area because, for example, there is no network pharmacy within a reasonable driving distance that provides 24-hour-a-day/7-day-per-week service.
Example 3: An enrollee must fill a prescription for a covered Part D drug in a timely manner, and that particular covered Part D drug (for example, an orphan drug or other specialty pharmaceutical typically shipped directly from manufacturers or special vendors) is not regularly stocked at accessible network retail or mail-order pharmacies.
Example 4: An enrollee is provided covered Part D drugs dispensed by an OON institution-based pharmacy while he or she is a patient in an emergency department, provider-based clinic, outpatient surgery, or other outpatient setting.
Example 5: During any Federal disaster declaration or other public health emergency declaration in which Part D enrollees are evacuated or otherwise displaced from their place of residence and cannot reasonably be expected to obtain covered Part D drugs at a network pharmacy. In addition, in circumstances in which normal distribution channels are unavailable, Part D sponsors are expected to liberally apply their OON policies to facilitate access to medications.

If a Part D sponsor offers coverage other than defined standard coverage, it may require enrollees to not only be responsible for any cost-sharing, including a deductible, that would have otherwise applied if a covered Part D drug had been purchased at a network pharmacy, but also any differential between an OON pharmacy's (or provider's) U&C price and the plan allowance.

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