Understanding Medicaid Home and Community Services: A Primer, 2010 Edition. Misperceptions

10/29/2010

Despite the unambiguous nature of Federal coverage and eligibility requirements, misperceptions that additional Federal requirements further restrict who may receive home health services are common. The first misperception is that individuals must be eligible for nursing facility care in order to receive home health services (i.e., that they must meet a state’s nursing facility level-of-care criteria).

This misunderstanding has arisen because the word entitledto nursing facility care has been interpreted to mean eligible for nursing facility care. The Federal requirement specifies the coverage groups entitled to the Home Health benefit. Those entitled include (a) categorically eligible persons age 21 or over, (b) persons under age 21 if the State Plan provides nursing facility services for them, and (c) medically needy persons if the State Plan provides nursing facility services for them. It also states clearly that eligibility does notdepend on the need for institutional care or for skilled nursing or therapy services. Additionally, even if the state does not cover persons under age 21, the Early Periodic Screening, Diagnosis, and Treatment mandate requires that home health services be provided to this group if they are needed.

A second misperception is that states must use Federal eligibility requirements for the Medicare Home Health benefit to determine eligibility for the Medicaid Home Health benefit. In particular, many incorrectly believe that to be eligible for Medicaid home health services, a person has to meet the Medicare home-bound requirement and need skilled nursing or therapy services. In fact, states may not limit Medicaid home health services to individuals who require skilled services as defined by Medicare (i.e., skilled nursing and therapy services).6

Additionally, while Federal regulations state that home health services must be provided in the home, there is no requirement that beneficiaries be homebound. A July 2000 State Medicaid Director Letter clarifies that a homebound requirement violates Medicaid comparability requirements.7

While Medicaid home health services must be provided by a Medicare-certified home health agency, this requirement is a provider qualification; it does not create an eligibility linkage between the two programs. Federal Medicaid policy permits states to provide home health services to persons with a wider range of needs than is possible through the Medicare program.

Federal Coverage and Eligibility Requirements for Medicaid Home Health Services

Mandatory State Plan home health services are (a) nursing services provided on a part-time or intermittent basis by a home health agency that meets requirements for participation in Medicare; (b) home health aide services provided by a home health agency that meets requirements for participation in Medicare; and (c) medical supplies, equipment, and appliances suitable for use in the home.

  • The optional home health services are physical therapy, occupational therapy, speech pathology, and audiology services.

  • Services must be ordered by a physician as part of a written plan of care that the physician reviews every 60 days.8

  • Once a state defines its Home Health benefit--whether it includes only mandatory home health services or both mandatory and optional services--the benefit must be available to all Medicaid beneficiaries entitled to nursing facility services under the State Plan.

  • States may place coverage limits on home health services if the limits are based on considerations related to medical necessity or utilization control.

  • Eligibility of beneficiaries to receive home health services does not depend on their need for, or discharge from, institutional care, or their need for skilled nursing or therapy services


Provision of Services Outside a Beneficiary’s Home

A Connecticut lawsuit--Skubel v. Fuoroli--challenged CMS’s regulation requiring that Medicaid home health care services be provided exclusively in a beneficiary’s place of residence. The lawsuit focused on the receipt of nursing services outside the home.

In 1997, the Court of Appeals ruled that the Medicaid statute is ambiguous with respect to whether home health care services must be provided exclusively at the recipient’s residence.9 Specifically, the court ruled that “the Medicaid statute neither allows nor prohibits reimbursement for home health services outside the recipient’s residence. The statute merely provides that states may include ‘home health care services’ in their Medicaid programs.10 It does not define home health care services, and though the statute implies that the services will normally be rendered in the home, neither the context of the provision nor the structure of the statute indicates whether the home is the exclusive locus of the necessary services.”

The court went on to hold that “the regulation as written is invalid,” because the restriction of home health care services to a beneficiary’s residence “ignores the consensus among health care professionals that community access is not only possible but desirable for disabled individuals.” The court further stated that the assumptions behind the restriction of services to the beneficiary’s residence were medically obsolete, and that “the technology and knowledge now exist to allow many people with disabilities, elderly or not, to venture into the community, where before they would have been considered permanently homebound.”

To ensure that the ruling would not result in increased costs for the state, the court expressly limited beneficiaries of Medicaid-covered home health nursing services to the number of hours of services to which they would be entitled if the services were provided exclusively at the recipient’s place of residence.11

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