CMS Pub. 100-01, ch. 1, § 10.2

To qualify for home health benefits under either Part A or Part B of the program, a beneficiary

must be confined to his/her home, under the care of a physician, and in need of skilled nursing

services on an intermittent basis, physical therapy, or speech-language pathology services.

Being "confined to the home" does not mean a beneficiary can never leave the home. See

chapter 7 of the Benefit Policy publication for the definition of homebound. A beneficiary who

requires one or more of these services in the treatment of his/her illness or injury and otherwise

qualifies for home health benefits is eligible to have payment made on his/her behalf for the

skilled nursing, physical therapy or speech-language pathology services he needs, as well as for

any of the other home health services specified in the law. These services include occupational

therapy, medical social services, the use of medical supplies and medical appliances, and the

part-time or intermittent services of home health aides. Conversely, a patient who does not

require intermittent skilled nursing or physical therapy or speech-language pathology services

cannot qualify to have payment made under the program for any home health services furnished

him. Excluded as home health services are the costs of housekeepers, food service

arrangements, and transportation to outpatient facilities.

To be covered, the home health services must be needed for a condition for which the patient

required inpatient hospital services or extended care services. See the chapter 7 of the Benefit

Policy publication for a description of services covered. Discharge from the hospital must have

occurred in a month in which the patient has attained age 65 or was entitled to health insurance

benefits under the disability or chronic renal disease provisions of the law.

Home health services are services provided by a home health agency or by others under

arrangements with such an agency. A home health agency is a public agency or private

organization which is primarily engaged in providing skilled nursing and other therapeutic

services. Where applicable the agency must be licensed under State or local law, or be approved

by the State or local licensing agency as meeting the licensing standards. Examples of home

health agencies are visiting nurse associations, official health agencies, and hospital-based home

care programs. To participate in the health insurance program, a home health agency must meet

certain other requirements included in the law as well as health and safety conditions prescribed

by the Secretary of the Department of Health and Human Services. It may not qualify under

hospital insurance, however, if it is primarily engaged in the treatment of mental diseases; such

an agency may qualify only under supplementary medical insurance.

Home health services are usually furnished on a visiting basis in a place of residence used as the

individual's home. However, outpatient services in a hospital, SNF, or rehabilitation center are

covered home health services, if arranged for by a home health agency, when equipment is

required that cannot be made available in the patient's home.

The services of an intern or resident-in-training are covered if the agency has an affiliation with

or is under common control of a hospital providing such medical services and the agency bills

for such services.

Prior to July 1, 1981, home health services under hospital insurance included up to 100 home

health visits, after the beginning of one benefit period and before the beginning of the next. The

visits must have been furnished to a patient within 1 year of his/her most recent discharge from a

hospital where he was an inpatient for at least 3 consecutive calendar days (counting the day of

admission, but not the day of discharge). If, after his/her hospitalization, he had a covered stay

in a SNF, the 1 year during which the patient may receive home health services began with the

discharge from the SNF. A plan of treatment must have been established within 14 days after the

hospital or SNF discharge. Home health services were also provided under supplementary

medical insurance where the 100-visit limit under Part A was exceeded.

Effective July 1, 1981, the 100-visit limitation under Parts A and B, and the prior inpatient stay

requirement under Part A were eliminated. In addition, a person could qualify for home health

services based on his or her need for skilled nursing services on an intermittent basis, physical

therapy, speech-language pathology services, or occupational therapy. Effective December 1,

1981, occupational therapy was eliminated as a basis for entitlement to home health services.

However, if a person has otherwise qualified for home health services because of the need for

skilled nursing care, physical therapy or speech-language pathology services, the patient's

eligibility for home health services may be extended solely on the basis of the continuing need

for occupational therapy.

Effective January 1, 1998, the first 100 visits must be paid under Part A if the beneficiary is

entitled under Part A, and the remainder of the visits may be paid under Part B.