CMS Pub. 100-02, ch. 1, § 130.4

Prior to the passage of the Medicare Prescription Drug, Improvement and Modernization

Act (MMA) of 2003, the Medicare program’s RNHCI benefit was limited to inpatient

services provided in an RNHCI facility. The MMA revised sections 1821(a) and 1861 of

the Social Security Act to extend coverage to RNHCI items and services that are

provided in a beneficiary’s home and that are comparable to items and services provided

by a home health agency that is not an RNHCI.

Beneficiaries elect the RNHCI benefit if they are conscientiously opposed to accepting

most medical treatment, since accepting such services would be inconsistent with their

sincere religious beliefs. The Medicare home health benefit provides skilled nursing,

physical therapy, occupational therapy, speech language pathology and home health aide

services to eligible beneficiaries under a physician’s plan of care. The home health

benefit also provides medical supplies, a covered osteoporosis drug and durable medical

equipment (DME) while under a plan of care (see chapter 7).

Medicare covers specified durable medical equipment and intermittent RNHCI nursing

visits provided in the home to RNHCI beneficiaries. These services comprise the RNHCI

home benefit. The remainder of the services covered under the Medicare home health

benefit are medical in nature and must be provided under the order of a physician. As

such, these services conflict with RNHCI beneficiaries’ conscientious opposition to

medical care.

The RNHCI home benefit must exclude the same services that are excluded from the

home health benefit, which include: drugs and biologicals; transportation; services that

would not be covered as inpatient services; housekeeping services; services covered

under the End Stage Renal Disease program; prosthetic devices; and medical social

services provided to family members. These exclusions are defined at 42 CFR 409.49.

Additionally, the RNHCI home benefit excludes the items or services provided by any

HHA that is not an RNHCI; or any supplier, independent RNHCI nurse or aide that is

working directly for a beneficiary rather than under arrangements with the RNHCI.

Medicare requires a brief letter of intent from the provider in order to determine the

number of RNHCIs that will be implementing the home service benefit.

In the case where an RNHCI chooses to provide home services then only care on an

intermittent basis, which is provided to an eligible beneficiary who is confined to their

home for health reasons, will be covered under the home benefit. The home benefit is not

to be confused with hospice care, which may involve more frequent visits and can

involve institutional services. If for some reason the home serviced patient requires more

than intermittent service, then institutional services may be required. However, the

patient would need to meet the criteria for admission to a RNHCI, or the patient would

require another institutional setting not necessarily covered by Medicare.

Similar to the inpatient RNHCI benefit, the physician role in certifying and ordering the

home benefit is replaced with the use of the RNHCI utilization review committee to

review the need for care and plan for initial and continued care in the home setting. The

home benefit will also require a prompt review of admission to the home service, since

the patient must be fully eligible (have a health condition that keeps them confined to the

home (42CFR409.42(a), have health needs that can be met with intermittent care, and

have a valid election) before billable services can be rendered and Medicare payment

requested. Additionally the utilization review committee is responsible for review and

approval of care plans and orders for DME items, and review of the need for the

continuation of services.

As in the original RNHCI benefit, Medicare will only pay for nonmedical services in the

home, but not for those religious items or services provided by the RNHCI.

Medicare covers these items and services for dates of service from January 1, 2005

through December 30, 2006. Total Medicare payments under this benefit for each

calendar year during this period are limited to $700,000.