CMS Pub. 100-02, ch. 7, § 50.3

A3-3119.3, HHA-206.3

Medical social services that are provided by a qualified medical social worker or a social

work assistant under the supervision of a qualified medical social worker may be covered

as home health services where the beneficiary meets the qualifying criteria specified in

§30, and:

1. The services of these professionals are necessary to resolve social or emotional

problems that are or are expected to be an impediment to the effective treatment

of the patient's medical condition or rate of recovery; and

2. The plan of care indicates how the services which are required necessitate the

skills of a qualified social worker or a social work assistant under the supervision

of a qualified medical social worker to be performed safely and effectively.

Where both of these requirements for coverage are met, services of these professionals

which may be covered include, but are not limited to:

1. Assessment of the social and emotional factors related to the patient's illness, need

for care, response to treatment and adjustment to care;

2. Assessment of the relationship of the patient's medical and nursing requirements

to the patient's home situation, financial resources and availability of community

resources;

3. Appropriate action to obtain available community resources to assist in resolving

the patient's problem (NOTE: Medicare does not cover the services of a medical

social worker to complete or assist in the completion of an application for

Medicaid because Federal regulations require the State to provide assistance in

completing the application to anyone who chooses to apply for Medicaid.);

4. Counseling services that are required by the patient; and

5. Medical social services furnished to the patient's family member or caregiver on a

short-term basis when the HHA can demonstrate that a brief intervention (that is,

two or three visits) by a medical social worker is necessary to remove a clear and

direct impediment to the effective treatment of the patient's medical condition or

to the patient's rate of recovery. To be considered "clear and direct," the behavior

or actions of the family member or caregiver must plainly obstruct, contravene, or

prevent the patient's medical treatment or rate of recovery. Medical social

services to address general problems that do not clearly and directly impede

treatment or recovery as well as long-term social services furnished to family

members, such as ongoing alcohol counseling, are not covered.

NOTE: Participating in the development of the plan of care, preparing clinical and

progress notes, participating in discharge planning and in-service programs, and acting as

a consultant to other agency personnel are appropriate administrative costs to the HHA.

EXAMPLE 1:

The physician has ordered a medical social worker assessment of a diabetic patient who

has recently become insulin dependent and is not yet stabilized. The nurse, who is

providing skilled observation and evaluation to try to restabilize the patient notices during

her visits that the supplies left in the home for the patient's use appear to be frequently

missing, and the patient is not compliant with the regimen although she refuses to discuss

the matter. The assessment by a medical social worker would be reasonable and

necessary to determine if there are underlying social or emotional problems impeding the

patient's treatment.

EXAMPLE 2:

A physician ordered an assessment by a medical social worker for a multiple sclerosis

patient who was unable to move anything but her head and who had an indwelling

catheter. The patient had experienced recurring urinary tract infections and multiple

infected ulcers. The physician ordered medical social services after the HHA indicated to

him that the home was not well cared for, the patient appeared to be neglected much of

the time, and the relationship between the patient and family was very poor. The

physician and HHA were concerned that social problems created by family caregivers

were impeding the treatment of the recurring infections and ulcers. The assessment and

follow-up for counseling both the patient and the family by a medical social worker were

reasonable and necessary.

EXAMPLE 3:

A physician is aware that a patient with atherosclerosis and hypertension is not taking

medications as ordered and adhering to dietary restrictions because he is unable to afford

the medication and is unable to cook. The physician orders several visits by a medical

social worker to assist in resolving these problems. The visits by the medical social

worker to review the patient's financial status, discuss options, and make appropriate

contacts with social services agencies or other community resources to arrange for

medications and meals would be a reasonable and necessary medical social service.

EXAMPLE 4:

A physician has ordered counseling by a medical social worker for a patient with

cirrhosis of the liver who has recently been discharged from a 28-day inpatient alcohol

treatment program to her home which she shares with an alcoholic and neglectful adult

child. The physician has ordered counseling several times per week to assist the patient

in remaining free of alcohol and in dealing with the adult child. The services of the

medical social worker would be covered until the patient's social situation ceased to

impact on her recovery and/or treatment.

EXAMPLE 5:

A physician has ordered medical social services for a patient who is worried about his

financial arrangements and payment for medical care. The services ordered are to

arrange Medicaid if possible and resolve unpaid medical bills. There is no evidence that

the patient's concerns are adversely impacting recovery or treatment of his illness or

injury. Medical social services cannot be covered.

EXAMPLE 6:

A physician has ordered medical social services for a patient of extremely limited income

who has incurred large unpaid hospital and other medical bills following a significant

illness. The patient's recovery is adversely affected because the patient is not maintaining

a proper therapeutic diet, and cannot leave the home to acquire the medication necessary

to treat their illness. The medical social worker reviews the patient's financial status,

arranges meal service to resolve the dietary problem, arranges for home delivered

medications, gathers the information necessary for application to Medicaid to acquire

coverage for the medications the patient needs, files the application on behalf of the

patient, and follows up repeatedly with the Medicaid State agency.

The medical social services that are necessary to review the financial status of the patient,

arrange for meal service and delivery of medications to the home, and arrange for the

Medicaid State agency to assist the patient with the application for Medicaid are covered.

The services related to the assistance in filing the application for Medicaid and the

follow-up on the application are not covered since they must be provided by the State

agency free of charge, and hence the patient has no obligation to pay for such assistance.

EXAMPLE 7:

A physician has ordered medical social services for an insulin dependent diabetic whose

blood sugar is elevated because she has run out of syringes and missed her insulin dose

for two days. Upon making the assessment visit, the medical social worker learns that

the patient's daughter, who is also an insulin dependent diabetic, has come to live with the

patient because she is out of work. The daughter is now financially dependent on the

patient for all of her financial needs and has been using the patient's insulin syringes. The

social worker assesses the patient's financial resources and determines that they are

adequate to support the patient and meet her own medical needs, but are not sufficient to

support the daughter. She also counsels the daughter and helps her access community

resources. These visits would be covered, but only to the extent that the services are

necessary to prevent interference with the patient's treatment plan.

EXAMPLE 8:

A wife is caring for her husband who is an Alzheimer's patient. The nurse learns that the

wife has not been giving the patient his medication correctly and seems distracted and

forgetful about various aspects of the patient's care. In a conversation with the nurse, the

wife relates that she is feeling depressed and overwhelmed by the patient's illness. The

nurse contacts the patient's physician who orders a social work evaluation. In her

assessment visit, the social worker learns that the patient's wife is so distraught over her

situation that she cannot provide adequate care to the patient. While there, the social

worker counsels the wife and assists her with referrals to a support group and her private

physician for evaluation of her depression. The services would be covered.

EXAMPLE 9:

The parent of a dependent disabled child has been discharged from the hospital following

a hip replacement. Although arrangements for care of the disabled child during the

hospitalization were made, the child has returned to the home. During a visit to the

patient, the nurse observes that the patient is transferring the child from bed to a

wheelchair. In an effort to avoid impeding the patient's recovery, the nurse contacts the

patient's physician to order a visit by a social worker to mobilize family members or

otherwise arrange for temporary care of the disabled child. The services would be

covered.

50.4 - Medical Supplies (Except for Drugs and Biologicals Other Than

Covered Osteoporosis Drugs), the Use of Durable Medical Equipment

and Furnishing Negative Pressure Wound Therapy Using a Disposable

Device

(Rev. 233, Issued: 02-24-17, Effective: 01-01-17, Implementation: 03-27-17)