CMS Pub. 100-02, ch. 7, § 50.4.1.1

Patient's Plan of Care

(Rev. 10438, Issued: 11-06-20, Effective: 03-01-20, Implementation: 01- 11-21)

A. The Law

The Medicare law governing the home health PPS is specific to the type of items and

services bundled to the HHA and the time the services are bundled. Medical supplies are

bundled while the patient is under a home health plan of care. If a patient is admitted for

a condition which is related to a chronic condition that requires a medical supply (e.g.,

ostomy patient) the HHA is required to provide the medical supply while the patient is

under a home health plan of care during a 30-day period of care. The physician or

allowed practitioner’s orders in the plan of care must reflect all nonroutine medical

supplies provided and used while the patient is under a home health plan of care. The

consolidated billing requirement is not superseded by the exclusion of certain medical

supplies from the plan of care and then distinguishing between medical supplies that are

related and unrelated to the plan of care. Failure to include medical supplies on the plan

of care does not relieve HHAs from the obligation to comply with the consolidated

billing requirements. The comprehensive nature of the current patient assessment and

plan of care requirements looks at the totality of patient needs. However, there could be a

circumstance where a physician or allowed practitioner could be uncomfortable with

writing orders for a preexisting condition unrelated to the reason for home health care. In

those circumstances, PRN orders for such supplies may be used in the plan of care by a

physician or allowed practitioner.

Thus, all medical supplies are bundled while the patient is under a home health plan of

care. This includes, but is not limited to, the above listed medical supplies as well as the

Part B items provided in the final PPS rule. The latter item lists are subsequently updated

in accordance with the current process governing the deletion, replacement and revision

of Medicare Part B codes. Parenteral and enteral nutrition, prosthetics, orthotics, DME

and DME supplies are not considered medical supplies and therefore not subject to

bundling while the patient is under a home health plan of care. However, §1834(h)(4)(c)

of the Act specifically excludes from the term "orthotics and prosthetics" medical

supplies including catheters, catheter supplies, ostomy bags and supplies related to

ostomy care furnished by an HHA under §1861(m) of the Act. Therefore, these items are

bundled while a patient is under a home health plan of care.

B. Relationship Between Patient Choice and Veterans Benefits

For veterans, both Medicare and Veteran's Administration (VA) benefits are primary.

Therefore, the beneficiary who is a veteran has some choices in cases where the benefits

overlap. The beneficiary, however, must select one or the other program as primary

when obtaining active care. If the VA is selected as primary for home health care, then

Medicare becomes a secondary payer. An HHA must provide the medical supplies a

Medicare beneficiary needs no matter the payer; it is not obligated to provide medical

supplies that are not needed. If a patient has medical supplies provided by the VA

because of the patient's preference, then the HHA must not duplicate the supplies under

Medicare. The beneficiary's choice is controlling. The HHA may not require the

beneficiary to obtain or use medical supplies covered by the primary payer from any

other source, including the VA.

C. Medical Supplies Purchased by the Patient Prior to the Start of Care

A patient may have acquired medical supplies prior to his/her Medicare home health start

of care date. If a patient prefers to use his or her own medical supplies after having been

offered appropriate supplies by the HHA and it is determined by the HHA that the

patient's medical supplies are clinically appropriate, then the patient's choice is

controlling. The HHA is not required to duplicate the medical supplies if the patient

elects to use his or her own medical supplies. However, if the patient prefers to have the

HHA provide medical supplies while the patient is under a Medicare home health plan of

care, then the HHA must provide the medical supplies. The HHA may not require that

the patient obtain or use medical supplies from any other source. Given the possibility of

subsequent misunderstandings arising between the HHA and the patient on this issue, the

HHA should document the beneficiary's decision to decline HHA furnished medical

supplies and use their own resources.