CMS Pub. 100-02, ch. 7, § 60.1

Home Health Benefit Period - Beneficiaries Enrolled in Part A and Part

B

(Rev. 1, 10-01-03)

A3-3122.1, HHA-212.1, A3-3122.1, HHA-212.2, PMs A-97-12, A-97-16, A-98-49

Section 1812(a)(3) of the Act provides post-institutional home health services for

individuals enrolled in Part A and Part B and home health services for individuals who

are eligible for Part A only. For beneficiaries who are enrolled in Part A and Part B, Part

A finances post-institutional home health services furnished during a home health spell of

illness for up to 100 visits during a spell of illness.

Part A finances up to 100 visits furnished during a home health spell of illness if the

following criteria are met:

• Beneficiaries are enrolled in Part A and Part B and qualify to receive the

Medicare home health benefit;

• Beneficiaries must have at least a three consecutive day stay in a hospital or rural

primary care hospital; and

• Home health services must be initiated and the first covered home health visit

must be rendered within 14 days of discharge from a 3 consecutive day stay in a

hospital or rural primary care hospital or within 14 days of discharge from a

skilled nursing facility in which the individual was provided post-hospital

extended care services. If the first home health visit is not initiated within 14 days

of discharge, then home health services are financed under Part B.

After an individual exhausts 100 visits of Part A post-institutional home health services,

Part B finances the balance of the home health spell of illness. A home health spell of

illness is a period of consecutive days beginning with the first day not included in a

previous home health spell of illness on which the individual is furnished post-institutional home health services which occurs in a month the individual is entitled to

Part A. The home health spell of illness ends with the close of the first period of 60

consecutive days in which the individual is neither an inpatient of a hospital or rural

primary care hospital nor an inpatient of a skilled nursing facility (in which the individual

was furnished post-hospital extended care services) nor provided home health services.

EXAMPLE 1:

An individual is enrolled in Part A and Part B, qualifies for the Medicare home health

benefit, has a three consecutive day stay in a hospital, and is discharged on May 1. On

May 5, the individual receives the first skilled nursing visit under the plan of care.

Therefore, post-institutional home health services have been initiated within 14 days of

discharge. The individual is later hospitalized on June 2. Prior to the June 2

hospitalization, the individual received 12 home health visits. The individual stays in the

hospital for four consecutive days, is discharged and receives home health services. That

individual continues the May 5 home health spell of illness and would have 88 visits left

under that home health spell of illness under Part A. That individual could not start

another home health spell of illness (100 visits under Part A) until a 60-day consecutive

period in which the individual was not an inpatient of a hospital, rural primary care

hospital, an inpatient of a skilled nursing facility (in which the individual was furnished

post-hospital extended care services), or provided home health services had passed.

EXAMPLE 2:

An individual is enrolled in Part A and Part B, qualifies for the Medicare home health

benefit, has a three consecutive day stay in a hospital, and home health is initiated within

14 days of discharge. The individual exhausts the 100 visits under Part A post-institutional home health services, continues to need home health services, and receives

home health services under Part B. The individual is then hospitalized for 4 consecutive

days. The individual is again discharged and receives home health services. The

individual cannot begin a new home health spell of illness because 60 days did not pass

in which the individual was not an inpatient of a hospital or rural primary care hospital or

an inpatient of a skilled nursing facility in which the individual was furnished post-hospital extended care services. The individual would be discharged and Part B would

continue to finance the home health services.