CMS Pub. 100-02, ch. 8, § 30.7.1

A3-3132.6.A, SNF-214.6.A

Alternative facilities or services may be available to a patient when health care providers

such as home health agencies are utilized. These alternatives are not always available in

all communities and even where they exist they may not be available when needed.

EXAMPLE: Where the residents of a rural community generally utilize the outpatient

facilities of a hospital located some distance from the area, the hospital outpatient

department constitutes an alternative source of care that is available to the community.

Roads in winter, however, may be impassable for some periods of time and in special

situations institutionalization might be needed.

In determining the availability of more economical care alternatives, the coverage or

noncoverage of that alternative care is not a factor to be considered. Home health care

for a patient who is not homebound, for example, may be an appropriate alternative in

some cases. The fact that Medicare cannot cover such care is irrelevant.

The issue is feasibility and not whether coverage is provided in one setting and not

provided in another. For instance, an individual in need of daily skilled physical therapy

might be able to receive the services needed on a more economical basis from an

independently practicing physical therapist. However, the fact that Medicare payment

could not be made for the services because an expense limitation (if applicable) to the

services of an independent physical therapist had been exceeded or because the patient

was not enrolled in Part B, would not be a basis for determining that, as a practical

matter, the needed care could only be provided in a SNF.

In determining the availability of alternate facilities or services, whether the patient or

another resource can pay for the alternate services is not a factor to be considered.