CMS Pub. 100-03, ch. 1, § 290.1

Many individuals who are blind and require daily insulin for the control of a diabetic condition

are able to administer their injections without assistance (other than possibly that which may be

furnished by family members or friends). There are organizations which encourage and train

blind diabetics, both to fill their own syringes and to inject themselves. There are also a number

of devices available for blind individuals to fill their syringes accurately. However, the

individuals who may need assistance with prefilling their syringes may also require periodic

observation and evaluation, even though their diabetes is fairly stabilized. In such cases,

probably few in number, home health services may be required for this purpose.

To qualify for home health benefits, a blind diabetic must be confined to his home, under the

care of a physician, and in need of either skilled nursing services on an intermittent basis or

physical therapy or speech-language pathology services. Effective July 1, 1981, a person may

qualify for home health benefits based on his or her need for skilled nursing services on an

intermittent basis, physical therapy, speech-language pathology, or occupational therapy.

Effective December 1, 1981, occupational therapy is eliminated as a basis for entitlement to

home health services. However, if a person has otherwise qualified for home health services

because of the need for skilled nursing care, physical therapy or speech–language pathology, the

patient’s eligibility for home health services may be extended solely on the basis of the

continuing need for occupational therapy. (See the Medicare Benefit Policy Manual, Chapter 7,

“Home Health Services,” §20.) There must be a plan of treatment, established and periodically

reviewed by a physician, which indicates that there is a recurring need for home health services

to supplement the physician’s contacts with the patient; e.g., skilled nursing visits for observing

and determining the need for changes in the level and type of care which has been prescribed.

(See the Medicare Benefit Policy Manual, Chapter 7, “Home Health Services,” §§30.) Once an

initial regimen has been established, the frequency of need for further home health services can

vary greatly from patient to patient, depending on their condition and the likelihood of its

changing. Some may need visits only every 90 days, for example, while others may require

them much more frequently. If a nurse makes a visit to provide skilled services, and also prefills

syringes, the purpose of the visit which was to provide skilled services, does not change.

However, if the sole purpose of the nurse’s visit is to prefill insulin syringes for a blind diabetic,

it is not a skilled nursing visit although it may be reimbursed as such as indicated below.

Filling a syringe can be safely and effectively performed by the average nonmedical person

without the direct supervision of a licensed nurse. Consequently, it would not constitute a skilled

nursing service even if it is performed by a nurse. (See the Medicare Benefit Policy Manual,

Chapter 7, “Home Health Services,” §30.2.2.) The personal care duties normally performed by

home health aides include assisting the patient with medications ordered by a physician which

are ordinarily self-administered. (See the Medicare Benefit Policy Manual, Chapter 7, “Home

Health Services,” §50.2.)

Performance of such a service by an aide is consistent with the Medicare conditions of

participation for home health agencies. Therefore, home health aide services would be

appropriate for those blind diabetics who are qualified for home health benefits and who cannot

fill their syringes. An adequately trained home health aide could make intermittent visits,

usually on a weekly basis, to the home for the purpose of filling that supply of insulin ordered by

the physician.

If State law, however, precludes a home health aide from prefilling insulin syringes, payment

may be made for this service as part of the cost of skilled nursing services when performed by a

nurse for a blind diabetic who is otherwise unable to prefill his or her syringes. There are no

adverse consequences with respect to reimbursement to the home health agency for providing the

service in this manner.

If State law does not preclude a home health aide from prefilling insulin syringes, but the home

health agency chooses to send a nurse to perform only this task, the visit is reimbursed as if made

by a home health aide.

NOTE: As indicated, to qualify for home health benefits, a patient must require skilled nursing

services on an intermittent basis or physical therapy or speech-language pathology. If a

beneficiary does not qualify for home health benefits but only needs someone to prefill syringes

with the correct dosage of insulin, then no program payment can be made.

Cross-reference:

The Medicare Benefit Policy Manual, Chapter 7, “Home Health Services,” §§20, §§30, §30.2.2

and, §§50.