Non-Reimbursable Home Health Services

 Supplies used for routine Home Health are not reimbursed separately through the Home Health or Durable Medical Equipment (DME) benefit. Non-routine or client specific supplies must be reimbursed through the client’s DME benefit. 

 Nursing Visits for purpose of psychiatric counseling 

 Certified nurse aide visits for the purpose of providing only unskilled personal care and/or homemaking services. 

 Nursing or CNA visits provided in a shift (visits lasting more than 4½ consecutive hours) 

 Nursing visits for the sole purpose of providing supervision of the CNA or other Home Health staff 

 Nursing visits for the sole purpose of completing the Home Health plan of care/recertification 

 Long-Term Home Health nursing visits for the sole purpose of teaching the client or their family member 

 Long-Term Home Health nursing visits for the sole purpose of assessing a stable client where management, and reporting to physician of specific conditions and/or symptoms which are not stable 

Special Reimbursement Conditions for Home Health Services

 Acute Home Health services provided to Medicaid MCO clients shall be prior authorized (if required) and reimbursed under Medicaid MCO rules

 If a client is eligible for Medicare and Medicaid, Medicare is always the first payer when a client has skilled Home Health needs and the client is unable to leave their residence for non-medical programs and treatments (Homebound). All Medicare requirements shall be met and exhausted prior to billing Medicaid for Home Health services, except when:

o Medication box pre-filling is the only service provided; 

o Certified Home Health Aide Services are the only services provided; 

o Occupational Therapy Services when provided as the sole skilled service; 

o Routine Laboratory Draw Services are the only service provided; 

o If the client is (1) stable, (2) not experiencing an acute episode, and (3) routinely leaves the home unassisted for social, recreational, educational and/or employment purposes (not Homebound)

 Medicare & Medicaid may be billed simultaneously, if Medicare deems that the client is homebound based on the documentation provided the all Medicaid funds shall be repaid to Medicaid.

o Any combination of a through e above. 

o The record contains clear and concise documentation describing any exceptions

 Home Health services provided to clients who are eligible for both Medicare & Medicaid or have another third party insurance & Medicaid must be billed to Medicare first. All insurance requirements must be met and exhausted prior to billing Home Health services to Medicaid. 

o A denial must be kept in the client’s record and updated annually on the anniversary of the denial. 

o The third party insurance denials must be based on non-coverage and not due to the failure of adhering to the requirements set forth by the insurance agency. 

o Medicaid will not accept a “no-pay” denial (type of bill 320, condition code 21) from Medicare as a valid denial of Medicare coverage. 

 The Home Health Agency must maintain a signed Advance Beneficiary Notice (ABN) that is completed as prescribed by Medicare.