May 2011

Information Bulletin 11-03
MHC-52

Medicare Certified HHAs and Medicaid Patients Clarification

Purpose:

To inform Medicare Certified Home Health Agencies (HHAs) of the clarification MDH received from the Centers for Medicare and Medicaid Services (CMS) regarding Medicaid patients and applicable Medicare Conditions of Participation (COP) Requirements for Medicaid patients.

These responses need to be read in conjunction with all other applicable Medicare requirements.

References

The Medicare Conditions of Participation for HHAs can be accessed at: http://www.cms.gov/manuals/downloads/som107_Appendicestoc.pdf

The Medicare State Operations Manual Chapter 2 - The Certification Process, See Home Health Agencies can be accessed at:

http://www.cms.gov/manuals/downloads/som107c02.pdf

Questions for CMS:

1. Question:

We have been "…contacted about agencies providing services for "maintenance patients". These agencies are sending in nurses and billing Medicaid for skilled nursing services. How would CMS consider these patients for purposes of compliance with HHA COPs? Would CMS consider them skilled or not? If they are billed as skilled but are not really receiving skilled nursing services would CMS consider them skilled? How does this impact OASIS? If the Medicaid program is paying for a nursing visit, when is it considered skilled?

Clarification from CMS:

If the Medicaid program is paying for a nursing visit, it is considered skilled.

The insurer considers the patient to need the service of an RN or LPN, thus skilled/professional. OASIS is required. In other cases, when nursing is provided just to supervise personal care, the nursing is absorbed as part of administrative and general costs, is not reimbursed separately, and OASIS is not required.

2. Question:

Do Medicare HHA COP requirements apply to patients on Medicaid being served by Medicare HHA?

Response:

Yes, the Medicare COPs apply to all patients served by the HHA.

See: http://www.cms.gov/manuals/downloads/som107_Appendicestoc.pdf

Subpart B - Administration

The Conditions of Participation for HHAs apply to each individual under its care unless a requirement is specifically limited to Medicare beneficiaries. Section 1861(o) of the Social Security Act (the Act) describes an HHA for purposes of participation in the Medicare program in broadly descriptive terms. All the requirements are stated generally as applicable to the HHA's overall activity, and not specifically to the Medicare patient. This provision, which was reaffirmed by Congress in the OBRA 1987 amendments to §1891(a) of the Act has been in the law since the inception of the Medicare program, and CMS' interpretation of it has remained the same. Do not attempt to resolve or enforce matters relating to Medicare/Medicaid coverage of services. If you observe what you believe are noncovered services, report this information to the Regional Office Medicare or Medicaid Divisions, as appropriate. Section 1891(c)(2)(C)(i)(II) of the Act requires that the standard survey shall include a survey of the quality of care and services furnished by the agency as measured by indicators of medical, nursing, and rehabilitative care.

3. Question:

Where in the Medicare COPs does it address which Medicaid patients need an OASIS?

Response:

The following language comes from the Centers for Medicare and Medicaid Services Home Health Agency Conditions of Participation. See underlined language of particular importance and relevance.

See §484.55 Condition of Participation: Comprehensive Assessment of Patients


G330
(Rev. 11, Issued: 08-12-05; Effective/Implementation: 08-12-05)

Each patient must receive, and an HHA must provide, a patient specific, comprehensive assessment that accurately reflects the patient's current health status and includes information that may be used to demonstrate the patient's progress toward achievement of desired outcomes. The comprehensive assessment must identify the patient's continuing need for home care and meet the patient's medical, nursing, rehabilitative, social, and discharge planning needs. For Medicare beneficiaries, the HHA must verify the patient's eligibility for the Medicare home health benefit including homebound status, both at the time of the initial assessment visit and at the time of the comprehensive assessment. The comprehensive assessment must also incorporate the use of the current version of the Outcome and Assessment Information Set (OASIS) items, using the language and groupings of the OASIS items, as specified by the Secretary.

Interpretive Guidelines §484.55
The comprehensive assessment includes the collection of OASIS data items for most patients, as described below, by a qualified clinician, i.e., an RN, physical therapist, occupational therapist, or speech language pathologist. For Medicare patients, there are some additional requirements. HHAs are expected to conduct a comprehensive assessment of each patient that accurately reflects the patient's current health status and includes information to establish and monitor a plan of care. The plan of care must be reviewed and updated at least every 60 days or as often as the severity of the patient's condition requires, per the requirements at 42 CFR 484.18 (a) and (b)

. The requirement to conduct a drug regimen review at §484.55(c) as part of the comprehensive assessment applies to all patients serviced by the HHA.

Patients to whom OASIS applies: The regulations require a comprehensive assessment, with OASIS data items integrated, for all patients who receive skilled services from an HHA meeting Medicare's home health conditions of participation, except for those patients who are--

  • Under age 18;
  • Receiving maternity services;
  • Receiving housekeeping or chore services only; or
  • Receiving only personal care services until further notice.
  • Patients for whom Medicare or Medicaid insurance is not billed

This includes Medicare, Medicaid, and Medicare Advantage (MA), formerly known as Medicare+Choice patients accepted by the HHA. It also includes Medicaid patients receiving services under a waiver program or demonstration to the extent they do not fall into one of the exception categories listed above, who are receiving services subject to the Medicare conditions of participation.

On December 8, 2003, Section 704 of the Medicare Prescription Drug, Improvement and Modernizatation Act of 2003 (MPDIMA), temporarily suspended the collection of OASIS data on non-Medicare/non-Medicaid patients of an HHA. However, Section 704 of the MMA does not effect or suspend any other provision of §484.55.

During this temporary suspension, CMS will conduct a study on how OASIS information on non-Medicare/non-Medicaid patients is and can be used by large HHAs. The study will also examine whether there are unique benefits for the analysis of this information that cannot be derived from other information available to, or conducted by, these HHAs. In addition, the study will address the value of collecting such information by small HHAs compared to the administrative burden of doing so. CMS will obtain recommendations from quality assessment experts in the use of the OASIS data and examine the necessity of small as well as large HHAs collecting this information. CMS is committed to thoroughly examining how all OASIS data may be used in future refinements of the Home Health Quality Initiative and oversight activities. At the conclusion of this study, CMS will submit a report to Congress. The results of the study will determine future CMS requirements regarding the collection of OASIS data as part of each patient's comprehensive assessment.

Until that time, SA and Regional Office (RO) surveyors should adhere to the following guidance when conducting HHA surveys:

  • HHAs must continue to comply with the aspects of the regulation at 42 CFR 484.55 regarding the comprehensive assessment of patients. HHAs must provide each agency patient, regardless of payment source, with a patient-specific comprehensive assessment that accurately reflects the patient's current health status and includes information that may be used to demonstrate the patient's progress toward the achievement of desired outcomes. The comprehensive assessment must also identify the patient's continuing need for home care, medical, nursing, rehabilitative, social, and discharge planning needs.
  • HHAs may continue to collect OASIS data on their non-Medicare/non-Medicaid patients for their own use.
  • Surveyors must continue to examine the completeness of the comprehensive assessment for all patients during a survey. However, surveyors must not investigate whether the HHA included the specific OASIS items in its patient-specific comprehensive assessments of non-Medicare/non-Medicaid patients, nor cite deficiencies based solely on this finding.
  • HHAs must continue to collect, encode, and transmit OASIS data for their non-maternity Medicare and Medicaid patients that are age 18 and over and receiving skilled services.

Under this condition, in addition to an initial assessment visit, the HHA must also conduct a start of care comprehensive assessment with OASIS data items integrated on patients to whom the requirements are applicable. Subsequent comprehensive assessments (updates and recertification) must be conducted at certain time points during the admission. These updates must include certain data items, i.e., those in the current OASIS data set. The recertification, transfer to an inpatient facility, resumption of care, significant change in condition (SCIC), and discharge comprehensive assessment apply to all patients, but it does not have to include OASIS for private pay patients. The recertification comprehensive assessment can be completed before the 5 day window as long as it continues to be done "not less frequently than the last five days of every 60 day episode beginning with the start-of-care date." The phrase "not less frequently than the last five days of every 60 days beginning with the start of care date" does not mean that HHAs must wait until the 55th - 60th day to perform another comprehensive assessment on non-Medicare/non-Medicaid patients or for pediatric patients, maternity patients or those receiving personal care services even when Medicare is the payor source. The assessment may be performed any time up to and including the 60th day. The timetable for the subsequent 60-day period would then be measured from the completion date of the most recently completed assessment. Clinicians may perform the comprehensive assessment for these patients more frequently than the last 5 days of the 60-day episode without conducting another comprehensive assessment on day 55-60, and remain in compliance with §484.55(d). The agency may develop its own comprehensive assessment for each time point.

OASIS data items are not meant to be the only items included in an HHA's assessment process. They are standardized health assessment items that must be incorporated into an HHA's own existing assessment policies and process. An example of a comprehensive assessment showing an integration of the OASIS data items with other agency assessment items can be found in "Appendix C: Sample Clinical Records Incorporating OASIS B-1 Data Set," in the OASIS User's Manual. For therapy-only cases, the comprehensive assessment should incorporate OASIS data items as well as other assessment data items the HHA currently collects for therapy patients, as opposed to simply adding them at the beginning or end.

Medicare patients: For Medicare patients, the HHA must include a determination of the patient's eligibility for the home health benefit, including homebound status.

Eligibility for the Medicare home health benefit is defined in the Medicare Benefit Policy Manual, CMS Pub.100-2 (see http://www.cms.hhs.gov/manuals/102_policy/bp102index.asp) and includes conditions patients must meet to qualify for coverage, such as:

  • Patient is confined to the home;
  • Services are provided under a plan of care established and approved by a physician;
  • Patient is under the care of a physician; and
  • Patient needs skilled nursing care on an intermittent basis or physical therapy or speech therapy services or has continued need for occupational therapy.

Incorporating OASIS items: HHA's must incorporate the OASIS data items into their own assessment instrument using the exact language of the items, replacing similar items/questions on their current assessment tool as opposed to simply adding the OASIS items at the beginning or end of the existing assessment tool.

4. Question:

Does this mean an OASIS must be completed for a Medicaid patient who receives only personal care services?

Response:

No. An OASIS does not need to be completed.

This is addressed under G 330. The following language comes from the Centers for Medicare and Medicaid Services Home Health Agency Conditions of Participation. See underlined language of particular importance and relevance.

Patients to whom OASIS applies: The regulations require a comprehensive assessment, with OASIS data items integrated, for all patients who receive skilled services from an HHA meeting Medicare's home health conditions of participation, except for those patients who are--

  • Under age 18;
  • Receiving maternity services;
  • Receiving housekeeping or chore services only; or
  • Receiving only personal care services until further notice.
  • Patients for whom Medicare or Medicaid insurance is not billed

This includes Medicare, Medicaid, and Medicare Advantage (MA), formerly known as Medicare+Choice patients accepted by the HHA. It also includes Medicaid patients receiving services under a waiver program or demonstration to the extent they do not fall into one of the exception categories listed above, who are receiving services subject to the Medicare conditions of participation.

  • HHAs must continue to collect, encode, and transmit OASIS data for their non-maternity Medicare and Medicaid patients that are age 18 and over and receiving skilled services.

5. Question:

Does this mean an OASIS must be completed if a Medicaid patient receives services of a professional such as a registered nurse or therapist?

Response

Yes. An OASIS does need to be completed.

This is addressed under G 330. The following language comes from the Centers for Medicare and Medicaid Services Home Health Agency Conditions of Participation. See underlined language of particular importance and relevance.

Patients to whom OASIS applies: The regulations require a comprehensive assessment, with OASIS data items integrated, for all patients who receive skilled services from an HHA meeting Medicare's home health conditions of participation, except for those patients who are--

  • Under age 18;
  • Receiving maternity services;
  • Receiving housekeeping or chore services only; or
  • Receiving only personal care services until further notice.
  • Patients for whom Medicare or Medicaid insurance is not billed

This includes Medicare, Medicaid, and Medicare Advantage (MA), formerly known as Medicare+Choice patients accepted by the HHA. It also includes Medicaid patients receiving services under a waiver program or demonstration to the extent they do not fall into one of the exception categories listed above, who are receiving services subject to the Medicare conditions of participation.

  • HHAs must continue to collect, encode, and transmit OASIS data for their non-maternity Medicare and Medicaid patients that are age 18 and over and receiving skilled services.

Updated Tuesday, May 10, 2011 at 08:09AM