CMS Home Health Orders Waiver Pilot Program
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Update 12/3/2019

As we prepare for January, 2020 and the start of the CMS waiver that will allow NPs to certify for home health services for patients it is very important to understand about which patients qualify for home health services and the eligibility requirements for home health services.  Below is a short synopsis.

 

 

Part II  Qualifying for Home Health Services

What criteria must be met to qualify for home health services? Medicare covers home health services when all of these criteria are met:

·       The beneficiary to whom services are furnished is eligible and enrolled in Part A and/or Part B of the Medicare Program

·       The beneficiary is eligible for coverage of home health services

·       The HHA furnishing the services has a valid agreement in effect to participate in the Medicare Program  

·       The services for which payment is claimed are covered under the Medicare home health benefit

·       Medicare is the appropriate payer and  

·       The services are not otherwise excluded from payment

What criteria must a patient meet to be eligible for home health services? For a patient to be eligible for Medicare home health services, he or she must meet these criteria:

1. Be confined to the home (that is, homebound)

2. Need skilled services

3. Be under the care of a physician or NPP (non-physician provider)

4. Receive services under a home health plan of care (POC) established and periodically reviewed by a physician or NPP and

5. Had a face-to-face encounter related to the primary reason the patient requires home health services with a physician or an allowed NPP no more than 90 days prior to the home health start-of-care date or within 30 days of the start of the home health care

 

 

Part III  How to determine Homebound Status

 

A patient is considered confined to the home (that is, homebound) if these two criteria are met: 

 

1. Criterion One: The patient must either: 

 

● Because of illness or injury, need the aid of supportive devices such as crutches, canes, wheelchairs, and walkers; the use of special transportation; or the assistance of another person to leave their place of residence OR 

● Have a condition such that leaving his or her home is medically contraindicated 

 

If the patient meets one of the Criterion One conditions, he or she must also meet the two additional requirements described in Criterion Two. 

 

2. Criterion Two: 

 

● There must exist a normal inability to leave home AND 

● Leaving home must require a considerable and taxing effort The patient may be considered confined to the home (that is, homebound) if absences from the home are: 

    ● Infrequent 

    ● For periods of relatively short duration 

    ● For the need to receive health care treatment 

    ● For religious services 

    ● To attend adult daycare programs or 

    ● For other unique or infrequent events (for example, funeral, graduation, trip to the barber) 

 

Some examples of persons who may be considered confined to the home (that is, homebound) are: 

 

● A patient who is blind or senile and requires the assistance of another person in leaving their place of residence 

● A patient who has just returned from a hospital stay involving surgery, who may be suffering from resultant weakness and pain, and therefore their actions may be restricted by their physician to certain specified and limited activities such as only getting out of bed for a specified period of time or only walking stairs once a day and 

● A patient with a psychiatric illness that is manifested, in part, by a refusal to leave home or is of such a nature that it would not be considered safe for the patient to leave home unattended, even if they have no physical limitations

 

 

Part IV Skilled Services

 

For a patient to be eligible for Medicare home health services, he or she must need skilled services.  Skilled services may include:

 

Part-time or intermittent skilled nursing services 

Part-time or intermittent home health aide services 

PT

OT

Speech/language pathology services

Medical social services 

 



Update 11/25/19  RESOURCES
Please find below 4 resources that will give more information regarding the new CMS Waiver for Home Health Care pilot program in Maryland

Home Health Orders for Nurse Practitioners under the Maryland Total Cost of Care (TCOC) Model

Home Health Prospective Payment System (HH PPS) Rate Update for Calendar Year (CY) 2020 

NPAM/MNCHA powerpoint: NP Waiver to Sign Homecare Orders

AARP Public Policy: Removing Barriers to Advanced Practice Registered Nurse Care: Home Health and Hospice Services
Campaign For Action

HH Certification & CPO Codes

Update 11/22/2019

As you might know, NPAM is working with MNCHA (Maryland National Capital Homecare Association) to get the word out about the exciting change that is happening on January 1, 2020, that will allow NPs in Maryland to certify for home health for Medicare patients. Last week, NPAM and MNCHA sponsored 3 learning sessions in the southern part of Maryland, which reviewed the changes that will be implemented. If you were not able to attend in person, please keep an eye out for future learning sessions and perhaps a webinar, so that, you, too, will understand how this change will affect you and your practice.

NPAM thanks Dawn Seek, Executive Director with MNCHA for explaining the back story of how Maryland was able to acquire this waiver with CMS, and Sandra Nettina, NPAM member and Past-President, who is the owner of Prime Care House Calls, for presenting on what NPs need to know prior to implementation.

Sandra Nettina

Additionally, we thank Andrea Brassard, NPAM member and home health advocate for assisting with the planning and implementation of these learning sessions.

Each week, NPAM will keep you up to date on what is happening and will be providing information to assist with preparation. We encourage you to share this information with your colleagues, home health referral sources and home health agencies.

Below is Part I: NPs Ordering Home Health Care in Maryland: The Rules

The waiver applies to:

Nurse Practitioners

  • who practice in Maryland
  • who are in the PECOS system (have an NPI)

Patients

  • who live in Maryland
  • who have Medicare Part A ("regular" Medicare)
  • who meet the home care requirements - homebound and need skilled services (more about this next two weeks)
  • are referred to a Medicare certified Home Health Agency

The Waiver DOES NOT apply to:

  • Hospice
  •  Medicaid
  •  Medicare Advantage Plans
  •  Commercial Insurance

 

NPAM is working with MNCHA to explore how this waiver might be extended to payers other than Medicare

If your practice refers patients for home health services, know that services will no longer be delayed until a physician signs the referral.
If you have current home health patients who need continuing home health care "recertifications" check the dates - it should be your signature after January 1!
Please spread the word to physicians, hospital discharge planners, case managers, and home health agencies.

For more information:
https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM11330.pdf

We are so proud to be the first state in the Nation to pilot this program.

Beverly Lang, Executive Director NPAM, NPAMExDir@npedu.com
Dawn Seek, Executive Director MNCHA dseek@MNCHA.org





Initial Post 11/1/19
On October 10, 2019, the Center for Medicare and Medicaid Services (CMS) approved a waiver that will allow all Medicare-enrolled NPs in Maryland to certify home health services for Medicare beneficiaries beginning on January 1, 2020, as part of the Maryland TCOC Model. The Maryland TCOC Model is the first model tested by the Centers for Medicare and Medicaid Innovation (CMMI) that holds a state fully at risk for the total cost of care for Medicare beneficiaries. CMS has instructed Maryland Medicare Administrative Contractors to begin accepting home health claims submitted by home health agencies with NPs in the attending provider field, as well as claims submitted directly by NPs for certification/re-certification and care plan oversight for home health plans of care. Access more information regarding the waiver and more information about the Maryland TCOC Model. Additionally, AANP has put together a brief primer on the waiver.   (must be AANP member to access).  AANP is very pleased to see that CMS recognizes authorizing NPs to fully oversee home health plans of care will decrease costs of care, lower unnecessary utilization and support patient/provider relationships. AANP will continue to work with CMS on expanding this authorization throughout other Medicare and Medicaid programs.
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