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Home Health Certification/Recertification Requirements

To qualify for the Medicare home health benefit, under §§1814(a)(2)(C) and 1835(a)(2)(A) of the Act, a Medicare beneficiary must meet the following requirements:

Be confined to the home
Under the care of a physician or allowed practitioner
Receiving services under a plan of care established and periodically reviewed by a physician or allowed practitioner
Need skilled nursing care on an intermittent basis (fewer than 7 days each week or less than 8 hours of each day for periods of 21 days or less) or physical therapy or speech-language pathology
Have a continuing need for occupational therapy

Confined to Home (Homebound)

An individual shall be considered "confined to the home" (homebound) if the following two criteria are met:

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 in order to leave their place of residence.
Have a condition such that leaving his or her home is medically contraindicated.

If the patient meets one of the criterion one conditions, then the patient must ALSO meet two additional requirements defined in criterion two below.

Criterion Two:

There must exist a normal inability to leave home; AND,
Leaving home must require a considerable and taxing effort.

Physician/Allowed Practitioner

Allowed practitioners in addition to physicians, can certify and recertify beneficiaries for eligibility, order home health services, and establish and review the care plan. Allowed practitioners are defined at § 484.2 as a physician assistant (PA), nurse practitioner (NP), or clinical nurse specialist (CNS) as defined at this part. NPs, CNSs, and PAs are required to practice in accordance with state law in the state in which the individual performs such services. Physician assistant means an individual as defined at § 410.74(a) and (c). Clinical nurse specialist means an individual as defined at § 410.76(a) and (b), and who is working in collaboration with the physician as defined at § 410.76(c)(3). Nurse practitioner means an individual as defined at § 410.75(a) and (b), and who is working in collaboration with the physician as defined at § 410.75(c)(3).

Content of the Plan of Care

The HHA must be acting upon a physician or allowed practitioner plan of care that meets the requirements of this section for HHA services to be covered. For HHA services to be covered, the individualized plan of care must specify the services necessary to meet the patient-specific needs identified in the comprehensive assessment. In addition, the plan of care must include the identification of the responsible discipline(s) and the frequency and duration of all visits as well as those items listed in 42 CFR 484.60(a) that establish the need for such services. All care provided must be in accordance with the plan of care.

Who Signs the Plan of Care

The physician or allowed practitioner who signs the plan of care must be qualified to sign the certification as described in 42 CFR 424.22.

Timeliness of Signature

The plan of care must be signed and dated by a physician or allowed practitioner as described who meets the certification and recertification requirements of 42 CFR 424.22 and before the claim for each 30-day period for services is submitted for the final percentage payment.

Frequency of Review of the Plan of Care

The plan of care must be reviewed and signed by the physician or allowed practitioner who established the plan of care, in consultation with HHA professional personnel, at least every 60 days. Each review of a patient's plan of care must contain the signature of the physician or allowed practitioner and the date of review.

Needs Skilled Nursing Care on an Intermittent Basis

The patient must need one of the following types of services:

Skilled nursing care that is:
- Reasonable and necessary as defined in §40.1
- Needed on an "intermittent" basis as defined in §40.1.3; and
- Not solely needed for venipuncture for the purposes of obtaining blood sample as defined in §40.1.2.13; or
Physical therapy as defined in §40.2.2; or
Speech-language pathology services as defined in §40.2.3; or
Have a continuing need for occupational therapy as defined in §§40.2.4.

Physician Certification Including Face to Face (FTF)

The certifying physician must attest to the 5 required elements/certification statement and supply a face-to-face assessment (clinical) documentation which shows evidence of the beneficiary's homebound criteria, skilled need, and primary reason care was being initiated. This assessment must have occurred no more than 90 days prior to the SOC, or 30 days after.

Initial certification

Initial certification is considered to be anytime that a Start of Care (SOC) OASIS is completed to initiate care. In such instances, a physician must certify (5 elements) (attest) that:

The home health services are or were needed because the patient is or was confined to the home as defined in the CMS Medicare Benefit Policy Manual (Pub. 100-02), chapter 7, §30.1.1.
The patient needs or needed skilled nursing services on an intermittent basis or physical therapy, or speech-language pathology services.
A plan of care has been established and is periodically reviewed by a physician or allowed practitioner.
The services are or were furnished while the patient is or was under the care of a physician or allowed practitioner.
A face-to-face encounter occurred no more than 90 days prior to or within 30 days after the start of the home health care, was related to the primary reason the patient requires home health services and was performed by a physician or non-physician practitioner. The certifying physician or allowed practitioner must also document the date of the encounter.

Note: If the patient is starting home health directly after discharge from an acute/post-acute care setting where the physician or allowed practitioner, with privileges, that cared for the patient in that setting is certifying the patient's eligibility for the home health benefit, but will not be following the patient after discharge, then the certifying physician or allowed practitioner must identify the community physician or allowed practitioner who will be following the patient after discharge.

Face-to-Face Encounter

As part of the certification of patient eligibility for the Medicare home health benefit, a face-to-face encounter with the patient must be performed by the certifying physician or allowed practitioner himself or herself, a physician or allowed practitioner that cared for the patient in the acute or post-acute care facility (with privileges who cared for the patient in an acute or post-acute care facility from which the patient was directly admitted to home health) or an allowed non-physician practitioner (NPP).

NPPs allowed to perform the encounter:

A nurse practitioner or a clinical nurse specialist working in accordance with State law and in collaboration with the certifying physician or in collaboration with an acute or post-acute care physician, with privileges, who cared for the patient in the acute or post-acute care facility from which the patient was directly admitted to home health.

A certified nurse midwife, as authorized by State law, under the supervision of the certifying physician or under the supervision of an acute or post-acute care physician with privileges who cared for the patient in the acute or post-acute care facility from which the patient was directly admitted to home health.

A physician assistant under the supervision of the certifying physician or under the supervision of an acute or post-acute care physician with privileges who cared for the patient in the acute or post-acute care facility from which the patient was directly admitted to home health.

The physician or allowed practitioner that performed the required face-to-face encounter must sign the certification of eligibility unless the patient is directly admitted to home health care from an acute or post-acute care facility and the encounter was performed by a physician or allowed practitioner in such setting.

Timeframe Requirements

The encounter must occur no more than 90 days prior to the home health start of care date or within 30 days after the start of care.

Physician Recertification

A physician's recertification is required at least every 60 days when there is a need for continuous home health care after an initial 60-day episode. Recertification should occur at the time the plan of care is reviewed and must be signed and dated by the physician who reviews the plan of care.

For recertification of home health services, the physician or allowed practitioner must certify (attest) that the home health services are or were needed because the patient is or was confined to the home as defined in §30.1. The patient needs or needed skilled nursing services on an intermittent basis (other than solely venipuncture for the purposes of obtaining a blood sample), or physical therapy, or speech-language pathology services; or continues to need occupational therapy, a plan of care has been established and is periodically reviewed by a physician or allowed practitioner; and the services are or were furnished while the patient is or was under the care of a physician or allowed practitioner.

Who May Sign the Certification or Recertification

The physician or allowed practitioner who signs the certification or recertification must be permitted to do so by 42 CFR 424.22. A physician or other allowed non-physician practitioner, other than the certifying physician or certifying allowed practitioner who established the home health plan of care, may sign the plan of care or the recertification statement in the absence of the certifying physician or certifying allowed practitioner. This is only permitted when such physician or allowed non-physician practitioner has been authorized to care for the certifying physician's or allowed practitioner's patients in his/her absence. The HHA is responsible for ensuring that the physician or allowed nonphysician practitioner who signs the plan of care and recertification statement was authorized by the physician or allowed practitioner who established the plan of care and completed the certification for his/her patient in his/her absence. The physician or allowed practitioner that performed the required face-to-face encounter must sign the certification of eligibility unless the patient is directly admitted to home health care from an acute or post-acute care facility and the encounter was performed by a physician or allowed practitioner in such setting.