Medicare and MO HealthNet Eligibility, Face-to-Face Encounter, and Homebound Status
Sets out how the Agency confirms that each patient meets the coverage rules of the program expected to pay: for Medicare, the qualifying conditions in 42 CFR §409.42, homebound status verified at the initial assessment visit and the comprehensive assessment, and the physician or allowed practitioner certification and face-to-face encounter in 42 CFR §424.22; for MO HealthNet, the conditions, face-to-face encounter, visit definition and visit limits in 13 CSR 70-90.010 and 42 CFR §440.70; and what happens when a patient does not qualify.
About this policy
- Policy number
- MO-HH-ADM-03
- Version
- 1.0
- Main rule
- 42 CFR §424.22
- Library
- Missouri home health · 57 policies
- Category
- Service delivery
- Sections
- 22
In short
- Check every payer and MO HealthNet eligibility before the first visit.
- For Medicare patients, record specific facts that show the patient is homebound at every skilled visit.
- The face-to-face visit must be within 90 days before or 30 days after the start of care.
- MO HealthNet does not require homebound status, but it limits visits. Watch the yearly count.
- Never change or back-date notes to make a patient look eligible. Report any pressure to do so.
What's inside
22 sections. The full text comes with the One-time Policy Pack.
- Terms of Reference
- 1. Purpose
- 2. Scope
- 3. Definitions
- 4. Policy Statement (42 CFR §§409.42, 424.22, 440.70; 42 CFR §484.55; 13 CSR 70-90.010)
- 5. Checking Payer and Eligibility at Intake
- 6. Medicare Qualifying Conditions (If the Agency Is Medicare-Certified)
- 7. Homebound Status
- 8. Certification and the Face-to-Face Encounter (Medicare)
- 9. Practitioners Who May Not Certify
- 10. Collecting and Tracking Documentation
- 11. MO HealthNet Coverage Conditions
- 12. Tracking MO HealthNet Visit Limits
- 13. Other Payers
- 14. When a Patient Does Not Qualify or Stops Qualifying
- 15. Responsibilities
- 16. Records and Compliance Monitoring
- 17. Staff Training
- 18. References
- 19. Related Policies and Forms
- 20. Approval
- 21. Revision History
An inspector may ask
- For this Medicare patient, show me how homebound status was verified at the initial assessment visit and the comprehensive assessment.
- Where is the face-to-face encounter documentation, and does the date fall within the allowed window?
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