Applicability

2202.3 - Applicability (Rev. 1, 05-21-04) 2202.3A - Medicare and Medicaid Patients (Rev. 1, 05-21-04) In general, the comprehensive assessment and reporting regulations apply to any HHA required to meet the Medicare CoPs for any reason and are applied to all patients of that HHA unless otherwise specified. This includes Medicare, Medicaid, Medicare and Medicaid Managed Care, and private pay patients served by the agency. It also includes Medicaid waiver and State plan patients to the extent they do not fall into one of the exception categories listed below, and are required by the State to meet Medicare CoPs. HHAs providing services under Medicaid’s home health benefit must meet the CoPs for Medicare, as specified at 42 CFR 440.70(d). As such, HHAs servicing only Medicaid patients (Medicaid-only HHAs) must meet Medicare CoPs, including the comprehensive assessment and OASIS reporting requirements. Health maintenance organizations serving Medicare/Medicaid patients can either provide home health services themselves or can contract out for those services. If they provide home health services themselves, they must meet the Medicare home health CoPs. If they contract out for home health services, they must contract with a Medicare-approved HHA in order to serve Medicare/Medicaid patients. (See 42 CFR 417.416 and §2194.) The HHA’s requirement to conduct comprehensive assessments that include OASIS data items applies to each patient of the agency receiving home health services with certain exceptions: ● Patients under the age of 18; ● Patients receiving maternity services; ● Patients receiving housekeeping or chore services only; and ● Patients receiving personal care services only. ● Patients for whom Medicare or Medicaid insurance is not billed. The comprehensive assessment and reporting regulations to patients receiving personal care only services, regardless of payor source is not applicable. 2202.3B - OASIS and the Medicare Home Health Benefit (Rev. 125, Issued: 10-31-14, Effective: 10-31-14, Implementation: 10-31-14) The comprehensive assessment and OASIS data collection requirements apply to Medicare beneficiaries as described below: • Medicare beneficiaries, using the Medicare home health benefit provided under either Part A, Part B, or Part C; • Medicare beneficiaries who require therapy services provided outside the home for special equipment needs, and who are using the Medicare home health benefit. If a Medicare beneficiary is under a home health plan of care, all therapy services, that is physical therapy, occupational therapy, speech language pathology (PT, OT, SLP), delivered under the home health benefit whether they are furnished directly by the HHA or under arrangement on behalf of the HHA are bundled into the PPS payment rate as part of the consolidated billing requirements. The consolidated billing governs Medicare home health PPS effective October 1, 2000 and requires that payment for home health services (including medical supplies described in §1861(m)(5) of the Act, but excluding DME to the extent provided for in §1861(m)(5)) furnished to an individual who (at the time the item or service was furnished) is under a plan of care of a HHA, be made to the agency (without regard to whether or not the item or service was furnished by the agency, by others under arrangement with them made by the agency, or under any other contracting or consulting arrangement, or otherwise). The services included in the consolidated billing governing home health PPS are: • Part-time or intermittent skilled nursing services; • Part-time or intermittent home health aide services; • Physical therapy; • Speech-language pathology services; • Occupational therapy; • Medical social services; • Routine and non-routine medical supplies; • Covered osteoporosis drug as defined in §1861(kk) of the Act, but excluding other drugs and biologicals; and • Home health services defined in §1861(m) provided under arrangement at hospitals, SNFs or rehabilitation centers when they involve equipment too cumbersome to bring to the home or are furnished while the patient is at the facility to receive such services. If a Medicare beneficiary under a home health plan of care is receiving therapy services from another provider (either an inpatient or outpatient provider) under arrangement made by the HHA as part of the home health benefit simply because the required equipment cannot be made available at the patient’s home, the Medicare CoPs apply, including the comprehensive assessment and collection and reporting of OASIS data by the HHA. 1. Medicare Advantage Plans. Medicare Advantage Plans are health plan options that are part of the Medicare program. Medicare beneficiaries who elect to have Medicare services provided by a Medicare Advantage Plan are entitled to all the Medicare-covered services that are available to beneficiaries residing in the plan’s geographic area. Medicare Advantage Plans, like a Medicare Health Maintenance Organization (HMO) or Preferred Provider Organization (PPO), which contract with Medicare to furnish HHA services may provide such services either directly by the Plan or through Medicare- approved HHAs that have a provider agreement and CCN with Medicare. (See §417.416(a)). If the Medicare Advantage Plan provides home health services directly as an integral part of the Plan, the HHA is still required to meet the HHA CoPs, including the OASIS requirements, have a Medicare CCN, enter into a provider agreement with the Secretary, and meet other survey and certification requirements, including Office of Civil Rights and enrollment requirements, with which an HHA certified under §484.1 would have to comply. When the SA receives a request to survey an HMO-operated HHA for compliance with the HHA CoPs, it schedules an unannounced standard survey. The SA conducts the survey, completes the Form CMS-2567, obtains a PoC when necessary, and sends this information along with a completed Form CMS-1539 to the CMS RO. The SA resurveys approved HMO-operated HHAs according to the survey frequency allowed by the Secretary and determined by the SA to assure quality care and to ascertain whether they continue to meet the HHA CoPs. In essence, these HHAs are surveyed and certified the same as any other Medicare-approved HHAs. 2. Medicaid Home Health Programs/Medicaid Waiver Programs The comprehensive assessment regulations apply to HHAs that are required to meet the Medicare home health CoPs. An HHA that currently must meet the Medicare CoPs under Federal and/or State law must meet the Medicare CoPs related to OASIS and comprehensive assessment and reporting. If an HHA provides skilled services to individuals under Medicaid, then OASIS applies. If the patient is not receiving skilled nursing, physical therapy, occupational therapy, or speech language pathology services, then OASIS does not apply. The requirement to collect OASIS on patients receiving only personal care services has been delayed until further notice. 3. Medicare Hospice Benefit The comprehensive assessment and OASIS data collection requirements do not apply to any individual receiving hospice services from a Medicare-approved hospice. A hospice patient may receive covered home health services for a condition unrelated to the treatment of the terminal condition for which hospice care was elected. This type of patient would be subject to the regulations governing the HHA services, including OASIS collection and reporting. 4. Outpatient Therapy Benefit If a Medicare beneficiary not under a home health plan of care is receiving therapy services under the Medicare Part B outpatient benefit from another Medicare provider, the OASIS collection and reporting requirements do not apply. 5. SNF or Inpatient Hospital Benefit The comprehensive assessment and OASIS data collection requirements do not apply to Medicare beneficiaries who are inpatients at a SNF or a hospital because these services are not considered home health services and the OASIS comprehensive assessment does not need to be conducted. The MDS is required in certified skilled nursing facilities. The following table summarizes the type of Medicare/Medicaid service and the application of the Federal OASIS requirements: Type of Medicare/Medicaid Service Further Description Application of OASIS Home Health Benefit Part A Yes Home Health Benefit Part B Yes Home Health Benefit Terminal Care Yes Home Health Benefit Therapy services provided either directly or under arrangement while under a home health PoC during an open episode. Yes Medicare Home Health under a Medicare Advantage plan The selected HHA must be Medicare approved Yes Medicaid Home Health Benefit Skilled services provided including expanded home health services, that are skilled, provided under a Home and Community– based Waiver Yes Medicaid Home Health Benefit Waiver service or home health aide services only provided without skilled services No Medicare Hospice Benefit Inpatient or at home No Outpatient Therapy Benefit (patient not under a home health plan of care) Provided in a clinic, rehabilitation agency, a public health agency or other provider of services No Skilled Nursing Facility, Hospital Inpatient services No The guidance above applies to all HHAs that participate in Medicare and to HHAs that are required to meet the Medicare CoPs, including Medicaid HHAs. 2202.3C - Non-Medicare/Non-Medicaid Patients (Rev. 125, Issued: 10-31-14, Effective: 10-31-14, Implementation: 10-31-14) The collection, encoding, and transmission requirement for non-Medicare and non- Medicaid patients receiving skilled care is temporarily suspended. While HHAs are not required to collect OASIS for non-Medicare/non-Medicaid patients, HHAs may continue to collect OASIS data for their own use but they may not submit the data for these patients to the state. The state system will reject any assessment with a M0150 value of ‘0’ (unchecked) for items 1, 2, 3 and 4. Also, HAVEN will not include these assessments in the submission file, but will mark them as complete. 2202.3D - Skilled Versus Nonskilled Care (Rev. 1, 05-21-04) Until the comprehensive assessment and reporting requirement resumes for all patients, regardless of type of care provided, the following definitions apply for determining skilled versus non-skilled care for comprehensive assessment purposes only: ● Skilled Services for Medicare Patients - The provision of skilled service is a pre- condition for Medicare payment for home health care. Therefore, all patients receiving Medicare (traditional) home health services are, by definition, receiving skilled care. ● Skilled Services for Non-Medicare Patients - For comprehensive assessment purposes, skilled services are services which can only be provided by a registered nurse (RN) (or a licensed practical nurse under the supervision of an RN), a physical therapist (PT), occupational therapist (OT), or a speech language pathologist (SLP), licensed by the State. Most States define the kind of care that is allowed by these practitioners under State practice acts. The former requirement to conduct an initial evaluation of a patient is expanded in the comprehensive assessment regulations. The regulations now require that, in addition to an initial evaluation, the agency must also conduct a comprehensive assessment of a patient with updates at certain time points. These updates include different combinations of OASIS data items. An agency that currently must meet the Medicare CoPs under Federal and/or State law will need to meet the comprehensive assessment and OASIS encoding and reporting CoPs and apply them to each patient of the agency for whom home health services are rendered, with the exceptions listed in A. above. 2202.3E - Agencies Serving Medicaid Waiver and State Plan Patients (Rev. 1, 05-21-04) If home care is provided by an entity required to meet the Medicare CoPs for any reason, then the entity must apply all the requirements of the CoPs, including the comprehensive assessment and OASIS data reporting requirements, to all patients of the agency, including patients treated under a Medicaid waiver or State plan, as applicable. The same exceptions apply as listed in A. above, i.e., patients under the age of 18; patients receiving maternity services; patients receiving housekeeping or chore services only; and until sometime in the future, patients receiving personal care services only. If home care is provided by an entity that is not required to meet the Medicare CoPs, then the provider must comply with only those requirements imposed under State or local law. In this case if the provider treats patients under a Medicaid waiver or State plan, then none of the Medicare CoPs for HHAs, including the comprehensive assessment and OASIS data reporting requirements, apply. See §2183 for information on separate entities. 2202.3F - Patients Turning 18 (Rev. 125, Issued: 10-31-14, Effective: 10-31-14, Implementation: 10-31-14) A patient who is under age 18 and turns 18 while under the care of an HHA is to receive a comprehensive assessment (including OASIS, if Medicare or Medicaid is billed) at the next appropriate time point. Any assessments due under the regulations at the time the patient turns 18 would be conducted, including the collection and reporting of OASIS data, if Medicare or Medicaid is billed. EXAMPLE If on 1/5/2013 a patient under the care of the agency turns 18 and is transferred to an inpatient facility on or after 1/5/2013, a transfer assessment with the corresponding OASIS data items must be collected. If the patient was discharged on his/her 18th birthday, a discharge assessment with the corresponding OASIS data items must be collected. From the day the patient turns 18, any assessment required per the regulations at the next particular time point is required. Agencies are not expected to collect and report start of care OASIS data on patients admitted to the agency prior to turning 18. 2202.3G - Patients Receiving Maternity Services (Rev. 1, 05-21-04) The HHA should not collect data on patients receiving maternity services, i.e., prenatal, antepartum, and postpartum. The patient is not exempt from OASIS data collection if under the care of a physician for a condition unrelated to pregnancy or delivery.