United States: CMS Finalizes Medicaid Home Health And Medical Equipment Policy Changes, Including Face-To-Face Encounter Requirements

Last Updated: February 9 2016
Article by Debra A. McCurdy

CMS published a final rule on February 2, 2016 to implement statutory requirements regarding documentation of face-to-face encounters with Medicaid beneficiaries within certain timeframes as a condition of Medicaid coverage of home health services and certain medical equipment. The rule also makes several clarifications to Medicaid policies related to coverage of home health services, including medical supplies furnished under this benefit.

With regard to face-to-face encounters, the final rule provides that for initial orders of home health services, the physician must document that a face-to-face encounter that is related to the primary reason the beneficiary requires home health services occurred no more than 90 days before or 30 days after the start of services (in alignment with Medicare timeframes). The face-to-face encounter may occur through telehealth. For initial orders of medical equipment, supplies, or appliances (as defined in the rule), the physician or authorized non-physician practitioners (NPP) must document that a face-to-face encounter that is related to the primary reason the beneficiary requires medical equipment occurred no more than 6 months prior to the start of services. The actual face-to-face encounter for home health and medical equipment may be performed by the physician or certain authorized NPPs. CMS explains that it is aligning the timing and scope of the Medicaid medical equipment face-to-face encounter requirements with the parallel rules for Medicare durable medical equipment (DME). CMS references the list of DME items subject to the Medicare face-to-face encounter requirements; state Medicaid programs may require face-to-face encounters for more items than would be required under Medicare if they choose, but not fewer items.

In addition, the final rule clarifies that Medicaid home health services and items are not limited to home settings, and cannot be restricted to services furnished to beneficiaries who are homebound. A beneficiary may receive home health services in any setting in which normal life activities take place, other than a hospital, nursing facility, intermediate care facility for individuals with intellectual disabilities, or other setting in which payment is made under Medicaid for inpatient services that include room and board. The rule also codifies longstanding policies about the use of lists or other presumptions in determining Medicaid coverage of medical equipment under the home health benefit, and it clarifies that certain items previously only covered under Medicaid waivers meet the definition of medical supplies, equipment, and appliances that are covered under the home health benefit.

While the rule is effective July 1, 2016, states will be expected to be in compliance by either July 1, 2017 or July 1, 2018, based on the calendars of state legislatures.

This article is presented for informational purposes only and is not intended to constitute legal advice.

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