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Q: Will Medicare cover homecare services to residents of assisted living facilities (ALFs)?

Homecare Insider Q&A, August 2, 2012

A: The Centers for Medicare and Medicaid Services (CMS) Publication 100-2, Chapter 7, does provide some guidance regarding the coverage of homecare services to residents of ALFs. They may qualify for homecare services if the facility is not an institution. Homecare services will not be covered if they duplicate the services that the facility is supposed to provide under state licensure, and services to those who have access to appropriate care from a willing caregiver would not be considered reasonable and necessary.

To qualify for Medicare coverage of home health services, the patient must live in a home, not an institution. To further clarify Medicare’s definition of institution: an institution primarily provides diagnostic and therapeutic services, rehabilitation services, or skilled nursing care or related services. If the facility provides these services, it is not considered a residence, it is an institution. However, most ALFs do not provide these services and, if they do provide nursing care, it may not meet Medicare's criteria for skilled nursing care, which means it could still be considered to be the patient’s residence. And remember, the patient must still qualify for Medicare coverage by being homebound, under the care of a physician, in need of intermittent skilled care, and the services must be reasonable and necessary to treat the patient’s need. Most often, the component of the criteria that is most confusing when evaluating patients who reside in an ALF is homebound status.

You must consider each case on an individual basis and apply coverage criteria in the manner an intermediary would view it. Patients who demonstrate the ability to get around without assistance or effort are generally not viewed as homebound, so carefully evaluate the activity level of patients living in ALFs. To avoid problems, assess the patient’s eligibility for Medicare coverage, determine the obligations of the ALF to provide the care—if it is state-licensed, look at its licensure requirements; if it is not state licensed, look at the contract—and thoroughly document the type of care the patient requires and why the ALF is unable to provide it.