Harvard Pilgrim HealthCare Medical Policy

Home Health Services

STRIDESM (HMO) MEDICARE ADVANTAGE

Subject: Home Health Services

Policy and Coverage Criteria:

Harvard Pilgrim StrideSM (HMO) Medicare Advantage considers part-time intermittent home health care services (described below) as reasonable and medically when documentation confirms specific criteria are met.

• Members must be homebound, and services must be ordered under a plan of care established and reviewed regularly by the attending physician caring for the member.

Covered services must be:

• Reasonable and medically necessary based on the member’s condition, complexity of requested service(s), and accepted standards of clinical practice;
• An essential part of active treatment of the member’s medical or behavioral health condition; AND
• Provided by a home health agency that is accredited/certified by an appropriate accrediting organization.

General Criteria

Harvard Pilgrim StrideSM (HMO) Medicare Advantage considers an episode of care, including part-time/intermittent services (i.e. less than eight hours of combined skilled nursing and home health aide [HHA] services per day, up to 35 hours per week), as reasonable and medically necessary when documentation confirms ALL the following:

• The member is homebound (i.e. leaving the home is medically contraindicated or member is confined tohome due to an illness, injury or disability that restricts his/her ability to leave home without a considerable and taxing effort). Exceptions to this criteria may be made only in limited situations where Harvard Pilgrim StrideSM (HMO) Medicare Advantage (in collaboration with the attending provider) determines that:
  1. The member’s medical condition prohibits safe travel to a treatment site where medically appropriate care can be furnished, OR
  2. The member’s residence is the most clinically appropriate setting for the member to receive needed care or maximize independence.
• Requested services are reasonable and necessary based on the member’s condition and an essential part of the active treatment plan developed by the attending physician.

NOTE: In some situations, a service cannot be provided at the residence of a homebound patient because required equipment is not available. If the services required by an individual involve the use of such equipment, the member may receive needed services on an outpatient basis at a hospital, skilled nursing facility or a rehabilitation center, and still be considered homebound if he/she requires the use of supportive devices, special transportation, or the assistance of another person to travel to the appropriate facility.

• Requested services are reasonable and necessary based on the member’s condition and an essential part of the active treatment plan developed by the attending physician.

HPHC Medical Policy

Public Domain Page 1 of 5

Home Health Services

VA03MAR22P

Harvard Pilgrim StrideSM (HMO) policies are based on medical science and relevant information including current Medicare coverage (including National and Local Coverage Determinations), Harvard Pilgrim medical policies, and Harvard Pilgrim StrideSM (HMO) Medicare Advantage Plan materials. These policies are intended to provide benefit coverage information and guidelines specific to the Harvard Pilgrim StrideSM (HMO) Medicare Advantage Plan. Providers are responsible for reviewing the CMS Medicare Coverage Center guidance; in the event that there is a conflict between this document and the CMS Medicare Coverage Center guidance, the CMS Medicare Coverage Center guidance will control.

Skilled services are medically necessary to achieve defined medical goals and expected to improve the patient's condition in a reasonable (and generally predictable) period of time. Documentation of the medical goals of the current home health care plan (e.g.

improved mobility, patient/family independence in care), estimated duration of need for the requested services, and member’s progress towards established goals (short and long-term) is required.

Harvard Pilgrim StrideSM (HMO) Medicare Advantage considers skilled nursing services that exceed part-time intermittent services as reasonable and medically necessary for the following:

• Daily Subcutaneous Heparin Injections: Skilled nursing visits may be authorized to administer subcutaneous injections of low dose heparin prescribed (by a physician) to a homebound individual who:
  • Is pregnant and requires anticoagulant therapy, OR
  • Requires anticoagulation (e.g., for treatment for deep venous thrombosis or pulmonary emboli when documentation confirms individual cannot tolerate warfarin.

If a member or caregiver is unable to administer the injection, daily nursing visits (seven days a week) may be considered for up to six months if reasonable and medically necessary. Documentation supporting the need for the extended course of treatment is required.

HPHC Medical Policy

Public Domain Page 2 of 5

Home Health Services

VA03MAR22P

Harvard Pilgrim StrideSM (HMO) policies are based on medical science and relevant information including current Medicare coverage (including National and Local Coverage Determinations), Harvard Pilgrim medical policies, and Harvard Pilgrim StrideSM (HMO) Medicare Advantage Plan materials. These policies are intended to provide benefit coverage information and guidelines specific to the Harvard Pilgrim StrideSM (HMO) Medicare Advantage Plan. Providers are responsible for reviewing the CMS Medicare Coverage Center guidance; in the event that there is a conflict between this document and the CMS Medicare Coverage Center guidance, the CMS Medicare Coverage Center guidance will control.

Services may also be considered when the member's clinical condition is so complex that an effective maintenance program must be delivered by the therapist (not an assistant) to ensure the individual's safety.

Home Health Aide (HHA) Services

Services are considered only when:

• The member requires skilled home health services; and
• HPHC determines HHA services are essential and directly related to authorized skilled plan of care.

Medical Social Services

Services are considered (as appropriate) only when:

• The member requires skilled home health services; and
• HPHC determines medical social services are essential and directly related to authorized skilled plan of care.

Nutritional Counseling

Services are considered (as appropriate) only when:

• The member requires skilled home health services; and
• HPHC determines nutritional counseling services are essential and directly related to authorized skilled plan of care.

Exclusions:

Harvard Pilgrim StrideSM (HMO) Medicare Advantage considers home health services as not medically necessary for all other indications. In addition, HPHC does not cover:

• Home health aides (HHA) or homemaking services that are not an essential part of an active, goal-oriented, skilled home health care program
• Homemaking services
• Custodial care (i.e., services furnished for companionship, maintenance therapy, supervision or primarily to assist a member with personal care)
• Private duty nursing or block nursing services

HPHC Medical Policy

Public Domain Page 3 of 5

Home Health Services

VA03MAR22P

Harvard Pilgrim StrideSM (HMO) policies are based on medical science and relevant information including current Medicare coverage (including National and Local Coverage Determinations), Harvard Pilgrim medical policies, and Harvard Pilgrim StrideSM (HMO) Medicare Advantage Plan materials. These policies are intended to provide benefit coverage information and guidelines specific to the Harvard Pilgrim StrideSM (HMO) Medicare Advantage Plan. Providers are responsible for reviewing the CMS Medicare Coverage Center guidance; in the event that there is a conflict between this document and the CMS Medicare Coverage Center guidance, the CMS Medicare Coverage Center guidance will control.