The Centers for Medicare & Medicaid Services (CMS) has reversed its position requiring Medicare Advantage plans (MA) to apply Medicare Fee-for-Service face-to-face certification requirements to home health services. This reversal is seen as a major victory for NAHC, who has been advocating for such a change, and the home health community as a whole.
CMS, in the final call letter for the 2015 rates for the MA plans, “clarified” that the MA plans were to apply the same certification requirements as fee-for-service (FFS) Medicare to plan members who receive home health services. This directive would also require that the plans apply the F2F encounter requirement.
The National Association for Home Care & Hospice (NAHC) had serious concerns with this directive and took those concerns to officials at CMS. NAHC questioned the rationale behind the requirement in light of the fact that the MA plans have a preauthorization process that would negate the need to follow Medicare FFS certification requirements. NAHC also expressed its interpretation of the regulations to require that MA plans offer the same scope of benefits to its members as Medicare, but does not require that the plans apply the same certification criteria as Medicare.
The following memorandum from CMS has been issued to Medicare Advantage plans:
This memorandum is to correct the Final Call Letter of April 7, 2014 regarding Medicare Advantage organization's (MAO's) certification of enrollees for home health services. We are clarifying that an MAO's authorization for home health services may substitute for the Original Medicare face-to-face certification requirement for the authorization of home health care services.
In certain circumstances, MAOs are not required to follow Original Medicare documentation requirements for the provision of Medicare covered services, but may substitute methods they deem appropriate for ensuring that the services provided are medically necessary, so long as they are not more restrictive than the coverage standards that apply in Original Medicare.
CMS’ reversal will be a great relief for home health agencies, particularly those agencies that have extensive contracts with MA plans. Requiring agencies to comply with the same face-to-face encounter requirement as FFS Medicare would significantly increase the burden for agencies servicing MA plan members.