CMS Medicare Skilled Home Health Guide Flashcards

Vocabulary flashcards covering CMS Medicare skilled home health eligibility rules, coverage requirements, face-to-face timelines, non-covered services, intake workflow, and referral management.

Core Medicare Admission Criteria

The six core requirements for a Medicare home health admission: 1) Medicare entitlement, 2) Homebound status, 3) Qualifying skilled need, 4) Practitioner oversight, 5) Plan of care (POC), and 6) Qualifying face-to-face (F2F) encounter.

Homebound Criterion 1

CMS criterion stating that because of illness or injury, the patient needs a supportive device, special transportation, or another person's help to leave home, OR leaving home is medically contraindicated.

Homebound Criterion 2

CMS criterion stating that the patient normally cannot leave home AND leaving home requires a considerable and taxing effort.

Homebound Status (Key Distinction)

A standard clarifying that a patient does not have to be bedridden; they may leave home for medical treatment, religious services, adult day care, or infrequent/short-duration events and still meet the homebound definition.

Qualifying Skilled Need

The requirement that a patient needs intermittent skilled nursing (SN), physical therapy (PT), or speech-language pathology (SLP) to establish initial home health eligibility.

Occupational Therapy (OT) Eligibility Rule

A rule specifying that OT alone generally does not establish initial eligibility, but continuing OT can remain covered after eligibility has been established through SN, PT, or SLP.

Face-to-Face (F2F) Encounter Timeframe

A mandatory clinical encounter related to the primary reason for home health that must occur no more than 90 days before the start of care (SOC) or within 30 days after SOC.

Plan of Care (POC) Review Cycle

An individualized plan established by a physician or allowed practitioner that specifies disciplines, visit frequency, interventions, and measurable goals, which must be reviewed and signed at least every 60 days.

PDGM Payment Period vs. Recertification Cycle

Under the Patient-Driven Groupings Model (PDGM), payment is organized into 30-day periods, whereas eligibility recertification and plan-of-care review remain on a 60-day cycle.

Improvement Potential Rule (Maintenance Therapy)

CMS policy stating coverage is based on the need for skilled care, not on a requirement to improve; skilled maintenance therapy is covered when a qualified therapist is required to maintain function or slow deterioration.

Stand-Alone Exclusions under Medicare Home Health

Services not covered as a stand-alone home health benefit, including 24-hour-a-day care, home-delivered meals, homemaker services only, personal care only, and routine care not requiring skill.

Medical Social Services

Short-term social/emotional assessment and resource coordination related to the patient's illness and plan of care.

Home Health Aide Services Coverage Rule

Part-time or intermittent personal care that is covered only when the patient also qualifies for covered skilled home health care (SN/PT/SLP) and the aide services are part of the plan of care.

Referral-to-Admission Workflow Steps

The 8 intake steps: 1) Receive referral, 2) Verify payer, 3) Clinical screen, 4) Homebound screen, 5) F2F/document screen, 6) Acceptance decision, 7) Start of care, and 8) Ongoing management.

July 2026 Acceptance-to-Service Focus

Updated CMS guidance requiring HHAs to make acceptance decisions based on whether they can meet the patient's ordered care needs and maintain clear processes for referrals they cannot accept.

Referral Funnel Tracking Metrics

Agency management data tracking referral source, referrals received, accepted, admitted, non-admit reason, payer, primary diagnosis, requested discipline, SOC timeliness, conversion rate, and repeat-referral rate.