Home Health Services in Managed Care

January 24, 2014

DAL: HCBS 14-01
Subject: Home Health Services in Managed Care Plans

Dear Administrator:

This letter is in response to numerous questions received by the Department related to licensed or certified home health agencies that provide home health services through agreements with Medicare & Medicaid managed care plans. This information is intended to provide guidance and clarification to both managed care plans and home health providers.

Many of these questions have sought clarification as to what provider type, i.e. Certified Home Health Agency (CHHA), Long Term Home Health Care Program (LTHHCP) or Licensed Home Care Services Agency (LHCSA) may provide home health services to Medicare/Medicaid beneficiaries when these individuals are enrolled in a managed care plan or managed long term care plan.

The State Operations Manual (SOM) contains official policy guidance issued by the Center for Medicare and Medicaid Services (CMS) pertaining to Medicare and Medicaid programs. The SOM contains official guidance related to services provided to both Medicare and Medicaid patients including home health services provided under the Medicaid home health benefit provided to Medicaid beneficiaries enrolled in managed care plans.

Section 2202.3A of the SOM states the following:

"Home Health Agencies providing services under Medicaid´s home health benefit must meet the Conditions of Participation (CoPs) for Medicare, as specified at 42 CFR 440.70(d)."

"Health maintenance organizations serving Medicare/Medicaid patients can either provide home health services themselves or can contract out for those services. If they provide home health services themselves, they must meet the Medicare home health CoPs. If they contract out for home health services, they must contract with a Medicare-approved home health agency in order to serve Medicare/Medicaid patients. (See 42 CFR 417.416 and §2194.)"

Home Health Agency is defined in 42 CFR 440.70(d) as a public or private agency or organization, or part of an agency or organization, that meets requirements for participation in Medicare, including the capitalization requirement under §489.28 of this chapter.

Home health services are defined in 42 CFR 440.70(b) as:

  • nursing service, as defined in the State Nurse Practice Act, that is provided on a part time or intermittent basis by a home health agency as defined above;
  • home health aide service provided by a home health agency; and
  • physical therapy, occupational therapy, or speech pathology and audiology services provided by a home health agency.

For further clarification, or questions related to this directive please contact the Department of Health at mltcquestions@health.state.ny.us. Thank-you.

Sincerely,

Karen Westervelt, Deputy Commissioner
Office of Primary Care and Health Systems Management

Jason Helgerson, Medicaid Director
Office of Health Insurance Programs