NAHC Discusses MA Plan and Home Health Certification Requirements with CMS Officials
May 16, 2014 10:08 AM
In the final call letter for the 2015 rates for the Medicare Advantage (MA) plans, CMS “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. The National Association for Home Care & Hospice (NAHC) has serious concerns with this directive.
Last week, NAHC discussed those concerns with officials at the Centers for Medicare & Medicaid Service (CMS) and questioned the rationale behind the requirement. NAHC expressed that the MA plans have a preauthorization process that negates the need to follow Medicare FFS certification requirements. In addition, NAHC interprets the regulation to require that the 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.
If the MA plans are required to follow the same certification requirements for home health services as FFS Medicare, our concern is that failure to meet the certification requirements will be used as a pretext to deny and /or not authorize needed home health services for plan members. It also raises questions regarding whether MA plans will be required to follow other coverage and payment criteria that apply to FFS Medicare.
CMS agreed to take another look at this directive to the MA plans. In the meantime NAHC sent the following questions to CMS for further clarification.
The home health certification requirement is not an element of the scope of home health benefits under traditional Medicare. Instead, it is a program integrity and accountability requirement as a condition for fee-for-services payment. Does 42 CFR 422.100 and 422.101 actually require such conditions for fee-for-service payments be imposed in Medicare Advantage as well?
If the plans are required to apply the certification requirements of 424.22, are the MA plans be permitted to retroactively deny claims for home health services if all the certification requirements were not met according to §424.22 in light of the conflicting CMS policy statements on the matter and the fact that the requirement applies to the physicians rather than the home health agencies?
Will MA plans now, and in the future, be permitted to deny or not authorize home health services if all the certification requirements at §424.22 are not met?
Will CMS require that the MA plans hold the certifying physician accountable for failing to meet all the certification requirements?
If CMS intends for the MA plans to comply with the same Medicare FFS certification requirements for home health services, does this extend to requiring compliance with all Medicare FFS rules, including the provision of a 60-day episodic benefit that bundles care management, services, and medical supplies as a responsibility of the home health agency?