Clarice Grote, MS, OTR/L

Clarice Grote, MS, OTR/L

Is OT a Qualifying Service in Home Health?

Update: AOTA has now published information on the Medicare Home Health Accessibility Act which if passed would add occupational therapy as a qualifying service for Medicare Part A HH benefit. Read more about it here.

The question for this week’s Amplify OT Q&A is: Is OT a qualifying service in home health?

Well, after the passage of legislation allowing OTs to initiate home health episodes in therapy-only cases, there has been much talk about whether or not this legislation changed if OT is a qualifying discipline. Unfortunately, this legislation did not change the issue of qualifying for Medicare home health cases. Here is an expert from the Draft OASIS-E Manual: (bold added for emphasis)

Services which establish eligibility for the Medicare home health benefit include skilled nursing, PT and SLP. The change allowing OT to conduct SOC comprehensive assessments did not alter Medicare’s criteria for establishing initial eligibility (i.e., the need for OT does not establish the initial eligibility for the HH benefit). The Medicare home health patient who initially qualifies for the home health benefit by requiring skilled nursing, PT or SLP, can retain eligibility if, over time, occupational therapy is the only remaining skilled discipline providing care. OT may conduct all subsequent comprehensive assessments with OASIS, if applicable.

CMS Outcome annd Assessment Insturment OASIS-E Manual
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So, what does a qualifying discipline mean?

A qualifying discipline means that having a certain service on the initial order means that the patient may be eligible for their service to be covered under the Medicare Part A home health benefit. There are other criteria such as a physician face-to-face, the patient needing intermittent skilled services, and being homebound. The patient must also need an order for physical therapy, speech therapy, or skilled nursing. Occupational therapy can be on the order, but having OT alone does not check the box for having home health services covered under the Medicare Part A benefit.

To qualify for the Medicare home health benefit, under §§1814(a)(2)(C) and 1835(a)(2)(A) of the Act, a Medicare beneficiary must meet the following requirements:
• Be confined to the home;
• Under the care of a physician or allowed practitioner;
• Receiving services under a plan of care established and periodically reviewed by a physician or allowed practitioner;
• Be in need of skilled nursing care on an intermittent basis or physical therapy or speech-language pathology; or
• Have a continuing need for occupational therapy.

Medicare Benefit Policy Manual Ch. 7 – Home Health Services Section 30 – Conditions Patient Must Meet to Qualify for Coverage of Home Health Services Rev. 10438

Is OT ever a qualifying discipline?

OT is a qualifying discipline for many other insurers, such as some Medicaid programs, private insurance plans, etc. So for some insurance plans, having OT alone may activate coverage under that patient’s home health coverage.

Additionally, OT is a qualifying service for recertification in Medicare home health cases. OT can also “stand alone,” meaning that if other disciplines discharge, OT can remain in and “stand alone.”

Common Myths in Home Health:

  • OT must discharge if other disciplines discharge. – False (OT can ‘stand alone’)
  • OT is not a qualifying service for any insurers. – False
  • OT and PT can’t see the patient at the same time. One must discharge before the other. – False
  • OT isn’t a qualifying service for a second 60-day certification period. – False (OT can be the only service in for Medicare patients at recertification)
  • If PT is on the order, OT can’t do the initial OASIS. – False

Send me an email if you have any other questions! Your question might be featured on my next Q&A episode.

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Other Home Health Resources:

Clarice standing in a light room smiling wearing black pants and a light green puff sleeve shirt

hi there,

I’m  Clarice

Occupational therapist & medicare specialist helping practitioners understand policy, engage in advocacy, and own their value!

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