Medicare Home Health and the Face-to-Face Encounter: The Visit That Starts Coverage

A hospital stay ends. The care team says home health can help at home. Then the agency asks about a doctor visit. Many people do not know why that visit counts so much. The visit is called a face-to-face encounter. It is one of the rules that starts Medicare home health cover. This guide shows what the visit is, when it must take place, and who can hold it. Our Home Health section holds more guides on care at home.

What the face-to-face encounter is

The encounter is a real visit with a care provider. It is not a phone call to book care. It is not the agency intake form. A provider sees you and checks the need that leads to home health.

The visit must link to the main reason you need home health services. If you need wound care after surgery, the visit should deal with that wound or that surgery. If you need therapy after a fall, the visit should deal with the fall and your strength. A visit for an unrelated gripe does not do the job.

Think of the visit as the proof step. It shows a provider saw you in person, in a broad sense, and saw the need with their own eyes. The rest of the home health claim rests on that proof.

When the visit must take place

The timing rule has two ends. The visit can be no more than 90 days before the start of home health care. It can also be within 30 days of the start of home health care.

That gives a wide span. A visit you had last month for the same need may count. A visit set for next week may count too, if it falls in the 30 days after care starts.

Count with care. A visit 100 days before the start date is too old. It does not count, no matter how full the check was. In that case, you need a fresh visit that falls in the span.

The agency can help you count the days. Ask the agency to tell you the start date they will use. Then count back 90 days and count ahead 30 days. Set the visit in that span.

Who can hold the visit

The doctor who certifies your care can hold the visit. That is the most direct route. The same doctor sees you and signs the papers that state you qualify.

Some other staff can hold the visit too. A nurse practitioner or clinical nurse specialist who works with the certifying doctor can hold it. A certified nurse-midwife can hold it, if state law allows and she is supervised in the way the rule sets out. A physician assistant can hold it as well, under the same kind of supervision.

There is a hospital route too. If you go straight from a hospital or care facility to home health, a doctor or staff member who cared for you there can hold the visit. That person must have privileges at that facility.

One duty stays with the person who certifies. The certifying doctor or allowed staff member must write down the date of the encounter as part of the certification. If the date is not on record, the claim can fail.

The visit can be by telehealth

The face-to-face encounter can occur through telehealth. That means a live video or audio visit can count, if it meets the telehealth rules in place at the time.

Ask before you rely on this route. Telehealth rules change over time. Ask the agency and the provider if a telehealth visit will count for your start date. Get that answer before the 30-day span runs out.

An in-person visit is the safe route when you can get one. If travel is hard, telehealth may be the route that gets the visit done on time.

The face-to-face visit is one part of a larger test

The visit alone does not bring home health cover. The full test has more parts. You must be confined to your home. That is the homebound test. Our guide on home health eligibility and the homebound rules walks through that test step by step.

You must be under the care of a doctor or allowed staff member. Your care must follow a plan of care that person sets up and reviews on a set cycle.

You must need a skilled service. That can be skilled nursing care on an intermittent basis. It can be physical therapy. It can be speech-language pathology services. You can also have a continuing need for occupational therapy, if your case first qualified through one of the other skilled needs.

Each part must hold at the same time. If one part fails, cover can fail with it. The visit is the part families hear about last, so it pays to check it first.

What home health costs

Covered home health services cost $0 (Ledger A13). That covers the skilled visits the plan of care calls for.

Gear is apart from the visits. For durable medical equipment, you pay 20% of the Medicare-approved amount. The Part B deductible applies to that gear cost (Ledger A13).

The 20% figure is the general Part B cost rule. In most cases, you pay 20% of the Medicare-approved amount after the deductible, when the provider accepts assignment (Ledger A16).

Ask the agency what gear they plan to bring. Ask what it costs and who bills for it. A walker or a hospital bed can carry a cost even when the nurse visits cost $0.

Who pays for what

• Original Medicare pays for covered home health services. Those services cost you $0 (Ledger A13).
• You pay 20% of the Medicare-approved amount for durable medical equipment, and the Part B deductible applies (Ledger A13).
• A Medicare Advantage plan covers home health too, but the plan may use its own approval steps first. Our guide on home health under Medicare Advantage prior authorization shows how that route works.
• Medicaid can help with some home care costs for people who qualify through their state. The state sets those rules.
• Private pay covers care Medicare does not cover, like long hours of personal care or help with baths and meals on its own. That help is not a skilled service.

Sample situation

Frank had knee surgery and came home weak. The hospital team said home health could help him get strong and safe at home. The agency asked when he last saw his doctor for the knee. Frank had seen his surgeon three weeks before care was to start. That visit dealt with the knee and the plan for care at home. It fell in the 90 days before the start date, so it counted as his face-to-face encounter. The doctor who certified his care wrote the visit date on the certification. Frank asked the agency to state the start date in writing as well. He kept the visit note and that letter with his own papers. If a denial or a bill comes later, he can show both dates at once. Frank was homebound and needed therapy, so the rest of the test held too. His therapy visits cost $0 (Ledger A13). The agency brought a walker as gear. For that gear, Frank paid 20% of the Medicare-approved amount, and his Part B deductible applied (Ledger A13).

What to check before care starts

The face-to-face rule sounds like red tape. At its core, it is a simple idea. A provider who can certify your care must see you, for the need at hand, close to the time care starts. Get that visit on the books and dated, and one big cause of denied home health claims goes away.

• Ask the agency for your start of care date. Write it down.
• Count back 90 days from that date. Count ahead 30 days. Your visit must fall in that span.
• Check that the visit dealt with the main reason you need home health care.
• Check who held the visit. The person must be on the list of allowed types.
• Ask if the visit date is on your certification. Ask to keep a copy.
• If no visit falls in the span, book one fast. Do not let the 30 days run out.
• Check the rest of the test too: homebound status, skilled need, and a plan of care.

Sources

• https://www.cms.gov/training-education/medicare-learning-networkr-mln/compliance/medicare-provider-compliance-tips/home-health-services