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Photo of Medicare Coverage for Personal Care Services and the annual OMIG Compliance Certifications

Medicare Coverage for Personal Care Services and the annual OMIG Compliance Certifications

Home Care Alert
December 11, 2018

Effective January 2019, Personal Care Services may be Covered by Medicare

The Centers for Medicare and Medicaid Services (CMS) announced during the month of April
2018 that it would cover non-skilled in-home personal care under the Medicare Advantage program (commonly referred to as “Part C” or “MA Plans”). LHCSAs should contact their MLTCs to see whether they can obtain Medicare reimbursement, at potentially higher rates, for provision of personal care services.

By way of background, to date, Medicare has only covered non-skilled aide services under Medicare part A’s home health category to patients who need at least one skilled service. Medicare part A paid for part-time or intermittent physician-ordered home health aide services provided under a plan of care and supervised by a skilled nurse. However, in May 2018, CMS Administrator, Seema Verma confirmed that personal care services, which offer assistance with activities of daily living, were included under Medicare’s “supplemental benefits” definition. Unlike the part-time and intermittent aide services previously offered under Medicare Part A’s home health category, personal care services under Part C are offered for daily maintenance to patients who do not need skilled services, such as skilled nursing or occupational, physical, or speech therapies.

CMS has reinforced that personal care services must be performed by individuals licensed by the
Department of Health. Additionally, all personal care services must be medically appropriate, focus directly on an enrollee’s health care needs, and must be recommended by a physician or
licensed medical professional as part of a care plan. CMS also urged that these personal care
services must not be used primarily for comfort, general use, or other non-medical reasons. CMS
stressed that the described requirements and prohibitions should not present a burden to home
care agencies that participate in Medicaid because most states place similar requirements on
personal or home care providers under their Medicaid programs.

Home Care providers currently enrolled in a Medicaid managed care plan must check with their account manager or plan representative to see if the plan is also an enrolled Medicare managed care provider participating in the Medicare part C program. If the MLTC is enrolled in Medicare part C, providers who offer personal care services may be eligible to provide personal care services and receive reimbursement under Medicare Part C.

Annual OMIG Compliance Certifications are now Due

As a reminder, providers must submit their annual OMIG compliance certifications within the
month of December for the certification to be valid for the certifying year.

By way of background, Article 28 providers (including nursing homes and clinics), Article 36
providers (including CHHAs and LHCSAs) and any person who has submitted at least $500,000
in Medicaid claims in any consecutive 12-month period are required to have an effective compliance program in place and certify annually to OMIG that they have an effective program. Assisted Living Program (ALP) providers with at least $500,000 in annual Medicaid claims are also subject to this requirement. Any ALP that operates a LHCSA to serve their ALP will need to have an effective compliance program in place for the LHCSA, even if the ALP did not submit $500,000 in annual Medicaid claims.

To assist providers, OMIG’s website identifies seven compliance areas that a provider’s Compliance Program must apply to, as well as eight elements that should be included in all Compliance Programs, regardless of provider type.

1. Billings;
2. Payments;
3. Medical necessity and quality of care;
4. Governance;
5. Mandatory reporting;
6. Credentialing; and
7. Other risk areas that are or should with due diligence be identified by the provider.

Beginning this year, “in order to make the annual compliance certification process more efficient,”
OMIG is transitioning from using Federal Employer Identification Numbers (FEIN) to a system
based on Provider Identification Numbers.

Providers that fail to fulfill their mandatory compliance certification obligations may be identified
for potential administrative action. Certification must be completed every December and be done
through the OMIG website.