Court Adopts New Payment Eligibility Standard For CMS Home Health Services


On February 1, 2017, a federal court in Vermont ruled that the Centers for Medicare and Medicaid Services (CMS) has been using the wrong standard of eligibility to pay for home healthcare services. According to the ruling, CMS has wrongly required that to be eligible for payment, the purpose of the services must be to improve the beneficiary’s health. In fact, CMS must pay for services so long as they aid in maintaining the beneficiary’s health condition. The court required CMS to:

  • Create a page on its website addressing the new standard.
  • Include a “frequently asked questions” section to the webpage.
  • Publish a statement disavowing the former “improvement” standard and affirming the “maintenance” standard.
  • Issue a Technical Direction Letter and Memorandum for Medicare Administrative Contractors with training instructions on the changes.
  • Organize a national call to Medicare providers and adjudicators to correct incomplete and inaccurate answers given by a CMS representative during a prior national call about the “improvement” standard.

Related Practices:   Healthcare Law

Related Attorney:   Lani M. Dornfeld