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TRICARE covers home health care—including skilled nursing care or physical, speech and occupational therapy—for a maximum of 28 hours per week part time or 35 hours per week intermittently. Here are some of the questions providers asked most about the home health care benefit.
How does a TRICARE beneficiary qualify for home health care under the Home Health Agency Prospective Payment System (HHA PPS)?
Under HHA PPS, the patient must be homebound, require skilled care intermittently or part-time, and be eligible for TRICARE. Also, the primary care manager (PCM) or treating physician must order a plan of treatment, and the home health agency must be Medicare-certified (although there are some exceptions).
Do beneficiaries have a copayment or costshare?
When an authorized home health care agency provides services covered under HHA PPS, the beneficiary does not have a copayment or cost-share. However, services provided outside of the PPS may be subject to a copayment or cost-share.
What is covered under HHA PPS?
All HHAs must provide skilled nursing services and at least one other service, including physical therapy, medical social services or home health aide services. The HHA’s employees must directly provide one of the services in its entirety; other services may be provided under arrangements with other providers. Covered benefits can include skilled nursing and home health aide visits, covered therapy, medical social services and supplies.
How long will care be provided?
TRICARE will pay home health agencies for each covered 60-day episode of care, and beneficiaries may receive an unlimited number of medically necessary episodes of care.
How are injectables and vaccines billed?
If a nurse administers injectables and vaccines in the home setting, the HHA may bill for them separately, meaning they are billed outside of the PPS payment.
Does TRICARE pay for durable medical equipment (DME)?
TRICARE will pay HHAs and other suppliers separately for medically necessary DME.
Where can providers get more information about HHA PPS?
Providers can review the most current UB-92 Editor for appropriate claim filing logic pertaining to HHA PPS. Providers also can read the TRICARE operations and reimbursement manuals on the TRICARE Website.
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