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Home Health Care Billing and Reimbursement

Monday, April 29, 2019

The TRICARE benefit for home health care services closely follows Medicare’s Home Health Agency Prospective Payment System (HHA-PPS), which offers in-home therapies, social work services and part-time or intermittent skilled nursing services up to a maximum of 35 hours per week for eligible beneficiaries. Please review the following reimbursement and billing guidelines.

Reimbursement
Medicare-certified billing is handled in 60-day-care episodes, allowing home health agencies to receive two payments of 60 percent and 40 percent, respectively, per 60-day cycle. This two-part payment process is repeated with every new cycle, following the patient’s initial 60 days of home health care. Medicare updates HHA-PPS rates annually on a calendar year basis. Visit our Home Health Billing page to review initial and final claim requirements, including those specific to providers in rural areas. Also see the TRICARE Reimbursement Manual, Chapter 12, Section 6, Paragraph 3.6. and Chapter 12, Addendum H. 

  • For non-pregnant adults (18 years of age or greater) who are receiving services from Medicare-certified home health agencies, TRICARE only allows for HHA-PPS reimbursement. The CHAMPUS maximum allowable charge (CMAC) does not apply, even for providers who have received such reimbursement in the past. 

  • For pediatric or pregnant beneficiaries, Medicare-certified home health agencies will always be used when available, and HHA-PPS reimbursement applies. If there is not a Medicare-certified home health agency available, Health Net Federal Services, LLC may authorize skilled therapy, social work or skilled nursing home health services to a non-Medicare certified, but state-licensed agency that is under a Corporate Services Provider participation agreement. In this instance, CMAC reimbursement would be allowed. Note: Home health agencies that serve children or pregnant women, even if they serve these populations exclusively, cannot be considered Corporate Service Providers for home health care if they are Medicare certified and cannot be reimbursed using CMAC reimbursement methodology. Medicare-certified providers treating children under age 18 or providing maternity care do not need a completed Outcome and Assessment Information Set (OASIS), but must perform an abbreviated assessment to generate a Health Insurance Prospective Payment System (HIPPS) code for HHA-PPS reimbursement.

Extended Care Health Option
The Extended Care Health Option (ECHO) provides supplemental services to active duty family members (ADFMs) beyond what is offered through the basic TRICARE program. The above guidance does not apply to home health care services provided to ADFMs under the ECHO Extended Home Health Care (ECHO-EHHC) benefit. Reimbursement for services covered under ECHO-EHHC is based on the CMAC.