Impact of Caregivers on Medical Necessity
Medicare Benefit Policy Manual (CMS Pub. 100-02, Ch. 7 §20.2)
A caregiver available in the home to provide services to the beneficiary usually does not affect the eligibility for Medicare covered home health services.
One exception is when the service is to provide normally self-injected medication (e.g., insulin or calcitonin). In this instance, if the beneficiary is either physically or mentally unable to self-inject the medication, and there is no other person willing and able to give the medication, nursing visits to administer the injection would be covered.
When a caregiver is providing a service that adequately meets the beneficiary's needs, it is not reasonable and necessary for the home health agency to provide the same service.
If a caregiver provides a skilled service, the service remains "skilled", despite a caregiver's willingness to do the care. If the caregiver decides they are no longer willing or able to provide the care, or are unavailable on certain days, the skilled nurse may provide the skilled service.
Updated: 07.30.12