Skip to Main Content

Print | Bookmark | Email | Font Size: + |

MA Plan Enrollment Ends During a Home Health Episode/Period of Care

When a Medicare beneficiary is covered under an MA plan during a period of home care, and subsequently decides to disenroll from the MA plan, traditional Medicare (Part A and/or Part B benefits) coverage begins.  In this situation, a new Outcome & Assessment Information Set (OASIS) assessment must be completed, as well as a new plan of care, certification, and face-to-face encounter, as is required any time the Medicare payment source changes. In addition, a Request for Anticipated Payment (RAP) should be sent to Medicare to open an episode/period of care. The Medicare Claims Processing Manual, (CMS Pub. 100-04, Ch. 10, § 10.1.23External PDF) advises HHAs "to verify the patient's payer source on a weekly basis when providing services to a patient with an MA Organization payer source to avoid the circumstance of not having an OASIS to generate a billing code for the RAP, or having the patient discharged without an OASIS assessment."

When a beneficiary disenrolls from MA coverage, the HHA should submit a RAP (322 type of bill) using the date of the first visit provided after the traditional Medicare coverage effective date as the episode "FROM" date (FL 4) and "ADMIT" date (FL 12), and using the OASIS assessment performed most recently after the change to traditional Medicare to produce a Health Insurance Prospective Payment System (HIPPS) code for that RAP.

Updated: 3.18.21


26 Century Blvd Ste ST610, Nashville, TN 37214-3685 © CGS Administrators, LLC. All Rights Reserved