CurrentMass General Brigham Health PlanPolicy 027

Home Health Care

Defines medical necessity, coverage, exclusions, prior authorization rules, plan-of-care and provider requirements for home health and hospice services across commercial, Medicare Advantage, ACO, OneCare and SCO products.

Policy Summary

PayerMass General Brigham Health Plan

PolicyHome Health Care

Policy CodePolicy 027

Change TypeUpdated prior authorization and product variationsMedicare and MassHealth references added

Effective DateJanuary 2026

Next Review DateN/A

Key ActionObtain prior authorization for home care services when required by product and ensure clinicians certify and recertify a written plan of care every 60 days, documenting diagnoses, services, frequency, goals, and safety measures.

SourceLink

POLICY UPDATE CHANGES

Updated prior authorization table and added variation for OneCare and SCO members (Effective January 2026).

Replaced MassHealth-specific policy sections with a MassHealth variation and updated code disclaimer (October 2025).

Added NCDs and LCDs referenced for Medicare determinations (June 2025).

027Policy number

PA requiredProduct-level PA requirement (Medicare Advantage)

T1502/T1503 not coveredExplicitly excluded HCPCS codes in some products

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Medical Necessity and Coverage Rules for Home Health Care

General medical necessity for home health care

Home health care is covered when InterQual criteria are met and when ALL of the following apply:

ALL of the following

Member is homebound OR Mass General Brigham Health Plan determines home/another non-medical office setting is the most appropriate to carry out plan of care to minimize deterioration or prevent placement in a more restrictive setting
Homebound defined in Definitions section; exceptions for MassHealth members noted.
Member is under the care of a physician, physician assistant, nurse practitioner, or clinical nurse who certifies medical necessity and establishes an individual plan of care
Plan of care must be signed and recertified every 60 days by the clinician.
Services are skilled per Definition of Skilled Care Policy and are reasonable and medically necessary to treat the member's covered illness or injury
Services are no more costly than medically comparable care in an appropriate institution and are the least costly form of comparable care available in the community
A benefit package includes coverage of home health care services

ALL of the following

Member is homebound OR Mass General Brigham Health Plan determines home/another non-medical office setting is the most appropriate to carry out plan of care to minimize deterioration or prevent placement in a more restrictive setting
Homebound defined in Definitions section; exceptions for MassHealth members noted.
Member is under the care of a physician, physician assistant, nurse practitioner, or clinical nurse who certifies medical necessity and establishes an individual plan of care
Plan of care must be signed and recertified every 60 days by the clinician.
Services are skilled per Definition of Skilled Care Policy and are reasonable and medically necessary to treat the member's covered illness or injury
Services are no more costly than medically comparable care in an appropriate institution and are the least costly form of comparable care available in the community
A benefit package includes coverage of home health care services

Covered home care service types

Home health care services are covered when medically necessary and meet plan criteria:

ANY of the following

Part-time or intermittent skilled nursing
Short-term skilled rehabilitative therapy (physical, occupational, speech, inhalation therapy)
Qualified home health aide services when essential and directly related to skilled nursing or therapy plan of care
Medical social services when essential and directly related to skilled nursing or therapy plan of care
Durable medical equipment

Plan of care requirements

ALL of the following must be present in the plan of care:

ALL of the following

Orders specify nature and frequency of services and type of professional providing them
Clinician signature on the plan of care; recertify and sign every 60 days
Clinician must recertify and sign the plan of care every 60 days.
Plan contains all pertinent diagnoses including mental status
Types of services, supplies, and equipment ordered
Frequency of visits

Nursing services criteria

Nursing services are medically necessary when ALL of the following are met:

ALL of the following

There is a clearly identifiable, specific medical need for nursing services
Services are ordered by a clinician and included in the plan of care
Services require skills of RN or LPN/LVN under RN supervision
Services are medically necessary to treat an illness or injury
Services meet Mass General Brigham's Definition of Skilled Care

ALL of the following

Home health aide services (conditioned on nursing/therapy need)

Home health aide services covered when ALL of the following are met:

ALL of the following

Member has a medically predictable recurring need for skilled nursing or skilled therapy services
Home health aide is essential part of authorized skilled home care program directly related to skilled plan of care
Services are medically necessary to provide personal care, promote health, or facilitate treatment under the skilled plan of care
Member must be homebound as defined within this policy (except specific MassHealth allowances)

ALL of the following

Therapies (PT, OT, Speech) criteria

Each therapy type is covered when ALL of the following are met:

ALL of the following

Service is directly and specifically related to an active treatment regimen
Service requires the judgment, knowledge and skills of a licensed therapist (level of complexity/sophistication)
Performed by licensed therapist or assistant under supervision as appropriate
Considered a specific and effective treatment under accepted standards of medical practice
Medically necessary for treatment of the member's condition

Medical social worker and nutritional counseling criteria

Covered only when ALL of the following are met:

ALL of the following

Directly and specifically related to an active treatment regimen
Essential part of an authorized skilled home care program directly related to the skilled plan of care
Provided by licensed professional (Medical Social Worker or registered/licensed dietitian) as appropriate
Considered effective under accepted standards of practice and medically necessary

ALL of the following

Exclusions (Not Covered)

Services not covered include (examples below) — these are excluded unless specific exception noted:

ANY of the following

Maintenance therapy except for initial design of patient/family program and education
Home health care services provided in a hospital, nursing facility, intermediate care facility, or other institutional facility
Services used for homemaking, heavy cleaning, household repair
Respite care
Services provided by a family member or other caregiver that adequately meet needs

Relevant CPT/HCPCS and Revenue Codes

Informational CPT/HCPCS codes listedmixed

92526	Treatment of swallowing dysfunction and/or oral function for feeding
97110	Therapeutic exercises
97112	Neuromuscular reeducation
97140	Manual therapy
97530	Therapeutic activities
97535	Self-care/home management training
99501	Home Visit Postnatal
99502	Home Visit NB Care
G0151	PT home health/hospice each 15 min
G0152	OT home health/hospice each 15 min

1–10 of 21

1/3

Revenue codes listedRevenue

0420	Physical Therapy
0421	Physical Therapy Visit Charge
0422	Physical Therapy Hourly Charge
0423	Physical Therapy Group Rate
0424	Physical Therapy Evaluation/Re-evaluation
0429	Physical Therapy Other
0430	Occupational Therapy
0434	Occupational Therapy Evaluation/Re-evaluation
0440	Speech Pathology
0550	Skilled Nursing

1–10 of 14

1/2

Explicitly noted not covered codes (product-specific)HCPCSNot Covered

T1502	Administration of medication by health care agency/professional — listed as Not Covered for Commercial & Qualified Health Plans and Medicare Advantage in policy table
T1503	Administration of medication, other than oral and/or injectable — listed as Not Covered for Commercial & Qualified Health Plans and Medicare Advantage in policy table

Authorization, Documentation, and Billing Requirements

Prior Authorization

Prior authorization by product

Prior authorization is required according to the policy's product-level prior authorization table. Medicare Advantage requires prior authorization for all home care services; other product lines have varying requirements per the table and updated prior authorization guidance (OneCare and SCO variations effective January 2026).

Documentation Required

Plan of care documentation and recertification

The treating clinician (physician, physician assistant, or nurse practitioner) must certify medical necessity, establish a written plan of care, sign it, and recertify/sign the plan every 60 days. The plan of care must include all pertinent diagnoses (including mental status), types and frequency of services, prognosis and rehabilitation potential, measurable goals and outcomes (with progress, barriers and plan when goals are unmet), safety measures, discharge plans, and other ordered treatments and supplies.

Clinician must recertify and sign the plan of care every 60 days (chunk 6).
Plan must contain diagnoses, types of services/supplies/equipment, visit frequency, prognosis/functional limitations/medications, safety measures, goals with progress/barriers for continued services, and discharge plans (chunk 7).

Documentation Required

Provider qualifications and orders

Services must be ordered by an eligible clinician (physician, physician assistant, nurse practitioner, or clinical nurse) and skilled services must be provided by appropriately licensed professionals — e.g., RN, LPN/LVN under RN supervision, licensed therapists, or licensed therapy assistants under supervision — consistent with the Definition of Skilled Care.

Eligible ordering clinicians include physician, physician assistant, nurse practitioner, or clinical nurse (chunk 4).
Nursing and other skilled services must require and be performed by licensed clinicians (registered nurse, LPN/LVN under RN supervision) (chunk 8).
Therapies must be performed by licensed therapists or supervised assistants as appropriate (chunk 11).

Denial Risk

Risk of noncoverage for unskilled or custodial services

Claims for services that are maintenance, custodial, homemaking, companionship, or other services that are not skilled per policy are at risk for denial because such services are excluded unless a specific skilled-need exception applies.

Exclusions list specifically names maintenance therapy, homemaking/household cleaning, personal care attendants, companionship, infant/child sitting, and custodial/long-term supports as not covered (chunks 16 and 17).
Home health aide services without a need for skilled nursing or therapy (ADL-only) are excluded (chunk 17).

Clinical and Administrative Context

Mass General Brigham Health Plan determines medical necessity for home health services primarily using InterQual criteria (Change Healthcare). For Medicare Advantage and related lines, the plan also applies applicable CMS guidance including National Coverage Determinations (NCDs), Local Coverage Determinations (LCDs), and Medicare manual guidance; when CMS guidance is available it governs Medicare determinations and InterQual is used to align with the Medicare Benefit Policy Manual Chapter 7 for Home Health Services. This approach is reflected in the policy's Medicare and OneCare/SCO variations and the June 2025 update adding NCDs and LCDs for clarity.

The policy emphasizes coverage of skilled services provided in the home setting when they are reasonable and medically necessary to treat illness or injury and to avoid institutional care. Home health coverage is intended for members who are homebound or for whom the plan determines the home (or another non‑medical location) is the most appropriate setting to carry out the plan of care in order to minimize deterioration or prevent placement in a more restrictive, costlier setting. Prior authorization rules were clarified in the January 2026 update and vary by product (for example, Medicare Advantage requires prior authorization for all home care services).

This policy defines the overall scope and operational expectations for providers: services must be ordered and certified by an eligible clinician, documented in a signed plan of care recertified every 60 days, provided by appropriately licensed clinicians when considered skilled, and limited to services that are the least costly medically comparable alternative to avoid higher‑level institutional care.

Key Defined Terms

Definitions

HomeboundInability to leave the home setting or leaving home would require considerable and taxing effort due to medical conditions; absences must be infrequent and short. Not required for some MassHealth authorizations per policy.

Home SettingPlace where the member has established residence for the time services are provided (home, apartment, group home, homeless shelter, or other temporary residence). Excludes hospitals, skilled nursing facilities, intermediate care facilities, or other institutional facilities.

Skilled CareService that must be provided by licensed clinical personnel (RN, LPN under RN supervision, licensed therapists or supervised assistants) to be safe and effective due to complexity or patient condition. Not skilled merely because a licensed person provides it if it could be safely done by a nonmedical person.

Policy Changes

January 2026material_changeLatest

Updated prior authorization table and added variation for OneCare and SCO members (Prior authorization requirements by product line were updated and clarified).

October 2025revision

Replaced MassHealth-specific policy sections with a MassHealth variation and updated code disclaimer (MassHealth guidance is now referenced via a variation rather than embedded policy text).

June 2025material_change

Added National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs) referenced for Medicare determinations (Specific Medicare coverage references were included to guide Medicare Advantage determinations).

Policy Summary

PayerMass General Brigham Health Plan

PolicyHome Health Care

Policy CodePolicy 027

Change TypeUpdated prior authorization and product variationsMedicare and MassHealth references added

Effective DateJanuary 2026

Next Review DateN/A

SourceLink

On This Page

Disposable medical supplies used in the course of an authorized home health visit

Provider house calls made within the enrollment area

Nutritional counseling when essential and directly related to an authorized skilled home care plan of care

Medication administration visit (noted historically for MassHealth members in prior versions)

ANY of the following

Part-time or intermittent skilled nursing
Short-term skilled rehabilitative therapy (physical, occupational, speech, inhalation therapy)
Qualified home health aide services when essential and directly related to skilled nursing or therapy plan of care
Medical social services when essential and directly related to skilled nursing or therapy plan of care
Durable medical equipment
Disposable medical supplies used in the course of an authorized home health visit
Provider house calls made within the enrollment area
Nutritional counseling when essential and directly related to an authorized skilled home care plan of care
Medication administration visit (noted historically for MassHealth members in prior versions)

Prognosis, rehabilitation potential, functional limitations, permitted activities, nutritional requirements, medications, and treatments

Safety measures to prevent injury

Goals and measurable outcomes; for continued services when goals not met include progress, barriers, plan to address barriers, and anticipated number of visits

ALL of the following

Orders specify nature and frequency of services and type of professional providing them
Clinician signature on the plan of care; recertify and sign every 60 days
Clinician must recertify and sign the plan of care every 60 days.
Plan contains all pertinent diagnoses including mental status
Types of services, supplies, and equipment ordered
Frequency of visits
Prognosis, rehabilitation potential, functional limitations, permitted activities, nutritional requirements, medications, and treatments
Safety measures to prevent injury
Goals and measurable outcomes; for continued services when goals not met include progress, barriers, plan to address barriers, and anticipated number of visits
Discharge plans

There is a clearly identifiable, specific medical need for nursing services
Services are ordered by a clinician and included in the plan of care
Services require skills of RN or LPN/LVN under RN supervision
Services are medically necessary to treat an illness or injury
Services meet Mass General Brigham's Definition of Skilled Care

Member has a medically predictable recurring need for skilled nursing or skilled therapy services

Home health aide is essential part of authorized skilled home care program directly related to skilled plan of care

Services are medically necessary to provide personal care, promote health, or facilitate treatment under the skilled plan of care

Member must be homebound as defined within this policy (except specific MassHealth allowances)

Must meet Definition of Skilled Care

ALL of the following

Service is directly and specifically related to an active treatment regimen
Service requires the judgment, knowledge and skills of a licensed therapist (level of complexity/sophistication)
Performed by licensed therapist or assistant under supervision as appropriate
Considered a specific and effective treatment under accepted standards of medical practice
Medically necessary for treatment of the member's condition
Must meet Definition of Skilled Care

Directly and specifically related to an active treatment regimen

Essential part of an authorized skilled home care program directly related to the skilled plan of care

Provided by licensed professional (Medical Social Worker or registered/licensed dietitian) as appropriate

Considered effective under accepted standards of practice and medically necessary

Personal care attendants

Home health aide services in absence of need for skilled nursing or therapy (e.g., ADL assistance only)

Services that can be safely and effectively performed or self-administered by average nonmedical person without RN supervision

Activities for general good and welfare (general exercise for fitness, diversion activities)

Maintenance/custodial care programs

Venipuncture as sole purpose of home visit when comparable community care available

Domestic housekeeping, meal services, companionship, infant/child sitting

Long-term services and supports in the home such as adult day health, adult foster care, day habilitation, group adult foster care, personal care attendants, private duty nursing, respite care

ANY of the following

Maintenance therapy except for initial design of patient/family program and education
Home health care services provided in a hospital, nursing facility, intermediate care facility, or other institutional facility
Services used for homemaking, heavy cleaning, household repair
Respite care
Services provided by a family member or other caregiver that adequately meet needs
Personal care attendants
Home health aide services in absence of need for skilled nursing or therapy (e.g., ADL assistance only)
Services that can be safely and effectively performed or self-administered by average nonmedical person without RN supervision
Activities for general good and welfare (general exercise for fitness, diversion activities)
Maintenance/custodial care programs
Venipuncture as sole purpose of home visit when comparable community care available
Domestic housekeeping, meal services, companionship, infant/child sitting
Long-term services and supports in the home such as adult day health, adult foster care, day habilitation, group adult foster care, personal care attendants, private duty nursing, respite care

Home Health Care

Medical Necessity and Coverage Rules for Home Health Care

Relevant CPT/HCPCS and Revenue Codes

Authorization, Documentation, and Billing Requirements

Clinical and Administrative Context

Key Defined Terms

Also See

Policy Changes