Skip Ribbon Commands Skip to main content

8. Home Care Services

Home Care Services Criteria | UCare for Seniors

UCare follows Medicare criteria for coverage of home care services. Services must be delivered by a Medicare-certified home health agency. Members must meet Medicare criteria.
Medicare home health services DO NOT include coverage for custodial care, general household services such as laundry, meal preparation, shopping, or other home care services furnished mainly to assist people in meeting personal, family, or domestic needs. 
The member is responsible for 20% of the cost under Point-of-Service coverage, if this benefit is being used. Medicare requires an out-of-pocket maximum for this benefit. UCare has a $20,000 benefit maximum per calendar year and a $100,000 lifetime benefit maximum. 

Home Care Services Criteria | UCare’s MSHO

Because UCare’s Minnesota Senior Health Options combines Medicare and Medicaid benefits, UCare follows both Medicare and Medicaid criteria for coverage. 
Medicare standards are reviewed first to. If a request for home care does not meet Medicare criteria, it is reviewed under Medicaid criteria. 
For Medicaid criteria for home care services refer to Chapter 23:  Medical Necessity Criteria of this manual.

Home Care Services Criteria | Minnesota Senior Care Plus (MSC Plus), UCare Connect, Prepaid Medical Assistance Program (PMAP), MinnesotaCare

UCare follows Medicaid criteria for MSC Plus, UCare Connect, PMAP, and MinnesotaCare (expanded Benefit set only; refer to Chapter 23:  Medical Necessity Criteria of this manual).

Some members of MSC Plus and UCare Connect also have Medicare coverage, which is not handled by UCare. In this case, UCare would be the secondary payer. Check for additional coverage on the UCare Provider Portal or by calling our Provider Assistance Center at 612-676-3300 or 1-888-531-1493. 

Medicaid services may be covered if the following member and provider conditions are met:

  • The member is eligible for the services provided.
  • Physician-ordered services are provided to recipients in their own residence.
  • Services also may be provided in a private foster care setting with no more than 4 residents, in assisted living if services are not part of customized living services, or in a group home licensed by the Commissioner of Health. 
  • Services must be documented in a written service plan and reviewed by the member’s physician at least once every 60 days for home health agency or private duty nursing* services.   
*Private duty nursing may be covered for UCare Connect members. Contact the member’s county of residence or the Minnesota Department of Human Services (DHS) to determine approval authority for private duty nursing. Providers of private duty nursing must be Medicare-certified.
Please refer to the medical authorization and notification requirements on the Eligibility & Authorizations page to verify private duty nursing requirements. 

Home Care Services | Transition of Provider

If a home care provider is unable to continue providing care to a UCare member in one of our Medicaid plans, the provider must notify the recipient, responsible party, and Minnesota DHS at least 30 days before terminating services. The provider must also help the recipient transition to another home care provider. If the termination is a result of sanctions on the provider, the provider must give each recipient a copy of the home care bill of rights at least 30 days before terminating services. Information can be found LEG-10-01:2010 Legislative Changes Ch 352, art 1, sec 8 

Billing Medicare-Certified Home Health Services

Billing for skilled home health care services depends on the member's plan.
UCare for Seniors (Medicare Advantage)
  • Members must meet Medicare coverage criteria and providers must bill Medicare rates.
  • Providers must bill specific G-codes along with revenue codes for Medicare reimbursement.
  • Bill units in visits, not in 15-minute units.
  • Use the UB-04 or 837I (electronic institutional claim form).

UCare's MSHO (Dual Special Needs Plan)

  • For Medicare billing, members must meet Medicare coverage criteria and providers must bill Medicare rates.
  • Providers must bill specific G-Codes along with the Revenue Codes when billing Medicare reimbursement.
  • Bill units in visits, not in 15-minute units.
  • If members of UCare’s MSHO do not meet Medicare criteria, they must meet Medicaid criteria. Providers must bill the specific Medicaid rates.
  • Providers must bill specific T-codes along with revenue codes for Medicaid reimbursement.
  • Must be billed on the 837I form. 

Prepaid Medical Assistance, Minnesota Senior Care Plus, UCare Connect & MinnesotaCare (MHCP plans)

  • Members must meet Medicaid home health criteria. 
  • Providers must bill the Medicaid rates.
  • Providers must bill the appropriate T-code along with the revenue code.
  • Must be billed on the 837I form.

Billing Multiple Visits on the Same Day

When billing for more than 1 visit on the same day for the same services, such as skilled nurse visit, physical therapy, occupational therapy, speech therapy, or home health aide, the second visit must be billed using a 76 modifier, or else the second visit will be denied as a duplicate claim.

UCare for Seniors | Enrollee Rights and Provider Responsibilities

UCare for Seniors members have the right to an expedited review by a Quality Improvement Organization (QIO) when they disagree with their plan’s decision that Medicare coverage of home health services should end.