Section 11: Medical Social Services Medical Social Services Coverage Criteria Medical social services that are provided by a qualified medical social worker or a social work assistant under the supervision of a qualified medical social worker may be covered as home health services where the patient/client meets the qualifying criteria listed below: • Be confined to the home. • Under the care of a physician. • Receiving services under a plan of care established and periodically reviewed by a physician. • Be in need of skilled nursing, physical therapy, or speech-language pathology care on an intermittent basis or have a continuing need for occupational therapy. In addition: • The services of these professionals are necessary to resolve social or emotional problems that are or are expected to be an impediment to the effective treatment of the patient’s/client’s medical condition or rate of recovery. • The plan of care indicates how the services which are required necessitate the skills of a qualified social worker or a social work assistant under the supervision of a qualified medical social worker to be performed safely and effectively. Where these requirements for coverage are met, services of these professionals which may be covered include, but are not limited to: • Assessment of the social and emotional factors related to the patient’s/client’s illness, need for care, response to treatment, and adjustment to care. • Assessment of the relationship of the patient’s/client’s medical and nursing requirements to the patient’s/client’s home situation, financial resources, and availability of community resources. • Appropriate action to obtain available community resources to assist in resolving the patient’s/client’s problem. • Counseling services that are required by the patient/client. • Medical social services furnished to the patient’s/client’s family member or caregiver on a short- term basis when the Agency can demonstrate that a brief intervention (that is, two or three visits) by a medical social worker is necessary to remove a clear and direct impediment to the effective treatment of the patient’s/client’s medical condition or to the patient’s/client’s rate of recovery. To be considered “clear and direct”, the behavior or actions of the family member or caregiver must plainly obstruct, contravene, or prevent the patient’s/client’s medical treatment or rate of recovery. Medical social services to address general problems that do not clearly and directly impede treatment or recovery as well as long-term social services furnished to family members, such as ongoing alcohol counseling, are not covered.
