authorization will include consideration of the following, if applicable:
Review of the
following factors when determining the appropriate services, units of service,
and length of period for prior authorized services for home care members:
(A) Severity of illness and
(B) Stability of the
condition and symptoms.
in medical condition that affects the type or units of service that can be
(D) Treatment plan,
including identified goals.
Intensity of care required to meet needs.
(F) Complexity of needs.
(G) Amount of time required to complete
(I) Whether the services
required in the current care plan are consistent with prior care
(J) Need for instructing the
member on self-care techniques in the home or need for instructing the
caregiver on caring for the member in the home, or both.
(K) Other caregiving services received by the
member, including, but not limited to, services provided by Medicare, Medicaid
Waiver Programs, CHOICE, vocational rehabilitation, and private insurance
to provide care for the member, including consideration of the following:
(i) Number of caregivers available.
(ii) Whether the caregiver works outside the
(iii) Whether the caregiver
attends school outside of the home.
(iv) Reasonably predictable or long term
physical limitations of the caregiver that limit the ability of the caregiver
to provide care to the member.
Whether the caregiver has additional child care responsibilities.
(vi) How and when the units of service
requested will be used to assist the caregiver in meeting the member's medical
(M) Whether the
member works or attends school outside of the home, including what assistance
when additional home health units may be authorized on a short term basis,
including the following:
deterioration in the condition of the member, particularly if additional units
will prevent an inpatient or extended inpatient hospital admission.
Major illness or injury of the caregiver
with expectation of recovery, including, but not limited to:
(AA) illness or injury that requires an
inpatient acute care stay;
chemotherapy or radiation treatments; or
(CC) a broken limb, which would impair the
caregiver's ability to lift the member.
Temporary, but significant, change in
the home situation, including, but not limited to:
(AA) a caregiver's call to military duty;
(BB) temporary unavailability
due to employment responsibilities.
(iv) Significant permanent change in the home
situation, including, but not limited to, death or divorce with loss of a
caregiver. Additional units of service may be authorized to assist in providing