405 IAC 5-16-3.1 - Home health agency services; limitations

Current through December 29, 2021

Authority: IC 12-15

Affected: IC 12-13-7-3; IC 12-15-13-6

Sec. 3.1.

(a) In addition to the prior authorization requirements as outlined in section 3 of this rule, services provided by a registered nurse, licensed practical nurse, home health aide, or renal dialysis aide employed by a home health agency must be as follows:
(1) Prescribed or ordered in writing by a physician.
(2) Provided in accordance with a written plan of treatment developed by the attending physician.
(3) Intermittent or part time, except for ventilator-dependent patients who have a developed plan of home health care.
(4) Health-related nursing care. Homemaker, chore services, and sitter/companion service are not covered, except as specified under applicable Medicaid waiver programs.
(5) Medically necessary.
(6) Less expensive than any alternate modes of care.
(b) In addition to the prior authorization requirements as outlined in section 3 of this rule, physical therapy, occupational therapy, respiratory therapy, and speech pathology must be as follows:
(1) Provided by an appropriately licensed, certified, or registered therapist employed or contracted by the home health agency.
(2) Ordered or prescribed in writing by a provider in accordance with 405 IAC 5-22-6(b)(1).
(3) Provided in accordance with a written plan of treatment developed cooperatively between the therapist and the attending physician.
(4) Medically necessary. Educational activities, such as the remediation of learning disabilities, are not covered by Medicaid.
(5) Provided in accordance with 405 IAC 5-22.
(c) Nursing services, which do not meet the definition of emergency services at 405 IAC 5-2-9, are covered without prior authorization when provided to a member for whom home health services have been currently authorized when the attending physician orders a one (1) time home visit due to a change in the patient's medical condition to prevent deterioration of the patient's medical condition, for example, reanchoring a foley catheter, obtaining a laboratory specimen, administering an injection, or assessing a reported change with signs and symptoms of potential for serious deterioration.
(d) In addition to the limitations as outlined in subsection (a) and section 3 of this rule, telehealth services provided by a home health agency are subject to the following requirements:
(1) The member must be receiving home health services.
(2) To initially qualify for telehealth services, the member must have had two (2) or more of the following events related to one (1) of the conditions listed in subdivision (3) within the previous twelve (12) months:
(A) An emergency room visit.
(B) An inpatient hospital stay.
(3) The member must have one (1) or more of the following conditions:
(A) Chronic obstructive pulmonary disease.
(B) Congestive heart failure.
(C) Diabetes.

Additional qualifying conditions may be added by the office upon satisfying the notice requirements set forth in IC 12-15-13-6.

(4) An emergency room visit resulting in an inpatient hospital admission does not constitute two (2) separate events for purposes of meeting the requirements of subdivision (2).
(5) In any telehealth encounter, a licensed registered nurse must perform the reading of transmitted health information provided to the member in accordance with the written order of the physician.
(e) Home health services are reimbursable only if the treating physician certifying the need for home health services documents that there was a face-to-face encounter with the individual as outlined in section 2(b) of this rule.


405 IAC 5-16-3.1
Office of the Secretary of Family and Social Services; 405 IAC 5-16-3.1; filed Aug 27, 1999, 10:15 a.m.: 23 IR 18; readopted filed Jun 27, 2001, 9:40 a.m.: 24 IR 3822; readopted filed Sep 19, 2007, 12:16p.m.: 20071010-IR-405070311RFA; readopted filed Oct 28, 2013, 3:18 p.m.: 20131127-IR-405130241RFA Filed 9/19/2014, 3:22 p.m.: 20141015-IR-405140194FRA Filed 8/1/2016, 3:44 p.m.: 20160831-IR-405150418FRA Errata filed 11/1/2016, 9:36 a.m.: 20161109-IR-405160493ACA Filed 3/27/2018, 2:52 p.m.: 20180425-IR-405170342FRA

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