Payment shall be approved for medically necessary home health
agency services prescribed by a physician, nurse practitioner, clinical nurse
specialist, or physician assistant in a plan of home health care provided by a
Medicare-certified home health agency.
The number of hours of home health agency services shall be
reasonable and appropriate to meet an established medical need of the member
that cannot be met by a family member, significant other, friend, or neighbor.
Services must be medically necessary in the individual case and be related to a
diagnosed medical impairment or disability.
The member need not be homebound to be eligible for home
health agency services; however, the services provided by a home health agency
shall only be covered when provided in the member's residence with the
following exception. Private duty nursing and personal care services for
persons aged 20 and under as described at 78.9(10)"a" may be
provided in settings other than the member's residence when medically
necessary.
Medicaid members of home health agency services need not
first require skilled nursing care to be entitled to home health aide
services.
Further limitations related to specific components of home
health agency services are noted in subrules 78.9(3) to 78.9(10).
Payment shall be made on an encounter basis. An encounter is
defined as separately identifiable hours in which home health agency staff
provide continuous service to a member.
Payment for supplies shall be approved when the supplies are
incidental to the patient's care, e.g., syringes for injections, and do not
exceed $15 per month. Dressings, durable medical equipment, and other supplies
shall be obtained from a durable medical equipment dealer or pharmacy. Payment
of supplies may be made to home health agencies when a durable medical
equipment dealer or pharmacy is not available in the member's community.
Payment may be made for restorative and maintenance home
health agency services.
Payment may be made for teaching, training, and counseling in
the provision of health care services.
Treatment plans for these services shall additionally
reflect: to whom the services are to be provided (patient, family member,
etc.); prior teaching training, or counseling provided; medical necessity for
the rendered service; identification of specific services and goals; date of
onset of the teaching, training, or counseling; frequency of services; progress
of member in response to treatment; and estimated length of time these services
will be needed.
The following are not covered: services provided in the home
health agency office, homemaker services, well child care and supervision, and
medical equipment rental or purchase.
Services shall be authorized by a physician, nurse
practitioner, clinical nurse specialist, or physician assistant, evidenced by
the physician's, nurse practitioner's, clinical nurse specialist's, or
physician assistant's signature and date on a plan of treatment.
(1)
Treatment plan. A plan
of treatment shall be completed prior to the start of care and at a minimum
reviewed every 60 days thereafter. There must be a face-to-face encounter
between a physician, a nurse practitioner, a clinical nurse specialist, a
certified nurse-midwife, or a physician assistant and the Medicaid member no
more than 90 days before or 30 days after the start of service. The plan of
care shall support the medical necessity and intensity of services to be
provided by reflecting the following information:
a. Place of service.
b. Type of service to be rendered and the
treatment modalities being used.
c.
Frequency of the services.
d.
Assistance devices to be used.
e.
Date home health services were initiated.
f. Progress of member in response to
treatment.
g. Medical supplies to
be furnished.
h. Member's medical
condition as reflected by the following information, if applicable:
(1) Dates of prior hospitalization.
(2) Dates of prior surgery.
(3) Date last seen by a physician, nurse
practitioner, clinical nurse specialist, or physician assistant.
(4) Diagnoses and dates of onset of diagnoses
for which treatment is being rendered.
(5) Prognosis.
(6) Functional limitations.
(7) Vital signs reading.
(8) Date of last episode of
instability.
(9) Date of last
episode of acute recurrence of illness or symptoms.
(10) Medications.
i. Discipline of the person providing the
service.
j. Certification period
(no more than 60 days).
k.
Estimated date of discharge from the hospital or home health agency services,
if applicable.
l. Physician's,
nurse practitioner's, clinical nurse specialist's, or physician assistant's
signature and date. The plan of care must be signed and dated by the physician,
nurse practitioner, clinical nurse specialist, or physician assistant before
the claim for service is submitted for reimbursement.
(2)
Supervisory visits.
Payment shall be made for supervisory visits two times a month when a
registered nurse acting in a supervisory capacity provides supervisory visits
of services provided by a home health aide under a home health agency plan of
treatment or when services are provided by an in-home health care provider
under the department's in-home health-related care program as set forth in
441-Chapter 177.
(3)
Skilled nursing services. Skilled nursing services are
services that when performed by a home health agency require a licensed
registered nurse or licensed practical nurse to perform. Situations when a
service can be safely performed by the member or other nonskilled person who
has received the proper training or instruction or when there is no one else to
perform the service are not considered a "skilled nursing service." Skilled
nursing services shall be available only on an intermittent basis. Intermittent
services for skilled nursing services shall be defined as a medically
predictable recurring need requiring a skilled nursing service at least once
every 60 days, not to exceed five days per week (except as provided below),
with an attempt to have a predictable end. Daily visits (six or seven days per
week) that are reasonable and necessary and show an attempt to have a
predictable end shall be covered for up to three weeks. Coverage of additional
daily visits beyond the initial anticipated time frame may be appropriate for a
short period of time, based on the medical necessity of service. Medical
documentation shall be submitted justifying the need for continued visits,
including the physician's, nurse practitioner's, clinical nurse specialist's,
or physician assistant's estimate of the length of time that additional visits
will be necessary. Daily skilled nursing visits or multiple daily visits for
wound care or insulin injections shall be covered when ordered by a physician,
nurse practitioner, clinical nurse specialist, or a physician assistant and
included in the plan of care. Other daily skilled nursing visits which are
ordered for an indefinite period of time and designated as daily skilled
nursing care do not meet the intermittent definition and shall be denied.
Skilled nursing services shall be evaluated based on the
complexity of the service and the condition of the patient.
Private duty nursing for persons aged 21 and over is not a
covered service. See subrule 78.9(10) for guidelines for private duty nursing
for persons aged 20 or under.
(4)
Physical therapy
services. Payment shall be made for physical therapy services when the
services relate directly to an active written treatment plan, follow a
treatment plan established by the physician, nurse practitioner, clinical nurse
specialist, or physician assistant after any needed consultation with the
qualified physical therapist, are reasonable and necessary to the treatment of
the patient's illness or injury, and meet the guidelines defined for
restorative, maintenance, or trial therapy as set forth in subrule 78.19(1),
paragraphs
"a" and
"b."
For physical therapy services, the treatment plan shall
additionally reflect goals, modalities of treatment, date of onset of
conditions being treated, restorative potential, and progress notes.
(5)
Occupational therapy
services. Payment shall be made for occupational therapy services when
the services relate directly to an active written treatment plan, follow a
treatment plan established by the physician, nurse practitioner, clinical nurse
specialist, or physician assistant, are reasonable and necessary to the
treatment of the patient's illness or injury, and meet the guidelines defined
for restorative, maintenance, or trial therapy as set forth in subrule
78.19(1), paragraphs
"a" and
"c."
For occupational therapy services, the treatment plan shall
additionally reflect goals, modalities of treatment, date of onset of
conditions being treated, restorative potential, and progress notes.
(6)
Speech therapy
services. Payment shall be made for speech therapy services when the
services relate directly to an active written treatment plan, follow a
treatment plan established by the physician, nurse practitioner, clinical nurse
specialist, or physician assistant, are reasonable and necessary to the
treatment of the patient's illness or injury, and meet the guidelines defined
for restorative, maintenance, or trial therapy as set forth in subrule
78.19(1), paragraphs
"a" and
"d."
For speech therapy services, the treatment plan shall
additionally reflect goals, modalities of treatment, date of onset of
conditions being treated, restorative potential, and progress notes.
(7)
Home health aide
services. Payment shall be made for unskilled services provided by a
home health aide if the following conditions are met:
a. The service as well as the frequency and
duration are stated in a written plan of treatment established by a physician,
nurse practitioner, clinical nurse specialist, or physician assistant. The home
health agency is encouraged to collaborate with the member, or in the case of a
child with the child's caregiver, in the development and implementation of the
plan of treatment.
b. The member
requires personal care services as determined by a registered nurse or other
appropriate therapist. The services shall be given under the supervision of a
registered nurse, physical, speech, or occupational therapist and the
registered nurse or therapist shall assign the aide who will provide the
care.
c. Services shall be provided
on an intermittent basis. "Intermittent basis" for home health agency services
is defined as services that are usually two to three times a week for two to
three hours at a time. Services provided for four to seven days per week, not
to exceed 28 hours per week, when ordered by a physician, nurse practitioner,
clinical nurse specialist, or physician assistant and included in a plan of
care shall be allowed as intermittent services. Increased services provided
when medically necessary due to unusual circumstances on a short-term basis of
two to three weeks may also be allowed as intermittent services when the home
health agency documents the need for the excessive time required for home
health aide services.
Home health aide daily care may be provided for persons
employed or attending school whose disabling conditions require the persons to
be assisted with morning and evening activities of daily living in order to
support their independent living.
Personal care services include the activities of daily
living, e.g., helping the member to bathe, get in and out of bed, care for hair
and teeth, exercise, and take medications specifically ordered by the
physician, but ordinarily self-administered, and retraining the member in
necessary self-help skills.
Certain household services may be performed by the aide in
order to prevent or postpone the member's institutionalization when the primary
need of the member for home health aide services furnished is for personal
care. If household services are incidental and do not substantially increase
the time spent by the aide in the home, the entire visit is considered a
covered service. Domestic or housekeeping services which are not related to
patient care are not a covered service if personal care is not rendered during
the visit.
For home health aide services, the treatment plan shall
additionally reflect the number of hours per visit and the living arrangement
of the member, e.g., lives alone or with family.
(8)
Medical social services.
Rescinded IAB 3/29/17, effective 5/3/17.
(9)
Home health agency care for
maternity patients and children. The intent of home health agency
services for maternity patients and children shall be to provide services when
the members are unable to receive the care outside of their home and require
home health care due to a high-risk factor. Routine prenatal, postpartum, or
child health care is a covered service in a physician's office or clinic and,
therefore, is not covered by Medicaid when provided by a home health agency.
a. Treatment plans for maternity patients and
children shall identify:
(1) The potential
risk factors,
(2) The medical
factor or symptom which verifies the child is at risk,
(3) The reason the member is unable to obtain
care outside of the home,
(4) The
medically related task of the home health agency,
(5) The member's diagnosis,
(6) Specific services and goals,
and
(7) The medical necessity for
the services to be rendered. A single high-risk factor does not provide
sufficient documentation of the need for services.
b. The following list of potential high-risk
factors may indicate a need for home health services to prenatal maternity
patients:
(1) Aged 16 or under.
(2) First pregnancy for a woman aged 35 or
over.
(3) Previous history of
prenatal complications such as fetal death, eclampsia, C-section delivery,
psychosis, or diabetes.
(4) Current
prenatal problems such as hypertensive disorders of pregnancy, diabetes,
cardiac disease, sickle cell anemia, low hemoglobin, mental illness, or drug or
alcohol abuse.
(5) Sociocultural or
ethnic problems such as language barriers, lack of family support, insufficient
dietary practices, history of child abuse or neglect, or single
mother.
(6) Preexisting
disabilities such as sensory deficits, or mental or physical
disabilities.
(7) Second pregnancy
in 12 months.
(8) Death of a close
family member or significant other within the previous year.
c. The following list of potential
high-risk factors may indicate a need for home health services to postpartum
maternity patients:
(1) Aged 16 or
under.
(2) First pregnancy for a
woman aged 35 or over.
(3) Major
postpartum complications such as severe hemorrhage, eclampsia, or C-section
delivery.
(4) Preexisting mental or
physical disabilities such as deaf, hard of hearing, blind, hemiplegic,
activity-limiting disease, sickle cell anemia, uncontrolled hypertension,
uncontrolled diabetes, mental illness, or intellectual disability.
(5) Drug or alcohol abuse.
(6) Symptoms of postpartum
psychosis.
(7) Special
sociocultural or ethnic problems such as lack of job, family problems, single
mother, lack of support system, or history of child abuse or neglect.
(8) Demonstrated disturbance in maternal and
infant bonding.
(9) Discharge or
release from hospital against medical advice before 36 hours
postpartum.
(10) Insufficient
antepartum care by history.
(11)
Multiple births.
(12) Nonhospital
delivery.
d. The
following list of potential high-risk factors may indicate a need for home
health services to infants:
(1) Birth weight
of five pounds or under or over ten pounds.
(2) History of severe respiratory
distress.
(3) Major congenital
anomalies such as neonatal complications which necessitate planning for
long-term follow-up such as postsurgical care, poor prognosis, home stimulation
activities, or periodic development evaluation.
(4) Disabling birth injuries.
(5) Extended hospitalization and separation
from other family members.
(6)
Genetic disorders, such as Down's syndrome, and phenylketonuria or other
metabolic conditions that may lead to intellectual disability.
(7) Noted parental rejection or indifference
toward baby such as never visiting or calling the hospital about the baby's
condition during the infant's extended stay.
(8) Family sociocultural or ethnic problems
such as low education level or lack of knowledge of child care.
(9) Discharge or release against medical
advice before 36 hours of age.
(10)
Nutrition or feeding problems.
e. The following list of potential high-risk
factors may indicate a need for home health services to preschool or school-age
children:
(1) Child or sibling victim of child
abuse or neglect.
(2) Intellectual
disability or other physical disabilities necessitating long-term follow-up or
major readjustments in family lifestyle.
(3) Failure to complete the basic series of
immunizations by 18 months, or boosters by 6 years.
(4) Chronic illness such as asthma, cardiac,
respiratory or renal disease, diabetes, cystic fibrosis, or muscular
dystrophy.
(5) Malignancies such as
leukemia or carcinoma.
(6) Severe
injuries necessitating treatment or rehabilitation.
(7) Disruption in family or peer
relationships.
(8) Suspected
developmental delay.
(9)
Nutritional deficiencies.
(10)
Private duty nursing or personal
care services for persons aged 20 and under. Payment for private duty
nursing or personal care services for persons aged 20 and under shall be
approved if determined to be medically necessary. Payment shall be made on an
hourly unit of service.
a. Definitions.
(1) Private duty nursing services are those
services which are provided by a registered nurse or a licensed practical nurse
under the direction of the member's physician to a member in the member's place
of residence or outside the member's residence, when normal life activities
take the member outside the place of residence. Place of residence does not
include nursing facilities, intermediate care facilities for the mentally
retarded, or hospitals.
Services shall be provided according to a written plan of
care authorized by a licensed physician. The home health agency is encouraged
to collaborate with the member, or in the case of a child with the child's
caregiver, in the development and implementation of the plan of treatment.
These services shall exceed intermittent guidelines as defined in subrule
78.9(3). Private duty nursing and personal care services shall be inclusive of
all home health agency services personally provided to the member. Enhanced
payment under the interim fee schedule shall be made available for services to
children who are technology dependent, i.e., ventilator dependent or whose
medical condition is so unstable as to otherwise require intensive care in a
hospital.
Private duty nursing or personal care services do not
include:
1. Respite care, which is a
temporary intermission or period of rest for the caregiver.
2. Nurse supervision services including chart
review, case discussion or scheduling by a registered nurse.
3. Services provided to other persons in the
member's household.
4. Services
requiring prior authorization that are provided without regard to the prior
authorization process.
5.
Transportation services.
6.
Homework assistance.
(2)
Personal care services are those services provided by a home health aide or
certified nurse's aide and which are delegated and supervised by a registered
nurse under the direction of the member's physician to a member in the member's
place of residence or outside the member's residence, when normal life
activities take the member outside the place of residence. Place of residence
does not include nursing facilities, intermediate care facilities for the
mentally retarded, or hospitals. Payment for personal care services for persons
aged 20 and under that exceed intermittent guidelines may be approved if
determined to be medically necessary as defined in subrule 78.9(7). These
services shall be in accordance with the member's plan of care and authorized
by a physician. The home health agency is encouraged to collaborate with the
member, or in the case of a child with the child's caregiver, in the
development and implementation of the plan of treatment.
Medical necessity means the service is reasonably calculated
to prevent, diagnose, correct, cure, alleviate or prevent the worsening of
conditions that endanger life, cause pain, result in illness or infirmity,
threaten to cause or aggravate a disability or chronic illness, and no other
equally effective course of treatment is available or suitable for the member
requesting a service.
b. Requirements.
(1) Private duty nursing or personal care
services shall be ordered in writing by a physician as evidenced by the
physician's signature on the plan of care.
(2) Private duty nursing or personal care
services shall be authorized by the department or the department's designated
review agent prior to payment.
(3)
Prior authorization shall be requested at the time of initial submission of the
plan of care or at any time the plan of care is substantially amended and shall
be renewed with the department or the department's designated review agent.
Initial request for and request for renewal of prior authorization shall be
submitted to the department's designated review agent. The provider of the
service is responsible for requesting prior authorization and for obtaining
renewal of prior authorization.
The request for prior authorization shall include a nursing
assessment, the plan of care, and supporting documentation. The request for
prior authorization shall include all items previously identified as required
treatment plan information and shall further include: any planned surgical
interventions and projected time frame; information regarding caregiver's
desire to become involved in the member's care, to adhere to program
objectives, to work toward treatment plan goals, and to work toward maximum
independence; and identify the types and service delivery levels of all other
services to the member whether or not the services are reimbursable by
Medicaid. Providers shall indicate the expected number of private duty nursing
RN hours, private duty nursing LPN hours, or home health aide hours per day,
the number of days per week, and the number of weeks or months of service per
discipline. If the member is currently hospitalized, the projected date of
discharge shall be included.
Prior authorization approvals shall not be granted for
treatment plans that exceed 16 hours of home health agency services per day.
(Cross reference 78.28(10))
(11)
Vaccines. In order to
be paid for the administration of a vaccine covered under the Vaccines for
Children (VFC) Program, a home health agency must enroll in the VFC program.
Payment for the vaccine will be approved only if the VFC program stock has been
depleted.
This rule is intended to implement Iowa Code section
249A.4.
