Ohio Admin. Code 5160-12-01 - Home health services: provision requirements, coverage and service specification
(A) "Home health services" includes home
health nursing, home health aide services and skilled therapies.
(B) Home health services are reimbursable
only if a qualifying treating physician, advance
practice nurse or physician assistant certifying the need for home health
services documents that he or she had a face-to-face encounter with the
individual within ninety days prior to the start of care date, or within thirty
days following the start of care date. To be a qualifying treating physician,
the physician must
will be a doctor of medicine or osteopathy legally
authorized to practice medicine and surgery as authorized under Chapter 4731.
of the Revised Code. Advanced practice registered nurses in accordance with
rule
5160-4-04
of the Administrative Code and in collaboration with
the qualifying treating physician, or a physician assistant in
accordance with rule
5160-4-03 of
the Administrative Code and under the supervision of
the qualifying treating physician, have the authority to conduct the
face-to-face encounter for the purposes of the
supervising physician certifying the need for home health services.
The face-to-face encounter with the individual must
will occur
independent of any provision of home health services to the individual.
The face-to-face encounter may be completed using
telehealth. The face-to-face encounter must
will be
documented as follows:
(1) For home health
services unrelated to an inpatient hospital stay, the face-to-face encounter
must
will be
documented by the qualifying treating physician,
advance practice nurse or physician assistant using:
(a) The ODM 07137 "Certificate of Medical
Necessity for Home Health Services and Private Duty Nursing Services" (rev.
2/2016) or
(b) The individual's
plan of care if all of the data elements specified for home health services
unrelated to an inpatient hospital stay on the ODM 07137 are included and the
plan of care contains the physician's
signature, physician's credentials
and the date of the physician's signature
of the qualifying treating physician, advance practice
nurse or physician assistant .
(2) For post hospital home health services,
the face-to-face encounter must
will be documented by the clinician
qualifying
treating physician using the ODM 07137.
(3) For an individual dually eligible for
medicare and medicaid, the face-to-face encounter must
will be
documented by the treating physician
clinician using the ODM 07137 if supporting
documents are attached, or using the individual's plan of care pursuant to
paragraph (B)(1)(b) of this rule when the face-to-face encounter date for
medicare home health services falls within ninety days prior to the medicaid
home health services start of care date, or within thirty days following the
medicaid start of care date.
(C) Home health services are covered only if
provided on a part-time or intermittent basis, which means:
(1) No more than a combined total of eight
hours per day of home health nursing, home health aide, and skilled therapies
except as specified in paragraph (H) of this rule;
(2) No more than a combined total of fourteen
hours per week of home health nursing and home health aide services except as
specified in paragraphs (D) and (H) of this rule or as prior authorized by ODM
or its designee; and
(3) Visits are
not more than four hours. Nursing visits over four hours may qualify for
coverage in accordance with rule
5160-12-02
of the Administrative Code.
(D) A combined total of twenty-eight hours
per week of home health nursing and home health aide services is available to
an individual for up to sixty consecutive days from the date of discharge from
an inpatient hospital stay if all of the following are met as certified by the
qualifying treating physician
clinician using the ODM 07137:
(1) The individual is discharged from a
covered inpatient hospital stay of three or more days, with the discharge date
recorded on form ODM 07137. It is considered one inpatient hospital stay when
an individual is transferred from one hospital to another hospital, either
within the same building or to another location. The sixty days will begin once
the individual is discharged to their place of residence or to a nursing
facility from the last inpatient stay in an inpatient hospital or inpatient
rehabilitation unit of a hospital.
(2) The individual has a comparable level of
care as evidenced by either:
(a) Enrollment
in a home and community based services (HCBS) waiver; or
(b) A medical condition that temporarily
meets the criteria for an institutional level of care as described in rule
5160-3-08
of the Administrative Code or as defined in rule
5123:2-8-01
of the Administrative Code. In no instance does this requirement constitute the
determination of a level of care for waiver eligibility status, or admission
into a medicaid covered long term care institution.
(3) The individual requires home health
nursing, or a combination of private duty nursing, home health nursing, or
waiver nursing and/or skilled therapy services at least once per week and the
services are medically necessary in accordance with rule
5160-1-01
of the Administrative Code.
(4) The
individual has had a covered inpatient hospital stay of three or more days,
with the discharge date recorded on form ODM 07137.
(E) Home health services may only be provided
by a medicare certified home health agency (MCHHA) that meets the requirements
in accordance with rule
5160-12-03
of the Administrative Code. In order for home health services to be covered,
MCHHAs must:
(1) Provide home health services
only if the qualifying treating
physician
clinician has documented a
face-to-face encounter with the individual as specified in paragraph (B) of
this rule.
(2) Provide home health
services that are appropriate given the individual's diagnosis, prognosis,
functional limitations and medical conditions as ordered by the individual's
treating physician
clinician for the treatment of the individual's
condition, illness or injury.
(3)
Provide home health services as specified in the individual's plan of care in
accordance with rule
5160-12-03
of the Administrative Code. Home health services not specified in a plan of
care are not reimbursable. Additionally the plan of care must provide the
amount, scope, duration, and type of home health service as:
(a) Documented on the person-centered
services plan as defined in rule
5160-45-01
of the Administrative Code that is prior approved by the Ohio department of
medicaid (ODM) or designee when an individual is enrolled on an ODM
administered HCBS waiver. Home health services that are not identified on the
person-centered services plan are not reimbursable; or
(b) Documented on the services plan when an
individual is enrolled on an Ohio department of aging (ODA) or Ohio department
of developmental disabilities (DODD) administered HCBS waiver. Home health
services that are not documented on the services plan are not reimbursable.
(4) Provide the home
health services in any setting in which normal life activities take place,
other than a hospital, nursing facility; intermediate care facility for
individuals with intellectual disabilities; or any setting in which payment is
or could be made under medicaid for inpatient services that include room and
board.
(5) Not provide home health
nursing and home health aide services for the provision of habilitative care,
or respite care, and not provide skilled therapies for the provision of
maintenance care, habilitative care or respite care.
(a) "Maintenance care" is the care given to
an individual for the prevention of deteriorating or worsening medical
conditions or the management of stabilized chronic diseases or conditions.
Services are considered maintenance care if the individual is no longer making
significant improvement in his or her medical condition.
(b) "Habilitative care" is the care provided
to assist individuals in acquiring, retaining, and improving the self-help,
socialization, and adaptive skills necessary to reside successfully in home and
community based settings.
(c)
"Respite care" is the care provided to an individual unable to care for himself
or herself because of the absence or need for relief of those persons normally
providing care.
(6) Bill
for provided home health services in accordance with visit policy rule
5160-12-04
of the Administrative Code.
(7)
Bill for provided home health services using the appropriate procedure code and
applicable modifiers in accordance with rule
5160-12-05
of the Administrative Code.
(8)
Bill after all documentation is completed for the services rendered during a
visit in accordance with rule
5160-12-03
of the Administrative Code.
(F) Individuals who receive home health
services must
will :
(1) Participate
in a face-to-face encounter as specified in paragraph (B) of this rule for the
purpose of certifying their medical need for home health services.
(2) Be under the supervision of a
treating physician
clinician who is providing care and treatment to the
individual. The treating physician
clinician
cannot
will not be a
physician
clinician whose sole purpose is to sign and authorize
plans of care or who does not have direct involvement in the care or treatment
of the individual. A treating physician
clinician may be a physician
clinician
who is substituting temporarily on behalf of a treating
physician
clinician .
(3) Participate in the development of a plan
of care along with the treating physician
clinician
and the MCHHA.
(4) Access home
health services in accordance with the program for the all-inclusive care of
the elderly (PACE) when the individual participates in the PACE
program.
(5) Access home health
services in accordance with the individual's provider of hospice services when
the individual has elected the hospice benefit.
(6) Access home health services in accordance
with the individual's managed care plan when the individual is enrolled in a
medicaid managed care plan.
(G) Covered home health services:
(1) "Home health nursing" is a nursing
service that requires the skills of and is performed by a registered nurse, or
a licensed practical nurse at the direction of a registered nurse. The nurse
performing the home health service must possess a current, valid and
unrestricted license with the Ohio board of nursing and must be employed or
contracted by a MCHHA that has an active medicaid provider agreement. A service
is not considered a nursing service merely because it is performed by a
licensed nurse.
(a) Nursing tasks and
activities that shall only be performed by an RN include, but are not limited
to, the following:
(i) Intravenous (IV)
insertion, removal or discontinuation;
(ii) IV medication administration;
(iii) Programming of a pump to deliver
medications including, but not limited to, epidural, subcutaneous and IV
(except routine doses of insulin through a programmed pump);
(iv) Insertion or initiation of infusion
therapies;
(v) Central line
dressing changes; and
(vi) Blood
product administration.
(b) Home health nursing services performed by
an RN and/or an LPN must
will be:
(i)
Performed within the nurse's scope of practice as defined in Chapter 4723. of
the Revised Code and rules adopted thereunder.
(ii) Provided and documented in accordance
with the individual's plan of care in accordance with rule
5160-12-03
of the Administrative Code.
(iii)
Provided during an in-person visit or using telehealth
if clinically appropriate given the needs of the individual, the nature of the
service, and the technology that is available .
(iv) Medically necessary in accordance with
rule
5160-1-01
of the Administrative Code to care for the individual's illness or
injury.
(c) Home health
nursing services do not include:
(i) A visit
when the sole purpose is for the supervision of the home health aide.
(ii) RN assessment services as defined in
rule
5160-12-08
of the Administrative Code.
(iii)
RN consultation services as defined in rule
5160-12-08
of the Administrative Code.
(2) "Home health aide services" are services
that requires
use the skills of and are performed by a home health
aide employed or contracted by the MCHHA providing the service. Home health
aide services:
(a) Are performed within the
home health aide's scope of practice as defined in 42 C.F.R. 484.36 (October 1,
2016). The home health aide cannot be the parent, step-parent, foster parent or
legal guardian of an individual who is under eighteen years of age, or the
individual's spouse.
(b) Are
provided and documented in accordance with the individual's plan of care in
accordance with rule
5160-12-03
of the Administrative Code.
(c)
Must be
Are
provided during an in-person visit or using telehealth
if clinically appropriate given the needs of the individual, the nature of the
service, and the technology that is available .
(d) Must be medically necessary in accordance
with rule
5160-1-01
of the Administrative Code to care for the individual's illness or injury.
(e) Must be necessary to assist
the nurse or therapist in the care of the individual's illness or injury, or
help the individual maintain a certain level of health in order to remain in a
home and community based setting.
(f) Include health related services including
but not limited to:
(i) Bathing, dressing,
grooming, hygiene, including shaving, skin care, foot care, ear care, hair,
nail and oral care, that are needed to facilitate care or prevent deterioration
of the individual's health, and including changing bed linens of an incontinent
or immobile individual.
(ii)
Feeding, assistance with elimination including administering enemas (unless the
skills of a home health nurse are required), routine catheter care, routine
colostomy care, assistance with ambulation, changing position in bed, and
assistance with transfers.
(iii)
Performing a selected nursing activity or task as delegated in accordance with
Chapter 4723-13 of the Administrative Code, and performed as specified in the
plan of care.
(iv) Assisting with
activities such as routine maintenance exercises and passive range of motion as
specified in the plan of care. These activities are directly supportive of
skilled therapy services but do not require the skills of a therapist to be
safely and effectively performed. The plan of care is developed by either a
licensed therapist or a licensed registered nurse within their scope of
practice.
(v) Performing routine
care of prosthetic and orthotic devices.
(g) May include incidental services, as long
as they do not substantially extend the time of the visit.
(i) Incidental services are necessary
household tasks that must be performed by someone to maintain a home and can
include light chores, laundry, light house cleaning, preparation of meals, and
taking out the trash.
(ii) The main
purpose of a home health aide visit cannot be solely to provide these
incidental services since they are not health related services.
(iii) Incidental services are to be performed
only for the individual and not for other people in the individual's place of
residence.
(3) "Skilled therapies" is defined as
physical therapy, occupational therapy, and speech-language pathology services
that require the skills of and are performed by skilled therapy providers to
meet the individual's medical needs, promote recovery, and ensure medical
safety for the purpose of rehabilitation.
(a)
"Skilled therapy providers" are licensed physical therapists, occupational
therapists, speech-language pathologists, licensed physical therapy assistants
(LPTA) under the direction of a physical therapist, or certified occupational
therapy assistants (COTA) under the direction of a licensed occupational
therapist who are contracted or employed by a MCHHA.
(b) "Rehabilitation" is the care of an
individual with the intent of curing the individual's disease or improving the
individual's condition by the treatment of the individual's illness or injury,
or the restoration of a function affected by illness or injury.
(c) Skilled therapies:
(i) Must be provided to the individual within
the therapist's or therapy assistant's scope of practice in accordance with
sections 4755.44,
4755.07, and
4753.07 of the Revised
Code.
(ii) Must be medically
necessary in accordance with rule
5160-1-01
of the Administrative Code to care for the individual's illness or
injury.
(iii) Must be provided and
documented in the individual's plan of care in accordance with rule
5160-12-03
of the Administrative Code.
(iv)
Must be reasonable in their amount, frequency, and duration. Treatment must be
considered to be safe and effective treatment for the individual's condition
according to the accepted standards of medical practice.
(v)
Must
be
Are provided with the expectation of
the individual's rehabilitation potential according to the treating
physician's
clinician's prognosis of illness or injury. The
expectation of the individual's rehabilitation potential is that the condition
of the individual will measurably improve within a reasonable period of time or
the services are necessary to the establishment of a safe and effective
maintenance program.
(vi) May
include treatments, assessments and/or therapeutic exercises but cannot include
activities that are for the general welfare of the individual, including
motivational or general activities for the overall fitness of the
individual.
(vii)
Are provided during an in person visit or using
telehealth if clinically appropriate given the needs of the individual, the
nature of the service, and the technology that is available.
(H) An
individual who meets the requirements in this paragraph may qualify for
increased home health services. The MCHHA must assure and document that the
individual meets all requirements in this paragraph prior to increasing
services. The U5 modifier must be used when billing in accordance to rule
5160-12-05
of the Administrative Code. The use of the U5 modifier indicates that all
conditions of this paragraph were met. The individual who meets the following
requirements may receive an increase of home health services if he or she:
(1) Is under age twenty-one and requires
services for treatment in accordance with Chapter 5160-14 of the Administrative
Code for the healthchek program.
(2)
Requires
Needs more
than, as ordered by the treating physician
clinician :
(a) Eight hours per day of any home health
service, or a combined total of fourteen hours per week of home health aide and
home health nursing as specified in paragraph (C) of this rule; or
(b) A combined total of twenty-eight hours
per week of home health nursing and home health aide for sixty days as
specified in paragraph (D) of this rule.
(3) Has a comparable level of care as
evidenced by either:
(a) Enrollment in a HCBS
waiver; or
(b) A level of care
evaluated initially and annually by ODM or its designee for an individual not
enrolled in a HCBS waiver. The criteria for an institutional level of care,
including a nursing facility-based level of care as defined in rule
5160-3-08
of the Administrative Code or an ICF-IID level of care as defined in rule
5123:2-8-01
of the Administrative Code. In no instance does this constitute the
determination of a level of care for waiver eligibility purposes, or admission
into a medicaid covered long term care institution; and
(4)
Requires
Needs home
health nursing or a combination of PDN, home health nursing, waiver nursing,
and skilled therapy visits at least once per week that is medically necessary
in accordance with rule
5160-1-01
of the Administrative Code as ordered by the treating
physician
clinician .
(I) Individuals subject to decisions
regarding home health services made by ODM or its designee pursuant to this
rule will be afforded notice and hearing rights to the extent afforded in
division 5101:6 of the Administrative Code.
Notes
Promulgated Under: 119.03
Statutory Authority: Ohio Revised Code Section 5164.02
Rule Amplifies: Ohio Revised Code Sections 5164.02 and 5162.03
Prior Effective Dates: 04/04/1977, 04/07/1977, 12/21/1977, 06/01/1980, 05/01/1987, 04/01/1988, 05/15/1989, 03/30/1990 (Emer.), 06/29/1990, 07/01/1990, 03/12/1992 (Emer.), 06/01/1992, 07/31/1992 (Emer.), 10/30/1992, 04/30/1993 (Emer.), 07/01/1993 (Emer.), 07/30/1993, 09/01/1993, 01/01/1996, 05/01/1998, 07/01/1998, 09/29/2000, 03/01/2002 (Emer.), 05/30/2002, 01/31/2005, 09/01/2005, 07/01/2006, 11/08/2007, 02/01/2011, 07/01/2015, 07/01/2017
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