Or. Admin. Code § 410-127-0060 - Reimbursement and Limitations
(1) The
Division reimburses home health services on a fee schedule by type of visit
(see home health rates on the Authority's website at:
http://www.oregon.gov/OHA/HSD/OHP/Pages/Policy-Home-Health.aspx).
(2) The Division recalculates its home health
services rates every other year. The Division shall reimburse home health
services at a level of 74 percent of Medicare costs reported on the audited,
most recently accepted or submitted Medicare Cost Reports prior to the rebase
date and pending approval from the Centers for Medicare and Medicaid Services
(CMS), and, if indicated, legislative funding authority.
(3) The Division shall request the Medicare
Cost Reports from home health agencies with a due date and shall recalculate
potential rates based on the Medicare Cost Reports received by the requested
due date. The home health agency shall submit requested cost reports by the
date requested.
(4) The Division
reimburses only for services that are medically appropriate.
(5) Limitations:
(a) Limits of covered services:
(A) Skilled nursing visits are limited to two
visits per day with payment authorization;
(B) All therapy services are limited to one
visit or evaluation per day for physical therapy, occupational therapy, or
speech-language pathology services. Therapy visits require payment
authorization;
(C) Home health aide
services are limited to those ordered by a physician, included in the plan of
care, permitted to be performed under state law, consistent with home health
aide training, and under the direction of a registered nurse or licensed
therapist familiar with the client and the client's plan of care. These
services must not duplicate other Medicaid-paid personal care
services.
(D) The Division shall
authorize home health visits for clients with uterine monitoring only for
medical problems that could adversely affect the pregnancy and are not related
to the uterine monitoring;
(E)
Medical supplies must be billed at acquisition cost, and the total of all
medical supply revenue codes may not exceed $50 per day. Only supplies that are
used during the visit or the specified additional supplies used for current
client/caregiver teaching or training purposes as medically appropriate are
billable. Client visit notes must include documentation of supplies used during
the visit or supplies provided according to the current plan of care;
(F) Durable medical equipment must be
obtained by the client by prescription through a durable medical equipment
provider.
(b) Services
not covered:
(A) Service not medically
appropriate;
(B) A service for a
diagnosis that does not appear on a line of the Prioritized List of Health
Services that has been funded by the Oregon Legislature (OAR
410-141-0520);
(C) Medical social worker service;
(D) Registered dietician counseling or
instruction;
(E) Drug and
biological;
(F) Fetal non-stress
testing;
(G) Respiratory therapist
service;
(H) Flu shot;
(I) Psychiatric nursing service.
Notes
Statutory/Other Authority:ORS 413.042
Statutes/Other Implemented:ORS 414.065
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