Utah Admin. Code R414-14-5 - Service Coverage

(1) The Department covers the following two levels of home health services:

(a) skilled home health services; and

(b) supportive maintenance home health services.

(2) Skilled nursing services encompass the expert application of nursing theory, practice and techniques by a registered professional nurse to meet the needs of members in their place of residence through professional judgments, through independently solving member care problems, and through application of standardized procedures and medically delegated techniques.

(3) Home health aide service encompasses assistance with, or direct provision of, routine care not requiring specialized nursing skill. The home health aide is closely supervised by a registered, professional nurse to assure competent care. The aide works under written instructions and provides necessary care for the member.

(4) Supportive maintenance home health care serves members with a stabilized medical condition who continue to demonstrate health problems that require minimal assistance, observation, teaching, or follow-up. A certified home health agency may provide this assistance through the knowledge and skill of a licensed practical nurse (LPN) or a home health aide with periodic supervision by a registered nurse. A physician continues to provide direction.

(5) Home health agencies provide IV therapy, enteral and parenteral nutrition therapy either in conjunction with skilled or maintenance care or as the only service to be provided. Specific policy is outlined in the Medical Supplies and Durable Medical Equipment Utah Medicaid Provider Manual, and requirements of the home health program must be met in relation to orders, plan of care, and 60-day review and recertification.

(6) Physical therapy and speech-language pathology services are occasionally indicated and approved for a member who needs home health services. Any therapy services offered by the home health agency directly or under arrangement must be ordered by a physician and provided by a qualified licensed therapist in accordance with the plan of care. Occupational therapy and speech-language pathology services in the home are available only to members who are pregnant women or who are eligible under the Early and Periodic Screening, Diagnostic and Treatment Program (EPSDT).

(7) Medical supplies utilized for home health service must be consistent with physician orders, and approved as part of the plan of care.

(8) Medical supplies provided by the home health agency do not require prior approval, but are limited to:

(a) supplies used during the initial visit to establish the plan of care;

(b) supplies that are consistent with the plan of care; and

(c) non-durable medical equipment.

(9) Supportive maintenance home health services are limited in time equal to one visit a day determined by care needs and caregiver participation.

(10) A registered nurse employed by an approved, certified home health agency must supervise home health services. An appropriate licensed professional must provide nursing and approved therapy services.

(11) Only one home health provider may provide service to a member during any period. A subcontractor of a home health provider, however, may provide services if the original agency is the only provider that bills for services. The Department shall deny a second provider or agency that requests approval of services.

(12) Medicaid does not cover home health care provided to a member capable of self-care.

(13) Medicaid does not cover personal care services, except as determined necessary in providing skilled care.

(14) Medicaid does not cover housekeeping or homemaking services.

(15) Medicaid does not cover occupational therapy except for children covered under the Child Health Evaluation and Care Program (CHEC) for medically necessary services.

(16) Home health nursing services beyond the initial evaluation visit require prior authorization.

(17) Home health services beyond the initial visit, including supplies and therapies, must be in the plan of care that the home health agency submits for prior authorization. After initial authorization, if level of service needs change and additional services are required, the home health agency must submit a new prior authorization request.

(18) A home health agency may provide therapy services only in accordance with medical necessity and after receiving prior authorization.

Notes

Utah Admin. Code R414-14-5

Adopted by Utah State Bulletin Number 2017-14, effective 7/1/2017 Amended by Utah State Bulletin Number 2023-15, effective 7/26/2023