12VAC30-50-160 - Home health services

12VAC30-50-160. Home health services

A. Service must be ordered or prescribed by a physician, nurse practitioner (NP), clinical nurse specialist (CNS), or physician assistant (PA). Services shall be directed or performed within the scope of a license of a practitioner of the healing arts. Home health services shall be provided in accordance with guidelines found in the Virginia Medicaid Home Health Manual.

B. Nursing services provided by a home health agency.

1. Intermittent or part-time nursing service provided by a home health agency or by a registered nurse when no home health agency exists in the area.

2. Patients may receive up to five visits by a licensed nurse annually. Limits are per recipient, regardless of the number of providers rendering services. "Annually" shall be defined as July 1 through June 30 for each recipient. If services beyond these limitations are determined by a practitioner, as defined in subsection A of this section, to be required, then the provider shall request prior authorization from DMAS for additional services. Payment shall not be made for additional service unless authorized by DMAS.

C. Home health aide services provided by a home health agency.

1. Home health aides must function under the supervision of a registered nurse.

2. Home health aides must meet the certification requirements specified in 42 CFR 484.80.

3. For home health aide services, patients may receive up to 32 visits annually. Limits shall be per recipient, regardless of the number of providers rendering services. "Annually" shall be defined as July 1 through June 30 for each recipient.

D. Physical therapy, occupational therapy, or speech pathology services and audiology services provided by a home health agency or medical rehabilitation facility.

1. Service covered only as part of a plan of care developed by a practitioner, as defined in subsection A of this section.

2. Patients may receive up to five visits for each rehabilitative therapy service ordered annually without authorization. Limits shall apply per recipient regardless of the number of providers rendering services. "Annually" shall be defined as July 1 through June 30 for each recipient. If services beyond these limitations are determined by the practitioner, as defined in subsection A of this section, to be required, then the provider shall request prior authorization from DMAS for additional services.

E. The following services are not covered under the home health services program:

1. Medical social services;

2. Services or items which would not be paid for if provided to an inpatient of a hospital, such as private-duty nursing services, or items of comfort which have no medical necessity, such as television;

3. Community food service delivery arrangements;

4. Domestic or housekeeping services that are unrelated to patient care and that materially increase the time spent on a visit;

5. Custodial care, which is patient care that primarily requires protective services rather than definitive medical and skilled nursing care; and

6. Services related to cosmetic surgery.

(Derived from VR460-03-3.1100 § 7, eff. September 1, 1993; amended, Virginia Register Volume 11, Issue 17, eff. July 1, 1995; Volume 12, Issue 16, eff. July 1, 1996; Volume 12, Issue 18, eff. July 1, 1996; Volume 13, Issue 7, eff. February 1, 1997; Volume 14, Issue 18, eff. July 1, 1998; Volume 16, Issue 2, eff. November 10, 1999; Volume 18, Issue 10, eff. February 27, 2002; Volume 19, Issue 18, eff. July 1, 2003; Amended, Virginia Register Volume 33, Issue 25, eff. 1/13/2018; Amended, Virginia Register Volume 36, Issue 24, eff. 8/19/2020.)

Statutory Authority: § 32.1-325 of the Code of Virginia; Title XIX of the Social Security Act (42 USC § 1396 et seq.).

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