DAR File No. 32623

Health, Health Care Financing, Coverage and Reimbursement Policy

R414-14-5

Service Coverage

NOTICE OF PROPOSED RULE

DAR File No.: 32623
Filed: 04/30/2009, 04:24
Received by: NL

RULE ANALYSIS

Purpose of the rule or reason for the change:

The purpose of this rule change is to reinstate physical therapy as a benefit of home health service for all Medicaid eligible adults.

Summary of the rule or change:

This change allows Medicaid eligible adults that receive home health services to have physical therapy included with prior authorization.

State statutory or constitutional authorization for this rule:

Section 26-18-3

Anticipated cost or savings to:

the state budget:

The increase of physical therapy will result in increased costs to the General Fund and to the federal budget. Estimates of these costs are listed in the companion filing to this proposed rule (Section R414-21-2). (DAR NOTE: The proposed amendment to Section R414-21-2 is under DAR No. 32619 in this issue, May 15, 2009, of the Bulletin.)

local governments:

This change does not impact local governments because they do not fund or provide physical therapy services to Medicaid clients in the home.

small businesses and persons other than businesses:

The Department estimates annual increases in revenue to providers of physical therapy. These estimates are listed in the companion filing to this proposed rule (Section R414-21-2). The explanation of annual savings to clients is also found in Section R414-21-2.

Compliance costs for affected persons:

The annual increase in revenue to a single provider of physical therapy is listed in the companion filing to this proposed rule (Section R414-21-2). The explanation of annual savings to a client is also found in Section R414-21-2.

Comments by the department head on the fiscal impact the rule may have on businesses:

The 2009 Legislature appropriated funds to permit restoration of these services. David N. Sundwall, MD, Executive Director

The full text of this rule may be inspected, during regular business hours, at the Division of Administrative Rules, or at:

Health
Health Care Financing, Coverage and Reimbursement Policy
CANNON HEALTH BLDG
288 N 1460 W
SALT LAKE CITY UT 84116-3231

Direct questions regarding this rule to:

Kimi McNutt at the above address, by phone at 801-538-6381, by FAX at 801-538-6099, or by Internet E-mail at [email protected]

Interested persons may present their views on this rule by submitting written comments to the address above no later than 5:00 p.m. on:

06/15/2009

Interested persons may attend a public hearing regarding this rule:

5/26/2009 at 1:00 PM, Utah Department of Health, Cannon Health Building, 288 N 1460 W, Room 114, Salt Lake City, UT

This rule may become effective on:

07/01/2009

Authorized by:

David N. Sundwall, Executive Director

R414. Health, Health Care Financing, Coverage and Reimbursement Policy.

R414-14. Home Health Services.

R414-14-5. Service Coverage.

1. Two levels of home health service are covered: Skilled Home Health Care and Supportive Maintenance Home Health Care.

2. Skilled nursing service encompasses the expert application of nursing theory, practice and techniques by a registered professional nurse to meet the needs of patients in their place of residence through professional judgments, through independently solving patient 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 patient.

4. Supportive maintenance home health care serves those patients who have a medical condition which has stabilized, but who demonstrate continuing health problems requiring minimal assistance, observation, teaching, or follow-up. This assistance can be provided by a certified home health agency 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. IV therapy, enteral and parenteral nutrition therapy are provided as a home health service either in conjunction with skilled or maintenance care or as the only service to be provided. Specific policy is outlined in the medical supplies program and all 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 pathology services are occasionally indicated and approved for the patient needing home health service. 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. [Physical therapy, o]Occupational therapy and speech pathology services in the home are available only to clients who are pregnant women or who are individuals eligible under the Early and Periodic Screening, Diagnosis and Treatment Program.

7. Medical supplies utilized for home health service must be suitable for use in the home in providing home health care, 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 care is limited in time equal to one visit per day determined by care needs and care giver participation.

10. A registered nurse employed by an approved, certified home health agency must supervise all home health services. Nursing service and all approved therapy services must be provided by the appropriate licensed professional.

11. Only one home health provider (agency) may provide service to a patient during any period of time. However, a subcontractor of a home health provider may provide service if the original agency is the only provider that bills for services. A second provider or agency requesting approval of service will be denied.

12. Home health care provided to a patient capable of self care is not a covered Medicaid benefit.

13. Personal care services, except as determined necessary in providing skilled care, is not a covered home health benefit.

14. Housekeeping or homemaking services are not covered home health benefits.

15. Occupational therapy is not a covered Medicaid benefit except for children covered under CHEC for medically necessary service.

16. Home health nursing service beyond the initial evaluation visit requires prior authorization.

17. All home health service beyond the initial visit, including supplies and therapies, shall be in the plan of care that the home health agency submits for prior authorization. Prior to providing the service, the home health agency must first obtain approval for the level of skilled or maintenance service based on the prior authorization request and a review of the plan of care. If level of service needs change, 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.

 

KEY: Medicaid

Date of Enactment or Last Substantive Amendment: [February 24], 2009

Notice of Continuation: October 6, 2004

Authorizing, and Implemented or Interpreted Law: 26-1-5; 26-18-3