Health, Health Care Financing, Coverage and Reimbursement Policy

Rule R414-14

Home Health Services

Notice of Proposed Rule

(Amendment)

DAR File No.: 34524
Filed: 03/24/2011 02:40:51 PM

RULE ANALYSIS

Purpose of the rule or reason for the change:

The purpose of this change is to update references to statutory authority for home health services and to clarify home health terminology. This change is also necessary to incorporate by reference the definitions from the home health agency provider manual.

Summary of the rule or change:

This amendment updates references to statutory authority for home health services, clarifies home health terminology, and incorporates by reference the definitions from the home health agency provider manual. It also removes a definition that already exists in another administrative rule and removes a definition that already exists in the home health agency provider manual. It also makes other minor corrections.

State statutory or constitutional authorization for this rule:

• Section 26-1-5
• Section 26-18-3

This rule or change incorporates by reference the following material:

• Adds Home Health Agency Provider Manual, published by Division of Medicaid and Health Financing, 04/01/2011

Anticipated cost or savings to:

the state budget:

The Department does not anticipate any impact to the state budget because this amendment only clarifies definitions, terminology, and statutory authority for home health services.

local governments:

There is no impact to local governments because they do not fund or provide home health services for Medicaid clients.

small businesses:

The Department does not anticipate any fiscal impact to small businesses because this amendment only clarifies definitions, terminology, and statutory authority for home health services.

persons other than small businesses, businesses, or local governmental entities:

The Department does not anticipate any fiscal impact to providers of home health services and to Medicaid clients because this amendment only clarifies definitions, terminology, and statutory authority.

Compliance costs for affected persons:

There are no compliance costs to a single provider of home health services or to a Medicaid client because this amendment only clarifies definitions, terminology, and statutory authority.

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

This rule should not have a direct fiscal impact on business. Incorporation of this section of the provider manual by this rule assures that the Medicaid program is implemented through administrative rule.

W. David Patton, PhD, Acting 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
288 N 1460 W
SALT LAKE CITY, UT 84116-3231

Direct questions regarding this rule to:

• Craig Devashrayee at the above address, by phone at 801-538-6641, by FAX at 801-538-6099, or by Internet E-mail at cdevashrayee@utah.gov

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:

05/16/2011

This rule may become effective on:

05/23/2011

Authorized by:

David Patton, Acting Executive Director

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

R414-14. Home Health Services.

R414-14-1. Introduction and Authority.

(1 )[.] Home health services are part-time intermittent health care services that are based on medical necessity and provided to eligible persons in their places of residence when the home is the most appropriate and cost effective setting that is consistent with the client's medical need. The goals of home health care are to minimize the effects of disability or pain; promote, maintain, or protect health; and prevent premature or inappropriate institutionalization.

2. This rule is authorized under [Utah Code]Section 26-18-3 and governs the services allowed under 42 CFR 440.70 and 42 CFR, Part 484. 42 U.S.C. Secs. 1395u, 1395x, and 1395y also authorize home health services.

 

R414-14-2. Definitions.

The following definition applies to home health services. In addition, the Department incorporates by reference the definitions in the Home Health Agency Provider Manual, effective April 1, 2011.

[ 1. "Home health agency" means a public agency or private organization that is licensed by the Department as a home health agency under the authority of Utah Code Title 26, Chapter 21, and in accordance with Utah Administrative Code R432-700. A home health agency is primarily engaged in providing skilled nursing service and other therapeutic services.

] [2.](1) "Plan of Care" means a written plan developed cooperatively by home health agency staff and the attending physician. The plan is designed to meet specific needs of an individual, is based on orders written by the attending physician, and is approved and periodically reviewed and updated by the attending physician.

[ 3. "Prior authorization" means that degree of approval for payment of services required to be obtained from Division of Health Care Financing staff by a licensed provider before the service is provided.

]

R414-14-3. Client Eligibility Requirements.

Home health services are available to categorically eligible and medically needy individuals.

 

R414-14-4. Program Access Requirements.

(1 )[.] Home health service shall be provided only to an individual who is under the care of a physician. The attending physician shall write the orders on which a plan of care is established and certify the necessity for home health services.

(2 )[.] The home health agency may accept a recipient for home health [care]services only if there is a reasonable expectation that a recipient's needs can be met adequately by the agency in the recipient's place of residence.

(3 )[.] The attending physician and home health agency personnel must review and sign a total plan of care [shall] as often as the severity of the patient's condition requires, but at least once every 60 days in accordance with 42 CFR 440.70.

(4 )[.] The home health agency must provide quality, cost-effective care and a safe environment in the home through registered or licensed practical nurses who have adequate training, knowledge, judgement, and skill.

(5 )[.] Home health aide services may only be provided pursuant to written instructions and under the supervision of a registered nurse by a person selected and trained to assist with routine care not requiring specialized nursing skills.

(6 )[.] Over the long term service period, the cost to provide the required [care and] service in the patient's home must be no greater than the cost to meet the client's medical needs in an alternative setting.

(7 )[.] A home health agency may provide an initial assessment visit without prior authorization to assess the patient's needs and establish a plan of care. After the initial visit, all home health care and service must be based on prior authorization.

 

R414-14-5. Service Coverage.

(1 )[.] Two levels of home health service are covered: Skilled Home Health [Care]Services and Supportive Maintenance Home Health [Care]Services.

(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. 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]services 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.

 

R414-14-6. Reimbursement for Services.

Reimbursement for home health services shall be provided as documented in the Utah [State Medicaid]Medicaid State Plan, ATTACHMENT 4.19-B. The fee schedule was established after examining usual and customary charges in the industry, applying appropriate discounts, and relying on professional judgment.

 

KEY: Medicaid

Date of Enactment or Last Substantive Amendment: [July 1, 2009]2011

Notice of Continuation: September 23, 2009

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