DAR File No. 38130
This rule was published in the December 1, 2013, issue (Vol. 2013, No. 23) of the Utah State Bulletin.
Health, Health Care Financing, Coverage and Reimbursement Policy
Rule R414-14
Home Health Services
Notice of Proposed Rule
(Amendment)
DAR File No.: 38130
Filed: 11/13/2013 09:58:49 AM
RULE ANALYSIS
Purpose of the rule or reason for the change:
The purpose of this change is to streamline and consolidate the scope of home health services for Medicaid recipients.
Summary of the rule or change:
This amendment consolidates the scope of home health services by removing sections in the rule text that specify reimbursement, eligibility, and service coverage, and deferring to the scope of services found in the Home Health Services Provider Manual and in the Medicaid State Plan.
State statutory or constitutional authorization for this rule:
- Section 26-18-3
- 42 CFR 440.70
- Section 26-1-5
Anticipated cost or savings to:
the state budget:
There is no impact to the state budget because this change only consolidates the scope of home health services for Medicaid recipients.
local governments:
There is no impact to local governments because they do not fund or provide home health services to Medicaid recipients.
small businesses:
There is no impact to small businesses because this change only consolidates the scope of home health services for Medicaid recipients.
persons other than small businesses, businesses, or local governmental entities:
There is no impact to Medicaid providers and to Medicaid recipients because this change only consolidates the scope of home health services for Medicaid recipients.
Compliance costs for affected persons:
There are no compliance costs to a single Medicaid provider or to a Medicaid recipient because this change only consolidates the scope of home health services for Medicaid recipients.
Comments by the department head on the fiscal impact the rule may have on businesses:
This makes no change in eligibility or benefits so it has no impact on business.
David Patton, PhD, Executive Director
The full text of this rule may be inspected, during regular business hours, at the Division of Administrative Rules, or at:
HealthHealth 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:
- Craig Devashrayee at the above address, by phone at 801-538-6641, by FAX at 801-538-6099, or by Internet E-mail at [email protected]
- Nina Baker at the above address, by phone at 801-538-9127, by FAX at 801-538-6412, 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:
12/31/2013
This rule may become effective on:
01/07/2014
Authorized by:
David Patton, Executive Director
RULE TEXT
R414. Health, Health Care Financing, Coverage and Reimbursement Policy.
R414-14. Home Health Services.
R414-14-1. Introduction.
The Home Health Services program provides a scope of home health services for Medicaid recipients in accordance with the Home Health Agencies Utah Medicaid Provider Manual and Attachment 4.19-B of the Medicaid State Plan, as incorporated into Section R414-1-5.
[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 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 adopts the definitions in the Home
Health Agencies Provider Manual and incorporates them by
reference in Section R414-1-5.
(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.
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 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 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 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 Services and Supportive Maintenance Home
Health 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 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 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: [November 15, 2011]2014
Notice of Continuation: September 23, 2009
Authorizing, and Implemented or Interpreted Law: 26-1-5; 26-18-3
Additional Information
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For questions regarding the content or application of this rule, please contact Craig Devashrayee at the above address, by phone at 801-538-6641, by FAX at 801-538-6099, or by Internet E-mail at [email protected]; Nina Baker at the above address, by phone at 801-538-9127, by FAX at 801-538-6412, or by Internet E-mail at [email protected].