Current through Register Vol. 49, No. 9, September, 2024
Section II
Home Health
203.000 Home Health and
the Primary Care Physician (PCP) Case Management Program (ConnectCare)
A. Home health care requires a PCP referral
except in the following circumstances:
1.
Medicaid does not require Medicare beneficiaries to enroll with PCPs;
therefore, a PCP referral is not required for home health services for
Medicare/Medicaid dual-eligibles.
2. Obstetrician/gynecologists may authorize
and direct medically-necessary home health care for postpartum complications
without obtaining a PCP referral.
B. A PCP may refer a beneficiary to a
specific home health agency only if he or she ensures the beneficiary's freedom
of choice by naming at least one alternative agency.
1. PCPs, authorized attending physicians and
home health agencies must maintain all required PCP referral documentation in
the beneficiary's clinical records!
2. PCP referrals must be renewed when
specified by the PCP or every 60 days, whichever period is shorter.
C. PCP referral is not required to
revise a plan of care during a period covered by a current referral, but the
agency must forward copies of the signed and dated assessment and the revision
to the PCP.
206.000
Documentation of Services
Home Health providers must maintain the following records for
patients of all ages; see Section 218.000 for additional documentation
guidelines regarding physical therapy for patients under the age of 21.
Additional information regarding documentation of services is located in
Section 140.000 of this manual.
A.
Signed and dated patient assessments and plans of care, including physical
therapy evaluations and treatment plans when applicable.
B. Signed and dated case notes and progress
notes from each visit by nurses, aides, physical therapy assistants and
physical therapists.
C. Signed and
dated documentation of pro re nata (PRN) visits, which must include the
following:
1. The medical justification for
each such unscheduled visit.
2. The
patient's vital signs and symptoms.
3. The observations of and measures taken by
agency staff and reported to the physician.
4. The physician's comments, observations and
instructions.
D.
Verification, by means of physician or approved non-physician practitioner
documentation, that there was a face-to-face encounter with the beneficiary
that meets the following requirements:
1. For
the initiation of home health services, the face-to-face encounter must be
related to the primary reason the beneficiary requires home health services and
must occur within the 90 days before or within 30 days after the start of
services.
2. For the initiation of
medical equipment, the face-to-face encounter must be related to the primary
reason the beneficiary requires medical equipment and must occur no more than 6
months prior to the start of services.
3. The face-to-face encounter may be
conducted by one of the following practitioners:
a. The primary care physician.
b. A nurse practitioner working in
collaboration with the primary care physician.
c. A certified nurse midwife by the scope of
practice.
d. A physician assistant
under the supervision of the primary care physician according to Arkansas
Medicaid physician policy. Physician assistant services are services furnished
according to AR Code §
17-105-101 (2012) and rules and
regulations issued by the Arkansas State Medical Board. Physician assistants
are dependent medical practitioners practicing under the supervision of the
physician for which the physician takes full responsibility. The service is not
considered to be separate from the physician's service.
e. For beneficiaries admitted to home health
immediately after an acute or post-acute stay, the attending acute or
post-acute physician.
4.
The allowed non-physician practitioner performing the face-to-face encounter
must communicate the clinical findings of that face-to-face to the ordering
physician. Those clinical findings must be incorporated into a written or
electronic document included in the beneficiary's medical record.
5. To assure clinical correlation between the
face-to-face encounter and the associated home health services, the physician
ordering the services must:
a. Document the
face-to-face encounter, which is related to the primary reason the patient
requires home health services, occurred within the required timeframes prior to
the start of home health services.
b. Must indicate the practitioner who
conducted the encounter and the date of the encounter.
6. The face-to-face encounter may occur
through telemedicine when applicable to the program manual of the performing
provider of the encounter.
E. No payment may be made for medical
equipment, supplies or appliances to the extent that a face-to-face encounter
requirement would qualify as a durable medical equipment (DME) claim under the
Medicare program unless the primary care physician or allowed non-physician
practitioner documents a face-to-face encounter with the beneficiary consistent
with the requirements. The face-to-face encounter may be performed by any of
the practitioners described in (D) 3 of this section with the exception of the
nurse midwives.
F. Copies of
current signed and dated plans of care, including interim and short-term
plan-of-care modifications, in each patient's medical records.
G. Copies of plans of care, PCP referrals,
case notes, etc., for all previous episodes of care within the period of
required record retention.
H. The
registered nurse's instructions to home health aides, detailing the aide's
duties at each visit.
I. The
registered nurse's (or physical therapist's when applicable) notes from
supervisory visits.
211.100 Plan of Care Review
A. All home health services are at the
direction of the patient's PCP or authorized attending physician.
B. The physician, in consultation with the
patient and professional staff, is responsible for establishing the plan of
care, specifying the type(s), frequency and duration of services.
C. Medicaid requires the PCP or authorized
attending physician to review the patient's plan of care as often as necessary
to address changes in the patient's condition, but no less often than every 60
days.
1. The physician establishes the start
date of each new, renewed or revised plan of care. A "renewed" plan of care is
a plan of care that has been reviewed in accordance with the 60-day requirement
and has been authorized by the PCP or authorized attending physician to
continue, either with or without revision. A "revised" plan of care is a plan
of care developed in response to a change in the patient's condition that
necessitates prompt review by the physician and reassessment by the case
nurse.
2. The PCP or authorized
attending physician must have performed a comprehensive (see Physician's Common
Procedural Terminology for guidelines regarding comprehensive evaluation and
management procedures) physical examination with medical history or history
update within the 12 months preceding the beginning date of a new plan of care,
the first date of service in an extended benefit period or the beginning date
of service in a revised or renewed plan of care.
211.200 Program Criteria for Home
Health Services
A. A Medicaid beneficiary is
eligible for home health services only if he or she has had a comprehensive
physical examination and a medical history or history update by his or her PCP
or authorized attending physician within the twelve months preceding the
beginning date of a new plan of care, the first date of service in an extended
benefit period or the beginning date of service in a revised or renewed plan of
care.
B. The appropriateness of
home health services is determined by the beneficiary's PCP or authorized
attending physician.
1. An individual's PCP or
authorized attending physician determines whether the patient needs home health
services, the scope and frequency of those services and the duration of the
services.
2. The PCP or authorized
attending physician is responsible for coordination of the patient's care, both
in-home and outside the home.
C. Some examples of individuals for whom home
health services may be suitable are those who need the following:
1. Specialized nursing procedures with regard
to catheters or feeding tubes.
2.
Detailed instructions regarding self-care or diet}
3. Rehabilitative services administered by a
physical therapist.
J Some beneficiaries may require home health services of very
short duration while they or their caregiver receive training enabling them to
provide for particular medical needs with little or no assistance from the home
health agency.
E, Some individuals may need only intermittent monitoring or
skilled care. When an individual's skilled care is so infrequent that more than
60 days elapse between services, that individual requires a new assessment and
a new plan of care for each episode of care, unless the physician documents
that the interval without such care is no detriment and appropriate to the
treatment of the beneficiary's illness or injury.
211.300 Home Health
Place of Service
Home health services may be provided in any normal setting in
which normal life activities take place, other than a hospital, nursing
facility or intermediate care facility for individuals with intellectual
disabilities (ICF/IID) or any setting in which payment is or could be made
under
Medicaid for Inpatient services that include room and board.
Home health services cannot be limited to services furnished to beneficiaries
who are homebound. The single exception to this policy permits Medicaid to
reimburse a home health agency for providing nursing services to an ICF/IID
resident on a short-term basis if the only alternative to home health services
is inpatient admission to a hospital or a skilled nursing facility. Medicaid
supplies, equipment and appliances suitable for use may be provided in any
setting in which normal life activities take place.
212.150 Intravenous Therapy in a Patient's
Home (Home IV Therapy)
Home IV therapy is a skilled nursing service that is included
in coverage of LPN and RN home health visits. Home IV therapy is available to a
Medicaid-eligible individual who is stabilized on a course of treatment and
requires continued IV therapies in the home for several days or weeks. Medicaid
requirements for establishing and maintaining home IV therapy are:
A. A Medicaid-eligible individual may qualify
for home IV therapy only if he or she has had a face-to-face encounter with
their physician or the allowed non-physician practitioner as prescribed in
206.000 (D).
B. The registered
nurse employed by the Home Health provider must assess the patient and the
patient's need for home IV therapy.
C. The PCP or authorized attending physician,
in consultation with the Home Health provider, establishes and authorizes a
home health plan of care that includes the physician's instructions for IV
therapy.
D. The physician
prescribes the IV drug(s).
1. Prescriptions
for IV drugs are subject to applicable Medicaid Pharmacy program policy and
Medicaid program benefit limits.
2.
The client, the client's representative or the Home Health provider may obtain
the drug(s) under the client's prescription drug benefit.
3. The pharmacy bills Medicaid or the
patient, in accordance with Medicaid program policy, for the IV
drugs.
E. The plan of
care must include the following:
1. Details
regarding the patient training that will occur, describing the type, the amount
and the frequency of self-care the patient will learn and perform.
2. Realistic training goals.
3. The projected date by which skilled
nursing care will end or decrease because the client will be capable of
self-care or of a designated portion of her or his self-care.
a. The registered nurse must visit and
reassess the client before the projected date that the complete or partial
self-care is to commence.
b. The
home health agency in consultation with the PCP or authorized attending
physician must terminate or revise the plan of care, basing its determination
on the degree of self-care of which the client has become capable.
F. The Home Health
provider or a provider enrolled in the Arkansas Medicaid Prosthetics program
may furnish the IV therapy supplies. Regardless of the source of the supplies,
the Home Health provider is responsible for the deployment and management of
the IV therapy supplies and for the documentation of their medical deployment
and management.
G. The Home Health
provider must report the patient's status to the PCP or authorized attending
physician in accordance with the physician's prescribed schedule in the plan of
care.
H. Nursing care in
conjunction with IV therapy is in accordance with a home health plan of care,
even if IV therapy is the only skilled service required and whether or not the
client is receiving other home health services.
217.000 Registered Nurse Supervision of Home
Health Aide Services
A. The supervising
registered nurse must issue written instructions to the home health aide.
1. The instructions must specify the aide's
specific duties at each visit.
2.
The aide must note that he or she has performed each task and note, with
written justification of the omission, which tasks he or she did not
perform.
B. If a
beneficiary is receiving home health aide services only, the registered nurse
must visit the beneficiary at least once every 60 days to assess his or her
condition and to evaluate the quality of service provided by the home health
aide.
C. If a beneficiary is
receiving only physical therapy and home health aide services, with no skilled
nursing services, either the registered nurse or the qualified physical
therapist may make this required supervisory visit.
242.430 Medical Supplies and
Diapers/Underpads
When billing for these services, which are benefit-limited to a
maximum number of dollars per month, providers must bill according to the
calendar month. Providers may not span calendar months when billing for medical
supplies and diapers and underpads. The date of delivery is the date of
service. Providers may not enter different dates for "from" and "through" dates
of service.
Supplies are healthcare-related items that are consumable or
disposable, or cannot withstand repeated use by more than one individual, and
that are required to address an individual medical disability, illness or
injury.
Equipment and appliances are items that are primarily and
customarily used to serve a medical purpose; generally are not useful to an
individual in the absence of a disability, illness or injury; can withstand
repeated use; and can be reusable or removable. Medical coverage of equipment
and appliances is not restricted to items covered as durable medical equipment
in the Medicare program.
Arkansas has a list of preapproved medical equipment, supplies
and appliances for administrative ease, but the state is prohibited from having
absolute exclusions of coverage on medical equipment, supplies or appliances.
Items not available on the preapproval list may be requested on a case-by-case
basis. When denying a request, the state must inform the beneficiary of the
right to a fair hearing.
Section II
Prosthetics
212.300 Medical Supplies, All
Ages
The Arkansas Medicaid Program reimburses home health providers
and prosthetics providers for covered medical supplies up to a maximum of
$250.00 per month, per beneficiary. The $250.00 may be provided by the Home
Health program, the Prosthetics program or a combination of the two.
A beneficiary may not receive more than a total of $250.00 of
supplies per month unless an extension has been granted. Extensions will be
considered for beneficiaries under age 21 in the Child Health Services (EPSDT)
program if documentation verifies medical necessity.
A provider must request an extension of the benefit limit for a
Medicaid beneficiary under age 21 by completing the Request for Extension of
Benefits for Medical Supplies for Medicaid Recipients Under Age 21 (form
DMS-602.) View or print form DMS-602 and instructions for
completion.
The Arkansas Medicaid program covers medical supplies using a
specific HCPCS procedure code for each specific item. Only supply items that
are listed and have a corresponding payable HCPCS procedure code are
covered.
Supplies are healthcare-related items that are consumable or
disposable, or cannot withstand repeated use by more than one individual, and
that are required to address an individual medical disability, illness or
injury.
Equipment and appliances are items that are primarily and
customarily used to serve a medical purpose; generally are not useful to an
individual in the absence of a disability, illness or injury; can withstand
repeated use; and can be reusable or removable. Medical coverage of equipment
and appliances is not restricted to items covered as durable medical equipment
in the Medicare program.
Arkansas has a list of preapproved medical equipment, supplies
and appliances for administrative ease, but the state is prohibited from having
absolute exclusions of coverage on medical equipment, supplies or appliances.
Items not available on the preapproval list may be requested on a case-by-case
basis. When denying a request, the state must inform the beneficiary of the
right to a fair hearing.
SUBJECT: Provider Manual Update Transmittal
CNM-1-16
Section II
Certified Nurse Midwife
204.100 Certified
Nurse Midwife's Role in Home Health Services
A. Home Health care requires a PCP referral
except in the following circumstances:
1.
Medicare/Medicaid dual-eligibles.
2. Obstetrician/gynecologists for postpartum
complications.
3. To revise a plan
of care during a period covered by a current referral; however, the agency must
forward copies of the signed and dated assessment and the revision to the
PCP.
B. A PCP may refer
a beneficiary to a specific Home Health agency only if he or she ensures the
beneficiary's freedom of choice by naming at least one alternative agency.
1. PCPs, authorized attending physicians and
Home Health agencies must maintain all required PCP referral documentation in
the beneficiary's clinical records.
2. PCP referrals must be renewed when
specified by the PCP or every 60 days, whichever period is shorter.
204.101 Documentation
of Services
Home Health Providers must maintain the following records for
patients of all ages.
A. Patient
assessments.
B. Plans of
care.
C. Physical therapy
evaluations.
D Treatment plans when applicable.
E. Case notes.
F. Progress notes from each visit by nurses,
aides, physical therapy assistants and physical therapists.
G.
Pro re natal (PRN) visits
and the medical justification for each such unscheduled visit. H. A
face-to-face encounter with the beneficiary must meet the following
requirements:
1. Regarding initiation of Home
Health services, the face-to-face encounter must be related to the primary
reason the beneficiary requires Home Health services and must occur within the
90 days before or the 30 days after the start of services.
2. Regarding initiation of medical equipment,
the face-to face encounter must be related to the primary reason the
beneficiary requires medical equipment and must occur no more than 6 months
prior to the start of services.
3.
Conducted by one of the following practitioners:
a. The primary care physician.
b. A nurse practitioner working in
collaboration with the primary care physician.
c. A certified nurse midwife by the scope of
practice.
d. A physician assistant
under the supervision of the primary care physician according to Arkansas
Medicaid Physician Policy. Physician assistant services are services furnished
according to A.C.A §
17-105-101 and rules and
regulations issued by the Arkansas State Medical Board. Physician assistants
are dependent medical practitioners practicing under the supervision of the
physician, for which the physician takes full responsibility. The service is
not considered to be separate from the physician's service.
e. The attending acute or post-acute
physician.
4. The
non-physician must communicate the clinical findings of that face-to-face to
the ordering physician. Those clinical findings must be incorporated into a
document included in the beneficiary's medical record.
5. The physician ordering the services must
assure clinical correlation between the face-to-face encounter and the
associated Home Health document:
a. The
primary reason the patient requires Home Health services.
b. The start of Home Health
services.
c. The practitioner who
conducted the encounter and the date of the encounter.
d. The face-to-face encounter may occur
through telemedicine, when applicable to the program manual of the performing
provider of the encounter.
E. No payment may be made for medical equipment, supplies or
appliances unless the primary care physician or allowed non-physician
practitioner documents a face-to-face encounter with the beneficiary consistent
with the requirements as listed in D.3.
204.102 Plan of Care Review
A. All Home Health services are at the
direction of the patient's PCP or authorized attending physician.
B. The physician, in consultation with the
patient and professional staff, is responsible for establishing the plan of
care, specifying the type(s), frequency and duration of services.
C. Medicaid requires the PCP or authorized
attending physician to review the patient's plan of care as often as necessary
to address changes in the patient's condition - but no less often than every 60
days.
1. The physician establishes the start
date of each new, renewed or revised plan of care.
a. A "renewed" plan of care has been reviewed
in accordance with the 60-day requirement and has been authorized by the PCP or
authorized attending physician to continue, either with or without
revision.
b. A "revised" plan of
care is developed in response to a change in the patient's condition that
necessitates prompt review by the physician and reassessment by the case nurse.
Z The PCP or authorized attending physician must have performed
a comprehensive (see Physician's Common Procedural Terminology for guidelines
regarding comprehensive evaluation and management procedures) physical
examination with medical history or history update within the 12 months
preceding the beginning date of a new plan of care, the first date of service
in an extended benefit period or the beginning date of service in a revised or
renewed plan of care.
204.103 Home Health Place of Service
Home Health services may be provided in any normal setting in
which normal life activities take place, other than a hospital, nursing
facility, or intermediate care facility for individuals with intellectual
disabilities (ICF/IID) or any setting in which payment is or could be made
under Medicaid for inpatient services that include room and board. Home Health
services cannot be limited to services furnished to beneficiaries who are
homebound. The single exception to this policy permits Medicaid to reimburse a
Home Health agency for providing nursing services to an ICF/IID resident on a
short-term basis if the only alternative to Home Health services is inpatient
admission to a hospital or a skilled nursing facility. Medicaid supplies,
equipment and appliances suitable for use may be provided in any setting in
which normal life activities take place.
Section II Nurse
Practitioner
203.000 The Nurse Practitioner's
Role in Home Health Services
203.010 Home Health and the Primary Care
Physician (PCP) Case Management Program (ConnectCare)
A. Home health care requires a PCP referral
except in the following circumstances:
1.
Medicaid does not require Medicare beneficiaries to enrol! with PCPs;
therefore, a PCP referral is not required for home health services for
Medicare/Medicaid dual-eiigibles.
2. Obstetrician/gynecologists may authorize
and direct medically-necessary home health care for postpartum complications
without obtaining a PCP referral.
B. A PCP may refer a beneficiary to a
specific home health agency only if he or she ensures the beneficiary's freedom
of choice by naming at least one alternative agency.
1. PCPs, authorized attending physicians and
home health agencies must maintain all required PCP referral documentation in
the beneficiary's clinical records.
2. PCP referrals must be renewed when
specified by the PCP or every 60 days, whichever period is shorter.
C. PCP referral is not required to
revise a plan of care during a period covered by a current referral, but the
agency must forward copies of the signed and dated assessment and the revision
to the PCP.
203.020
Documentation of Services
Home Health providers must maintain the following records for
patients of all ages:
A. Signed and
dated patient assessments and plans of care, including physical therapy
evaluations and treatment plans, when applicable.
B. Signed and dated case notes and progress
notes from each visit by nurses, aides, physical therapists and physical
therapy assistants.
C. Signed and
dated documentation of
pro re nata (PRN) visits, which must
include the following:
1. The medical
justification for each such unscheduled visit.
2. The patient's vital signs and
symptoms.
3. The observations of
and measures taken by agency staff and reported to the physician.
4. The physician's comments, observations and
instructions.
D.
Verification, by means of physician or approved non-physician practitioner
documentation that there was a face-to-face encounter with the beneficiary that
meets the following requirements:
1. For the
initiation of home health services, the face-to-face encounter must be related
to the primary reason the beneficiary requires home health services and must
occur within the 90 days before or the 30 days after the start of
services.
2. For the initiation of
medical equipment, the face-to-face encounter must be related to the primary
reason the beneficiary requires medical equipment and must occur no more than 6
months prior to the start of services.
3. The face-to-face encounter may be
conducted by one of the following practitioners:
a. The primary care physician;
b. A nurse practitioner working in
collaboration with the primary care physician;
c. A certified nurse midwife by the scope of
practice;
d. A physician assistant
under the supervision of the primary care physician according to Arkansas
Medicaid Physician Policy. Physician assistant services are services furnished
according to AR Code §
17-105-101 (2012) and rules and
regulations issued by the Arkansas State Medical Board. Physician assistants
are dependent medical practitioners practicing under the supervision of the
physician, for which the physician takes full responsibility. The service is
not considered to be separate from the physician's service..
e. For beneficiaries admitted to home health
immediately after an acute or post-acute stay, the attending acute or
post-acute physician.
4.
The allowed non-physician practitioner performing the face-to-face encounter
must communicate the clinical findings of that encounter to the ordering
physician. These clinical findings must be incorporated into a written or
electronic document included in the beneficiary's medical record.
5. To assure clinical correlation between the
face-to-face encounter and the associated home health services, the physician
ordering the services must:
a. Document that
the face-to-face encounter which is related to the primary reason the patient
requires home health services occurred within the required timeframes prior to
the start of home health services.
b. Indicate the practitioner who conducted
the encounter, and the date of the encounter.
6. The face-to-face encounter may occur
through telemedicine when applicable to the program manual of the performing
provider of the encounter.
E. No payment may be made for medical
equipment, supplies, or appliances to the extent that a face-to-face encounter
requirement would apply as durable medical equipment (DME) under the Medicare
program unless the primary care physician or allowed non-physician practitioner
documents a face-to-face encounter with the beneficiary consistent with the
requirements. The face-to-face encounter may be performed by any of the
practitioners described In D.3. with the exception of nurse-midwives.
F. Copies of current signed and dated plans
of care, including interim and short-term plan-of-care modifications.
G. Copies of plans of care, PCP referrals,
case notes, etc., for all previous episodes of care within the period of
required record retention.
H. The
registered nurse's instructions to home health aides, detailing the aide's
duties at each visjt
I. The
registered nurse's (or physical therapist's when applicable) notes from
supervisory visits.
203.030 Plan of Care Review
A. All home health services are at the
direction of the patient's PCP or authorized attending physician.
B. The physician, in consultation with the
patient and professional staff, is responsible for establishing the plan of
care, specifying the type(s), frequency and duration of services.
C. Medicaid requires the PCP or authorized
attending physician to review the patient's plan of care as often as necessary
to address changes in the patient's condition, but no less often than every 60
days.
1. The physician establishes the start
date of each new, renewed or revised plan of care. A "renewed" plan of care is
a plan of care that has been reviewed in accordance with the 60-day requirement
and has been authorized by the PCP or authorized attending physician to
continue, either with or without revision. A "revised" plan of care is a plan
of care developed in response to a change in the patient's condition that
necessitates prompt review by the physician and reassessment by the case
nurse.
2. The PCP or authorized
attending physician must have performed a comprehensive (see Physician's Common
Procedural Terminology for guidelines regarding comprehensive evaluation and
management procedures) physical examination with medical history or history
update within the 12 months preceding the start date of a new plan of care, the
first date of service in an extended benefit period or the beginning date of
service in a revised or renewed plan of care.
203.040 Program Criteria for Home Health
Services
A. A Medicaid beneficiary is
eligible for home health services only if he or she has had a comprehensive
physical examination and a medical history or history update by his or her PCP
or authorized attending physician within the twelve months preceding the
beginning date of a new plan of care, the first date of service in an extended
benefit period or the beginning date of service in a revised or renewed plan of
care.
B. The appropriateness of
home health services is determined by the beneficiary's PCP or authorized
attending physician.
1. An individual's PCP or
authorized attending physician determines whether the patient needs home health
services, the scope and frequency of those services and the duration of the
services.
2. The PCP or authorized
attending physician is responsible for coordination of the patient's care, both
in-home and outside the home.
C. Some examples of individuals for whom home
health services may be suitable are those who need the following:
1. Specialized nursing procedures with regard
to catheters or feeding tubes.
2.
Detailed instructions regarding self-care or diet.
3. Rehabilitative services administered by a
physical therapist.
D.
Some beneficiaries may require home health services of very short duration
white they or their caregivers receive training enabling them to provide for
particular medical needs with little or no assistance from the home health
agency.
E. Some individuals may
need only intermittent monitoring or skilled care. When an individual's skilled
care is so infrequent that more than 60 days elapse between services, that
individual requires a new assessment and a new plan of care for each episode of
care, unless the physician documents that the interval without such care is no
detriment and appropriate to the treatment of the beneficiary's illness or
injury.
203.050 Home
Health Place of Service
Home health services may be provided in any normal setting in
which normal life activities take place, other than a hospital, nursing
facility or intermediate care facility for individuals with intellectual
disabilities (ICF/IID) or any setting in which payment is or could be made
under
Medicaid for inpatient services that include room and board.
Home health sen/ices cannot be limited to services furnished to beneficiaries
who are homebound. The single exception to this policy permits Medicaid to
reimburse a home health agency for providing nursing services to an ICF/IID
resident on a short-term basis if the only alternative to home health services
is inpatient admission to a hospital or a skilled nursing facility. Medicaid
supplies, equipment and appliances suitable for use may be provided in any
setting in which normal life activities take place.
203.060 Intravenous Therapy in a Patient's
Home (Home IV Therapy)
Home IV therapy is a skilled nursing service that is included
in coverage of LPN and RN home health visits. Home IV therapy is available to a
Medicaid-eligible individual who is stabilized on a course of treatment and
requires continued IV therapies in the home for several days or weeks. Medicaid
requirements for establishing and maintaining home IV therapy are:
A.
A Medicaid-eligible individual may
qualify for home IV therapy only if he or she has had a face-to-face encounter
with their physician or the allowed non-physician
practitioner.
B. The
registered nurse employed by the Home Health provider must assess the patient
and the patient's need for home IV therapy.
C. The PCP or authorized attending physician,
in consultation with the Home Health provider, establishes and authorizes a
home health plan of care that includes the physician's instructions for IV
therapy.
D. The physician
prescribes the IV drug(s).
1. Prescriptions
for IV drugs are subject to applicable Medicaid Pharmacy program policy and
Medicaid program benefit limits.
2.
The client, the client's representative or the Home Health provider may obtain
the drug(s) under the client's prescription drug benefit.
3. The pharmacy bills Medicaid or the
patient, in accordance with Medicaid program policy, for the IV
drugs.
E. The plan of
care must include the following:
1. Details
regarding the patient training that will occur, describing the type, the amount
and the frequency of self-care the patient will learn and perform.
2. Realistic training goals.
3. The projected date by which skilled
nursing care will end or decrease because the client will be capable of
self-care or of a designated portion of her or his self-care.
a. The registered nurse must visit and
reassess the client before the projected date that the complete or partial
self-care is to commence.
b. The
home health agency in consultation with the PCP or authorized attending
physician must terminate or revise the plan of care, basing its determination
on the degree of self-care of which the client has become capable.
F. The Home Health
provider or a provider enrolled in the Arkansas Medicaid Prosthetics program
may furnish the IV therapy supplies. Regardless of the source of the supplies,
the Home Health provider is responsible for the deployment and management of
the IV therapy supplies and for the documentation of their medical deployment
and management.
G. The Home Health
provider must report the patient's status to the PCP or authorized attending
physician in accordance with the physician's prescribed schedule in the plan of
care.
203.070 Registered
Nurse Supervision of Home Health Aide Services
A. The supervising registered nurse must
issue written instructions to the home health aide.
1. The instructions must specify the aide's
specific duties at each visit.
2.
The aide must note that he or she has performed each task and note, with
written justification of the omission, which tasks he or she did not
perform.
B. If a
beneficiary is receiving home health aide services only, the registered nurse
must visit the beneficiary at least once every 60 days to assess his or her
condition and to evaluate the quality of service provided by the home health
aide.
C. If a beneficiary is
receiving only physical therapy and home health aide services, with no skilled
nursing services, either the registered nurse or the qualified physical
therapist may make this required supervisory visit.
203.080 Medical Supplies and
Diapers/Underpads
When billing for these services, which are benefit-limited to a
maximum number of dollars per month, providers must bill according to the
calendar month. Providers may not span calendar months when
billing for medical supplies and diapers and underpads. The date of
delivery is the date of service. Providers may not enter different dates for
"from" and "through" dates of service.
Supplies are healthcare-related items that are consumable or
disposable, or cannot withstand repeated use by more than one individual, and
are required to address an individual medical disability, illness or
injury.
Equipment and appliances are items that are primarily and
customarily used to serve a medical purpose; generally are not useful to an
individual in the absence of a disability, illness or injury; can withstand
repeated use; and can be reusable or removable. Medical coverage of equipment
and appliances is not restricted to items covered as durable medical equipment
in the Medicare program.
Arkansas has a list of preapproved medical equipment, supplies
and appliances for administrative ease, but the state is prohibited from having
absolute exclusions of coverage on medical equipment, supplies or appliances.
Items not available on the preapproval list may be requested on a case-by-case
basis. When denying a request, the state must inform the beneficiary of the
right to a fair hearing.
