Current through Register Vol. 49, No. 18, September 16, 2024
PURPOSE: This amendment changes the practitioners
that may order home health services due to a change in federal regulations
found at 42 CFR
440.70, updates incorporated by reference
dates, and corrects a reference error.
(1) An otherwise eligible MO HealthNet
participant is eligible for MO HealthNet reimbursement on his/her behalf for
home health services if all the conditions of subsections (1)(A)-(C) are met-
(A) The services are prescribed by the
participant's physician, a nurse practitioner, a clinical nurse specialist, or
a physician assistant within the scope of practice authorized under state law,
who documents a face-to-face patient encounter occurred in accordance with
42 CFR
440.70(f). If a Medicare
face-to-face encounter document has already been provided for the same
participant episode of care, it will suffice as the MO HealthNet face-to-face
documentation requirement;
(B) The
services are provided in accordance with a written plan of care which clearly
documents the need for services and is reviewed by the ordering practitioner at
least every sixty (60) days; and
(C) The services are provided in the
participant's place of residence as specified in
42 CFR
440.70(c) by a qualified
person in the employ of or under contract to a Medicare-certified home health
agency which is also licensed by Missouri and enrolled with the MO HealthNet
program. 42 CFR
440.70 as published by the Federal Register,
at
https://www.ecfr.gov/, September
19, 2022, is incorporated by reference and made a part of this rule. A copy of
42 CFR
440.70 is available at the Department of
Social Services, MO HealthNet Division, 615 Howerton Ct., Jefferson City, MO
65109, and at its website at
https://dssruletracker.mo.gov/dss-proposed-rules/welcome.
action. This rule does not incorporate any subsequent amendments or
additions.
(2) Home health
services include the following services and items:
(A) Intermittent skilled nursing care which
is reasonable and necessary for the treatment of an injury or
illness;
(B) Physical,
occupational, or speech therapy when the following conditions are met:
1. The participant is an eligible child,
pregnant woman, or blind person; and
2. Physical, occupational, or speech therapy
reasonable and necessary for restoration to an optimal level of functioning
following an injury or illness, in accordance with limitations set forth in
section (8) of this rule;
(C) Physical, occupational, or speech therapy
when the following conditions are met:
1. The
participant is age nineteen (19) or over and under age sixty-five (65) and
enrolled under the Medicaid eligibility criteria for the adult expansion group
as described in Article IV section 36(c) of the Missouri Constitution;
and
2. Physical, occupational, or
speech therapy is a habilitative service that will help the individual keep,
learn, or improve skills and functioning for daily living, in accordance with
limitations set forth in section (9) of this rule;
(D) Intermittent home health aide;
and
(E) Supplies identified as
specific and necessary to the delivery of a participant's nursing care and
prescribed in the plan of care. Supplies are health care related items that are
consumable or disposable, or cannot withstand repeated use by more than one (1)
individual, that are required to address an individual medical disability,
illness, or injury. Medical supplies are classified as-
1. Routine-medical supplies used in small
quantities for patients during the usual course of most home visits;
or
2. Non-routine-medical supplies
needed to treat a patient's specific illness or injury in accordance with the
physician's, advanced practice registered nurse's, or physician
assistant's plan of care and meet further conditions discussed in more
detail below
(3) To qualify as skilled nursing care or as
physical, occupational, or speech therapy under subsection (2)(A) or subsection
(2)(B) and to be reimbursable under the MO HealthNet Home Health Program, a
service must meet the following criteria:
(A)
The service must require performance by an appropriate licensed or qualified
professional to achieve the medically desired result. Determination that a
professional is required to perform a service will take into account the nature
and complexity of the service itself and the condition of the patient as
documented in the plan of care;
(B)
The service must generally consist of no more than one (1) visit per discipline
per day, as further defined in section (6); and
(C) The service must constitute active
treatment for an illness or injury and be reasonable and necessary. To be
considered reasonable and necessary, services must be consistent with the
nature and severity of the individual's illness or injury, his/her particular
medical needs, and accepted standards of medical practice. Services directed
solely to the prevention of illness or injury will neither meet the conditions
of subsection (2)(A) or subsection (2)(B), nor be reimbursed by the MO
HealthNet Home Health Program.
(4) Necessary items of durable medical equipment and
appliances prescribed by the physician as a part of the home health service are
available to participants of home health services through the MO HealthNet
Durable Medical Equipment Program subject to the limitations of amount,
duration, and scope where applicable.
(5) The services of a home health aide must be
reasonable and necessary to maintain the participant at home, be based on the
participant's illness or injury, and there must be no other person available
who could and would perform the services. The duties of the aide shall include
the performance of procedures such as, but not limited to, the extension of
covered therapy services, personal care, ambulation, and exercise and certain
household services essential to health care. The services of the aide must be
supervised by a registered nurse or other appropriate professional staff
member, whose visits will not be separately reimbursed unless a covered skilled
nursing or therapy service as prescribed on the plan of care is performed
concurrently. Participants eligible for the State Plan Personal Care Program in
need of the services covered in this section who will not concurrently receive
home health skilled nursing or physical, occupational, or speech therapy, must
receive any services in this section that are covered under the State Plan
Personal Care program through the State Plan Personal Care Program.
(6) The unit of service for both
professional and home health aide services is a visit. A visit is a personal
contact for a period of time, not to exceed three (3) continuous hours, in the
patient's place of residence, made for the purpose of providing one (1) or more
covered home health services. The combined total of all skilled nurse and home
health aide visits reimbursed on behalf of a MO HealthNet participant may not
exceed one hundred (100) visits per calendar year.
(A) Where two (2) or more staff are visiting
concurrently to provide a single type of service, or where one (1) staff
provides more than one (1) type of service or where one (1) staff is present in
the home only to supervise another, only one (1) visit is reimbursable by MO
HealthNet.
(B) Unless the plan of
care documents a specific need for more than one (1) visit per day, MO
HealthNet will reimburse only one (1) visit per day for each of the following:
skilled nurse, home health aide, physical therapist, occupational therapist, or
speech therapist.
(C) When more
than one (1) visit per day is medically required and documented by the plan of
care, each single visit will be counted toward the combined total limit of one
hundred (100). Documentation submitted with a claim supporting extended daily
visits, multiple visits per day, or both does not override the one hundred
(100) visit per calendar year limitation. For example: A patient requires a
visit for a procedure that takes one (1) hour in the morning and requires
another visit for a procedure that takes one (1) hour in the afternoon. Each
visit may be reimbursed, but two (2) visits will be counted toward that
participant's total home health visits for that year.
(7) To be reimbursed by MO HealthNet, all
home health services and supplies must be provided in accordance with a written
plan of care authorized by the ordering practitioner. The criteria for the
development of the written plan of care and changes to the written plan of care
through interim order(s) are described in the MO Health-Net Division Home
Health Provider Manual. The MO HealthNet Division Home Health Provider Manual
is incorporated by reference and made a part of this rule as published by the
Department of Social Services, MO HealthNet Division, 615 Howerton Court,
Jefferson City, MO 65109, at its website at
http://manuals.momed.com/manuals/,
September 21, 2022. This rule does not incorporate any subsequent amendments or
additions. Plans of care and interim order(s) are to be maintained in the
client record.
(8) Skilled therapy
services as described in subsection (2)(B) will be considered reasonable and
necessary for treatment if the conditions of paragraphs (8)(A)1.-4. are met.
(A) The services-
1. Must be consistent with the nature and
severity of the illness or injury and the participant's particular medical
needs;
2. Must be considered, under
accepted standards of medical practice, to be specific and effective treatment
for the patient's condition;
3.
Must be provided with the expectation of good potential for rehabilitation,
based on assessment made by the ordering practitioner; and
4. Are necessary for the establishment of a
safe and effective maintenance program, or for teaching and training a
caregiver.
(B) Therapy
services may be delivered for one (1) certification period (up to sixty (60)
days), if services are initiated within sixty (60) days of onset of the
condition or within sixty (60) days from date of discharge from the hospital,
if the participant was hospitalized for the condition. Prior authorization to
continue therapy services beyond the initial certification period may be
requested by the home health provider. Prior authorization requests will be
reviewed by the MO HealthNet Division, and approval or denial of the
continuation of services will be based on the following criteria:
1. The service must be consistent with the
nature and severity of the illness or injury and the participant's particular
medical needs;
2. The services are
considered, under accepted standards of medical practice, to be specific and
effective treatment for the patient's condition; and
3. The services must be provided with the
expectation, based on the assessment made by the ordering practitioner, that
the participant's condition will improve materially in a reasonable and
generally predictable period of time, or are necessary to the establishment of
a safe and effective maintenance program.
*Original authority: 208.152, RSMo 1967, amended 1969,
1971, 1972, 1973, 1975, 1977, 1978, 1978, 1981, 1986, 1988, 1990, 1992, 1993,
2004, 2005, 2007; 208.153, RSMo 1967, amended 1967, 1973, 1989, 1990, 1991,
2007; and 208.201, RSMo 1987, amended
2007.
