21-003.01
General
Requirements
21.003.01A
Medical Necessity: Rehabilitation services must be
provided in accordance with the medical necessity guidelines outlined in 471
NAC 1-002.02A.
21.003.01B
Prior Authorization of Medical Rehabilitation Care:
Medicaid requires prior authorization of all medical inpatient rehabilitation
services to determine the medical necessity, appropriateness of setting, and
length of stay. Prior authorization functions, admission reviews, concurrent
reviews, and retrospective prepayment reviews are conducted by the peer review
organization (PRO), an entity contracted with Medicaid to perform these
services. The PRO also performs reconsideration reviews of inpatient hospital
denials when requested by the provider.
21.003.01C
Services Provided for
Clients Enrolled in the Nebraska Medicaid Managed Care Program:
See 471 NAC 1-002.01.
21.003.01C1
Delayed Enrollment: When a client is in an acute care
medical or rehabilitation facility prior to the client's enrollment in Managed
Care, the effective date of enrollment is delayed until the client is
discharged from the facility or transferred to a lower level of care. See 482
NAC 2-002.05D.
21.003.01D
HEALTH CHECK (EPSDT) Treatment Services: See 471 NAC
Chapter 33
21-003.02
Covered Services
Medicaid covers rehabilitation services for patients
requiring a hospital level of care, and a rehabilitation program which
incorporates a multidisciplinary coordinated team approach to upgrade his/her
ability to function as independently as possible. A program of this scope
usually includes:
i. Intensive skilled
rehabilitation nursing care;
ii.
Physical therapy;
iii. Occupational
therapy; and
iv. If needed, speech
therapy;
v. Nursing staff to
provide general nursing services, and support the other disciplines by
monitoring the patient's activities on the nursing floor to ensure that s/he
participates in carrying out the activities of daily living utilizing the
training received in therapy;
vi.
Ongoing general and, as needed, direct supervision of a physician with special
training or experience in the field of rehabilitation (For coverage
limitations, billing, and payment of physicians services, see 471 NAC 18-000.);
and,
vii. If needed, a psychologist
and/or social worker to help resolve any psychological and social problems
which are impeding rehabilitation. (For coverage limitations, billing, and
payment of psychological services, see 471 NAC 20-000 and/or 32-000.)
21-003.02A
Rehabilitation Evaluation: When a client is admitted
to the hospital for rehabilitation care, an assessment must be made of his/her:
i. Medical condition;
ii. Functional limitations;
iii. Prognosis;
iv. Possible need for corrective
surgery;
v. Attitude toward
rehabilitation; and
vi. The
existence of any social problems affecting rehabilitation.
After these assessments are made, the physician, in
consultation with the rehabilitation team, decides whether rehabilitation is
possible; what the reasonable rehabilitation goals are; and what type of
rehabilitation program is required to achieve these goals.
21-003.02A1
Limitations to
Coverage of the Initial Evaluation:
21-003.02A1a
Duration of
Evaluation: When more than 10 days are required to complete the
initial evaluation, the Department will carefully review the case to ensure
that the additional time was necessary. The Department may request, and the
hospital shall submit, documentation showing the necessity of the additional
time. Inpatient hospital care is required for this period, and covered under
Medicaid if the client's condition warrants a multidisciplinary team
evaluation.
21.003.02A1b
Identical or Similar Admission Conditions: If, during
a previous hospital stay, the client completed a program for essentially the
same condition for which inpatient hospital care is now being provided, the
Department covers the initial evaluation period only if:
i. A change in circumstances has occurred
which makes an evaluation reasonable and necessary; or,
ii. The subsequent admission is to an
institution utilizing advanced techniques or technology not available in the
first institution.
21-003.02A1c
Dementia or
Senility: In view of the client's limited rehabilitation
potential, a multidisciplinary team evaluation is not considered reasonable and
necessary for a client who is demented or severely senile.
21-003.02A2
Mental
Confusion: Medicaid does not cover hospitalization for
rehabilitation following an evaluation if mental confusion with an inability to
learn is the only existing disability. Alternatively, the fact that an
individual is "confused" is not a basis for concluding that a multidisciplinary
team evaluation is not warranted.
21-003.02B
Rehabilitation
Program: Medicaid covers hospitalization in cases where the
rehabilitation team determines, after the initial evaluation, that a
significant practical improvement can be expected in a reasonable period of
time. Rehabilitation goals must be realistic and reasonable. Vocational
rehabilitation is generally not considered a realistic goal for most clients
receiving rehabilitation services under Medicaid. For the majority of clients,
the most realistic rehabilitation goal is self-sufficiency in:
1. Bathing;
2. Ambulation;
3. Toileting;
4. Eating;
5. Dressing;
6. Homemaking; or
7. Sufficient improvement in the areas of
self-sufficiency to allow the client to live in the community with assistance
rather than in an institution.
In assessing the reasonableness of the established goal or
the likelihood that the rehabilitation goal can be achieved in a reasonable
period of time, considerable weight must be given to the rehabilitation team's
judgment, except where experience indicates that in a significant number of
cases the team's judgment has proven to be unreliable. An expectation of the
attainment of complete independence in the activities of daily living is not
necessary, but there must be an expectation of an improvement that would be of
a practical benefit to the client.
21-003.02C
Team
Conferences: Rehabilitation team conferences must be held at least
every 2 weeks to:
1. Assess the individual's
progress or the problems impeding progress;
2. Consider possible resolutions to the
problems;
3. Reassess the
continuing validity of the rehabilitation goals established at the time of the
initial evaluation;
4. Reassess the
need for any adjustment in these goals or in the prescribed treatment program;
and
5. Develop discharge plans.
Team conferences may be a formal or informal, but must
involve interactive discussion regarding the patient. The decisions made during
conferences must be recorded in the patient's clinical record. The Department
may request, and the hospital shall provide, documentation of team
conferences.
21-003.02D
Discharge: Medicaid covers a maximum of 3 days to
discharge the client. If more than 3 days is needed to safely discharge the
client, payment for additional days will be made only when adequate
justification for the delayed discharge is submitted to the
Department.
21-003.03
Non-Covered Services
21-003.03A
Poor Candidate for
Rehabilitation: When the initial evaluation results in a
conclusion that the client is a poor candidate for rehabilitation care,
Medicaid limits coverage of inpatient hospital care to a reasonable number of
days needed to permit appropriate placement of the client. An intensive
rehabilitation program under these circumstances is not considered reasonable
and necessary to the treatment of the client's illness or injury.
21-003.03B
Further Progress is
Unlikely: Rehabilitation services are covered until further
progress toward the established rehabilitation goal is unlikely, or further
progress may be achieved in a less intensive setting. In making decisions as to
whether further progress may be carried out in a less intensive setting, the
Department considers:
1. The degree of
improvement which has occurred; and
2. The type of program required to achieve
further improvement.
When further progress is unlikely, coverage is provided
through the time it is reasonable for the physician, in consultation with the
rehabilitation team, to have concluded that further improvement would not
occur, and effected the client's discharge. Because planning is an integral
part of any rehabilitation program and must begin upon the client's admittance
to the facility, an extended period of time for discharge action is not
reasonable after:
1. Established goals
have been reached;
2. A
determination has been made that further progress is unlikely; or
3. Care in less intensive setting is
appropriate
