Current through Register Vol. 35, No. 18, September 24, 2024
A.
Medicaid covers those home health services which are skilled, intermittent and
medically necessary. The focus of home health services shall be on the
curative, restorative or preventive aspects of care. The goal of these services
shall be to assist the recipient to return to an optimum level of functioning
and to facilitate the timely discharge of the recipient to self-care or to care
by their family, guardian or significant other. Services must be ordered by the
recipient's attending physician and included in the plan of care established by
the recipient's attending physician in consultation with home health agency
staff. The plan of care must be reviewed, signed and dated by the attending
physician. The attending physician certifies that the recipient has a medical
need to receive care at home at the initial certification, and as part of the
plan of care review at recertification. The attending physician certifies that
the recipient requires the skilled services of a nurse, physical therapist,
occupational therapist or speech therapist. If the recipient requires home
health aide services, the physician shall certify the need for these services.
The evaluation visit is covered whether or not the recipient is admitted to
home health care. Covered services include the following:
(1) skilled nursing services;
(2) home health aide services;
(3) physical and occupational therapy
services; and
(4) speech therapy
services.
B. Skilled
nursing services: Medicaid covers skilled, intermittent and medically necessary
skilled nursing services if the following conditions are met:
(1) Services must be ordered by the attending
physician and included in the plan of care established by the recipient's
attending physician in consultation with the home health agency staff. The plan
of care must be reviewed, signed and dated by the attending
physician;
(2) Skills of a
registered nurse or licensed practical nurse must be required for direct care
or supervision of home health aides.
(3) Services must be furnished by or under
the supervision of a registered nurse licensed in New Mexico who is responsible
for the initial evaluation, care planning and coordination of
services.
(4) Services must be
reasonable and necessary to the treatment of an illness or injury. To be
considered reasonable and necessary, the services furnished shall be:
(a) consistent with the recipient's
particular medical needs as determined by the recipient's attending
physician.
(b) consistent with
accepted standards of medical and nursing practice.
(c) consistent with provision of care in the
safest, least restrictive setting for meeting the recipient's needs.
(d) consistent with the New Mexico MAD
approved medical necessity criteria for home health.
(5) Skilled nursing care includes, but is not
limited to, the following:
(a) observation and
evaluation of recipient's health needs
(b) teaching the recipient, family members or
significant other caretaker to provide care such as, but not limited to:
(i) giving an injection;
(ii) irrigating a catheter;
(iii) providing wound care, including
applying dressings to wounds, positioning, and recognizing signs of infection
and other complications;
(iv) using
medications properly and safely, and understanding potential side
effects;
(v) using special
equipment and adaptive devices; and
(vi) home safety.
(c) insertion and sterile irrigation of
catheters;
(d) administering
injections;
(e) administering
intravenous antibiotics and enteral and intravenous total parenteral
nutrition;
(f) treating decubitus
ulcers and other skin disorders; and
(g) providing other health teaching according
to recipient's needs.
C. Therapy services: Medicaid covers the
therapy services furnished through the home health agency by licensed physical
therapists, occupational therapists or speech language pathologists.
(1) Services must be ordered by the
recipient's attending physician and included in the plan of care established by
the attending physician in consultation with the home health agency
staff.
(2) All therapy services
must conform with practice standards and licensing requirements as defined by
state law.
(3) Services can be
furnished by a public, private for-profit or private non-profit home health
agency directly or under arrangement.
D. Home health aide services: Medicaid covers
home health aide services if the following conditions are met:
(1) home health aides must complete training
or a competency evaluation program that meets certain requirements. See 42 CFR,
Section 484.36 ;
(2) services must
be ordered by the attending physician and included in the plan of care
established by the recipient's attending physician in consultation with the
home health agency staff;
(3)
written instructions for patient care are prepared by a registered nurse or
therapist;
(4) assignment to a
particular recipient is made by a registered nurse;
(5) duties of the home health aide include:
(a) performance of simple procedures as an
extension of nursing and therapy services;
(b) personal care;
(c) walking and exercises;
(d) household services essential to health
care at home;
(e) help with
medications that are normally self-administered;
(f) reporting changes in the recipient's
condition; and
(g) completing
appropriate records.
(6)
registered nurses or other appropriate professional staff members must make a
supervisory visit to the recipient's residence at least every two weeks to
observe and decide whether goals are being met. The recipient's record must
contain documentation that, at least every two weeks or more often if
necessary, there has been communication between the home health aide and the
supervisory nurse or other appropriate professional staff member regarding the
recipient's condition; and
(7)
services must be furnished directly through the home health agency staff or by
contractual arrangement.
E. Durable medical equipment and medical
supplies: Medicaid covers medically necessary durable medical equipment and
medical supplies which are specified in the plan of care. See 8.324.5 NMAC,
Durable Medical Equipment and Medical Supplies.
(1) Reimbursement is made to the home health
agency and is limited to medical supplies necessary during the course of the
plan of care. The following durable medical equipment and medical supplies are
covered as specified:
(a) Medicaid does not
cover stock or routine items, such as band-aids, cotton balls, thermometers,
lotion, personal care items, tape and alcohol.
(b) Non-routine supplies, such as catheters,
ostomy supplies, feeding tubes, intravenous supplies, dressing supplies,
ointments, solutions, chux diapers and home testing kits must be ordered as
part of the plan of care.
(2) Utilization review, including
retrospective review, can be made by MAD or its designee to assess the medical
necessity for durable medical equipment and medical supplies and program
compliance. If MAD determines that the equipment and supplies that were billed
were not medically necessary or a covered service for the care of that
recipient, the MAD payments are recouped.
F. Maternal/child services: Medicaid covers
perinatal and pediatric home health services if the following conditions are
met:
(1) the service is prescribed by the
recipient's attending physician and is included in the plan of care established
by the recipient's physician in consultation with home health agency
staff;
(2) if the recipient has a
medical need to receive care at home, in the sense that care in the home is
more appropriate to the needs of the recipient, safe, cost-effective and will
prevent or delay institutionalization;
(3) the services are reasonable and medically
necessary to treat a high risk pregnancy, at-risk infant, illness, injury and
to prevent infection. To be considered reasonable and medically necessary, the
services furnished shall be:
(a) consistent
with the recipient's particular medical needs as determined by the recipient's
attending physician;
(b) consistent
with accepted standards of medical and nursing practice;
(c) consistent with the New Mexico MAD
approved medical necessity criteria for home health.
