Ohio Administrative Code
Title 5160 - Ohio Department of Medicaid
Chapter 5160-12 - Ohio Home Care Program
Section 5160-12-01 - Home health services: provision requirements, coverage and service specification
Universal Citation: OH Admin Code 5160-12-01
Current through all regulations passed and filed through September 16, 2024
(A) "Home health services" includes home health nursing, home health aide services and skilled therapies.
(B) Home health services are reimbursable only if a qualifying treating physician, advance practice nurse or physician assistant certifying the need for home health services documents that he or she had a face-to-face encounter with the individual within ninety days prior to the start of care date, or within thirty days following the start of care date. To be a qualifying treating physician, the physician will be a doctor of medicine or osteopathy legally authorized to practice medicine and surgery as authorized under Chapter 4731. of the Revised Code. Advanced practice registered nurses in accordance with rule 5160-4-04 of the Administrative Code or a physician assistant in accordance with rule 5160-4-03 of the Administrative Code have the authority to conduct the face-to-face encounter . The face-to-face encounter with the individual will occur independent of any provision of home health services to the individual. The face-to-face encounter may be completed using telehealth. The face-to-face encounter will be documented as follows:
(1) For home health
services unrelated to an inpatient hospital stay, the face-to-face encounter
will be
documented by the qualifying treating physician,
advance practice nurse or physician assistant using:
(a) The ODM 07137 "Certificate of Medical
Necessity for Home Health Services and Private Duty Nursing Services" (rev.
2/2016) or
(b) The individual's
plan of care if all of the data elements specified for home health services
unrelated to an inpatient hospital stay on the ODM 07137 are included and the
plan of care contains the signature, credentials
and the date of the signature
of the qualifying treating physician, advance practice
nurse or physician assistant.
(2) For post hospital home health services,
the face-to-face encounter will be documented by the clinician
using the ODM 07137.
(3) For an individual dually eligible for
medicare and medicaid, the face-to-face encounter will be
documented by the treating
clinician using the ODM 07137 if supporting
documents are attached, or using the individual's plan of care pursuant to
paragraph (B)(1)(b) of this rule when the face-to-face encounter date for
medicare home health services falls within ninety days prior to the medicaid
home health services start of care date, or within thirty days following the
medicaid start of care date.
(C) Home health services are covered only if provided on a part-time or intermittent basis, which means:
(1) No more than a combined total of eight
hours per day of home health nursing, home health aide, and skilled therapies
except as specified in paragraph (H) of this rule;
(2) No more than a combined total of fourteen
hours per week of home health nursing and home health aide services except as
specified in paragraphs (D) and (H) of this rule or as prior authorized by ODM
or its designee; and
(3) Visits are
not more than four hours. Nursing visits over four hours may qualify for
coverage in accordance with rule
5160-12-02 of the Administrative
Code.
(D) A combined total of twenty-eight hours per week of home health nursing and home health aide services is available to an individual for up to sixty consecutive days from the date of discharge from an inpatient hospital stay if all of the following are met as certified by the qualifying treating clinician using the ODM 07137:
(1) The individual is discharged from a
covered inpatient hospital stay of three or more days, with the discharge date
recorded on form ODM 07137. It is considered one inpatient hospital stay when
an individual is transferred from one hospital to another hospital, either
within the same building or to another location. The sixty days will begin once
the individual is discharged to their place of residence or to a nursing
facility from the last inpatient stay in an inpatient hospital or inpatient
rehabilitation unit of a hospital.
(2) The individual has a comparable level of
care as evidenced by either:
(a) Enrollment
in a home and community based services (HCBS) waiver; or
(b) A medical condition that temporarily
meets the criteria for an institutional level of care as described in rule
5160-3-08 of the Administrative
Code or as defined in rule
5123:2-8-01 of the
Administrative Code. In no instance does this requirement constitute the
determination of a level of care for waiver eligibility status, or admission
into a medicaid covered long term care institution.
(3) The individual requires home health
nursing, or a combination of private duty nursing, home health nursing, or
waiver nursing and/or skilled therapy services at least once per week and the
services are medically necessary in accordance with rule
5160-1-01 of the Administrative
Code.
(4) The individual has had a
covered inpatient hospital stay of three or more days, with the discharge date
recorded on form ODM 07137.
(E) Home health services may only be provided by a medicare certified home health agency (MCHHA) that meets the requirements in accordance with rule 5160-12-03 of the Administrative Code. In order for home health services to be covered, MCHHAs must:
(1) Provide home health services only if the
clinician has documented a face-to-face encounter with
the individual as specified in paragraph (B) of this rule.
(2) Provide home health services that are
appropriate given the individual's diagnosis, prognosis, functional limitations
and medical conditions as ordered by the individual's treating
clinician for the treatment of the individual's
condition, illness or injury.
(3)
Provide home health services as specified in the individual's plan of care in
accordance with rule
5160-12-03 of the Administrative
Code. Home health services not specified in a plan of care are not
reimbursable. Additionally the plan of care must provide the amount, scope,
duration, and type of home health service as:
(a) Documented on the person-centered
services plan as defined in rule
5160-45-01 of the Administrative
Code that is prior approved by the Ohio department of medicaid (ODM) or
designee when an individual is enrolled on an ODM administered HCBS waiver.
Home health services that are not identified on the person-centered services
plan are not reimbursable; or
(b)
Documented on the services plan when an individual is enrolled on an Ohio
department of aging (ODA) or Ohio department of developmental disabilities
(DODD) administered HCBS waiver. Home health services that are not documented
on the services plan are not reimbursable.
(4) Provide the home health services in any
setting in which normal life activities take place, other than a hospital,
nursing facility; intermediate care facility for individuals with intellectual
disabilities; or any setting in which payment is or could be made under
medicaid for inpatient services that include room and board.
(5) Not provide home health nursing and home
health aide services for the provision of habilitative care, or respite care,
and not provide skilled therapies for the provision of maintenance care,
habilitative care or respite care.
(a)
"Maintenance care" is the care given to an individual for the prevention of
deteriorating or worsening medical conditions or the management of stabilized
chronic diseases or conditions. Services are considered maintenance care if the
individual is no longer making significant improvement in his or her medical
condition.
(b) "Habilitative care"
is the care provided to assist individuals in acquiring, retaining, and
improving the self-help, socialization, and adaptive skills necessary to reside
successfully in home and community based settings.
(c) "Respite care" is the care provided to an
individual unable to care for himself or herself because of the absence or need
for relief of those persons normally providing care.
(6) Bill for provided home health services in
accordance with visit policy rule
5160-12-04 of the Administrative
Code.
(7) Bill for provided home
health services using the appropriate procedure code and applicable modifiers
in accordance with rule
5160-12-05 of the Administrative
Code.
(8) Bill after all
documentation is completed for the services rendered during a visit in
accordance with rule
5160-12-03 of the Administrative
Code.
(F) Individuals who receive home health services will:
(1) Participate
in a face-to-face encounter as specified in paragraph (B) of this rule for the
purpose of certifying their medical need for home health services.
(2) Be under the supervision of a
clinician who is providing care and treatment to the
individual. The clinician
will not be a
clinician whose sole purpose is to sign and authorize
plans of care or who does not have direct involvement in the care or treatment
of the individual. A treating
clinicianmay be a clinician
who is substituting temporarily on behalf of a treating
clinician.
(3) Participate in the development of a plan
of care along with the treating clinician
and the MCHHA.
(4) Access home
health services in accordance with the program for the all-inclusive care of
the elderly (PACE) when the individual participates in the PACE
program.
(5) Access home health
services in accordance with the individual's provider of hospice services when
the individual has elected the hospice benefit.
(6) Access home health services in accordance
with the individual's managed care plan when the individual is enrolled in a
medicaid managed care plan.
(G) Covered home health services:
(1) "Home health nursing" is a nursing
service that requires the skills of and is performed by a registered nurse, or
a licensed practical nurse at the direction of a registered nurse. The nurse
performing the home health service must possess a current, valid and
unrestricted license with the Ohio board of nursing and must be employed or
contracted by a MCHHA that has an active medicaid provider agreement. A service
is not considered a nursing service merely because it is performed by a
licensed nurse.
(a) Nursing tasks and
activities that shall only be performed by an RN include, but are not limited
to, the following:
(i) Intravenous (IV)
insertion, removal or discontinuation;
(ii) IV medication administration;
(iii) Programming of a pump to deliver
medications including, but not limited to, epidural, subcutaneous and IV
(except routine doses of insulin through a programmed pump);
(iv) Insertion or initiation of infusion
therapies;
(v) Central line
dressing changes; and
(vi) Blood
product administration.
(b) Home health nursing services performed by
an RN and/or an LPN will be:
(i)
Performed within the nurse's scope of practice as defined in Chapter 4723. of
the Revised Code and rules adopted thereunder.
(ii) Provided and documented in accordance
with the individual's plan of care in accordance with rule
5160-12-03 of the Administrative
Code.
(iii) Provided during an
in-person visit or using telehealth if clinically
appropriate given the needs of the individual, the nature of the service, and
the technology that is available.
(iv) Medically necessary in accordance with
rule 5160-1-01 of the Administrative
Code to care for the individual's illness or injury.
(c) Home health nursing services do not
include:
(i) A visit when the sole purpose is
for the supervision of the home health aide.
(ii) RN assessment services as defined in
rule 5160-12-08 of the Administrative
Code.
(iii) RN consultation
services as defined in rule
5160-12-08 of the Administrative
Code.
(2)
"Home health aide services" are services that use the
skills of and are performed by a home health aide employed or contracted by the
MCHHA providing the service. Home health aide services:
(a) Are performed within the home health
aide's scope of practice as defined in 42 C.F.R. 484.36 (October 1, 2016). The
home health aide cannot be the parent, step-parent, foster parent or legal
guardian of an individual who is under eighteen years of age, or the
individual's spouse.
(b) Are
provided and documented in accordance with the individual's plan of care in
accordance with rule
5160-12-03 of the Administrative
Code.
(c)
Are
provided during an in-person visit or using telehealth
if clinically appropriate given the needs of the individual, the nature of the
service, and the technology that is available.
(d) Must be medically necessary in accordance
with rule
5160-1-01 of the Administrative
Code to care for the individual's illness or injury.
(e) Must be necessary to assist the nurse or
therapist in the care of the individual's illness or injury, or help the
individual maintain a certain level of health in order to remain in a home and
community based setting.
(f)
Include health related services including but not limited to:
(i) Bathing, dressing, grooming, hygiene,
including shaving, skin care, foot care, ear care, hair, nail and oral care,
that are needed to facilitate care or prevent deterioration of the individual's
health, and including changing bed linens of an incontinent or immobile
individual.
(ii) Feeding,
assistance with elimination including administering enemas (unless the skills
of a home health nurse are required), routine catheter care, routine colostomy
care, assistance with ambulation, changing position in bed, and assistance with
transfers.
(iii) Performing a
selected nursing activity or task as delegated in accordance with Chapter
4723-13 of the Administrative Code, and performed as specified in the plan of
care.
(iv) Assisting with
activities such as routine maintenance exercises and passive range of motion as
specified in the plan of care. These activities are directly supportive of
skilled therapy services but do not require the skills of a therapist to be
safely and effectively performed. The plan of care is developed by either a
licensed therapist or a licensed registered nurse within their scope of
practice.
(v) Performing routine
care of prosthetic and orthotic devices.
(g) May include incidental services, as long
as they do not substantially extend the time of the visit.
(i) Incidental services are necessary
household tasks that must be performed by someone to maintain a home and can
include light chores, laundry, light house cleaning, preparation of meals, and
taking out the trash.
(ii) The main
purpose of a home health aide visit cannot be solely to provide these
incidental services since they are not health related services.
(iii) Incidental services are to be performed
only for the individual and not for other people in the individual's place of
residence.
(3) "Skilled therapies" is defined as
physical therapy, occupational therapy, and speech-language pathology services
that require the skills of and are performed by skilled therapy providers to
meet the individual's medical needs, promote recovery, and ensure medical
safety for the purpose of rehabilitation.
(a)
"Skilled therapy providers" are licensed physical therapists, occupational
therapists, speech-language pathologists, licensed physical therapy assistants
(LPTA) under the direction of a physical therapist, or certified occupational
therapy assistants (COTA) under the direction of a licensed occupational
therapist who are contracted or employed by a MCHHA.
(b) "Rehabilitation" is the care of an
individual with the intent of curing the individual's disease or improving the
individual's condition by the treatment of the individual's illness or injury,
or the restoration of a function affected by illness or injury.
(c) Skilled therapies:
(i) Must be provided to the individual within
the therapist's or therapy assistant's scope of practice in accordance with
sections 4755.44,
4755.07, and
4753.07 of the Revised
Code.
(ii) Must be medically
necessary in accordance with rule
5160-1-01 of the Administrative
Code to care for the individual's illness or injury.
(iii) Must be provided and documented in the
individual's plan of care in accordance with rule
5160-12-03 of the Administrative
Code.
(iv) Must be reasonable in
their amount, frequency, and duration. Treatment must be considered to be safe
and effective treatment for the individual's condition according to the
accepted standards of medical practice.
(v)
Are provided with the expectation of
the individual's rehabilitation potential according to the treating
clinician's prognosis of illness or injury. The
expectation of the individual's rehabilitation potential is that the condition
of the individual will measurably improve within a reasonable period of time or
the services are necessary to the establishment of a safe and effective
maintenance program.
(vi) May
include treatments, assessments and/or therapeutic exercises but cannot include
activities that are for the general welfare of the individual, including
motivational or general activities for the overall fitness of the
individual.
(vii)
Are provided during an in person visit or using
telehealth if clinically appropriate given the needs of the individual, the
nature of the service, and the technology that is available.
(H) An individual who meets the requirements in this paragraph may qualify for increased home health services. The MCHHA must assure and document that the individual meets all requirements in this paragraph prior to increasing services. The U5 modifier must be used when billing in accordance to rule 5160-12-05 of the Administrative Code. The use of the U5 modifier indicates that all conditions of this paragraph were met. The individual who meets the following requirements may receive an increase of home health services if he or she:
(1) Is under age twenty-one and requires
services for treatment in accordance with Chapter 5160-14 of the Administrative
Code for the healthchek program.
(2)
Needs more
than, as ordered by the treating clinician:
(a) Eight hours per day of any home health
service, or a combined total of fourteen hours per week of home health aide and
home health nursing as specified in paragraph (C) of this rule; or
(b) A combined total of twenty-eight hours
per week of home health nursing and home health aide for sixty days as
specified in paragraph (D) of this rule.
(3) Has a comparable level of care as
evidenced by either:
(a) Enrollment in a HCBS
waiver; or
(b) A level of care
evaluated initially and annually by ODM or its designee for an individual not
enrolled in a HCBS waiver. The criteria for an institutional level of care,
including a nursing facility-based level of care as defined in rule
5160-3-08 of the Administrative
Code or an ICF-IID level of care as defined in rule
5123:2-8-01 of the
Administrative Code. In no instance does this constitute the determination of a
level of care for waiver eligibility purposes, or admission into a medicaid
covered long term care institution; and
(4)
Needs home
health nursing or a combination of PDN, home health nursing, waiver nursing,
and skilled therapy visits at least once per week that is medically necessary
in accordance with rule
5160-1-01 of the Administrative
Code as ordered by the treating clinician.
(I) Individuals subject to decisions regarding home health services made by ODM or its designee pursuant to this rule will be afforded notice and hearing rights to the extent afforded in division 5101:6 of the Administrative Code.
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