Home Health Provider Manual

LOUISIANA MEDICAID PROGRAMCHAPTER 23: HOME HEALTHSECTION 23.1: DESCRIPTION OF SERVICESISSUED:REPLACED:08/18/2112/01/18PAGE(S) 6Supervision of Home Health AidesPeriodic on-site supervision with the home health aide present is part of the Minimum Standardsfor HHAs.It is required that if the beneficiary is receiving a skilled service (nursing, physical therapy,occupational therapy, or speech-language therapy), the beneficiary shall have a RN or appropriatetherapist supervisory visit made randomly every 14 days.Beneficiaries not receiving skilled services must have an RN supervisory visit at the beneficiary’sresidential setting at least once every 62 days while the home health aide is present and providingcare. Supervisory visits are not billable services.Extended Home HealthExtended Home Health, also known as extended skilled nursing services (a minimum of three ormore hours of nursing services per day) may be provided to beneficiaries under the age of 21 bythe HHA if determined to be medically necessary, ordered by a physician, and prior authorized bythe PAU. The beneficiary must require skilled nursing care that exceeds the caregiver’s ability tocare for the beneficiary without the extended home health services.NOTE: Skilled nursing services are to be conducted in the beneficiary’s residential setting.Extended home health services may be provided outside of the residential setting when the nurseaccompanies the beneficiary for medical reasons such as doctor appointments, treatments oremergency room visit. Medicaid will not reimburse for skilled nursing services performed outsideof state boundaries.Rehabilitation ServicesPhysical, occupational and speech therapy services are covered when provided by the HHA. Theseservices are covered with prior authorization (PA).Physical TherapyPhysical Therapy Services are rehabilitative services necessary for the treatment of thebeneficiary’s illness or injury, or restoration and maintenance of function affected by thebeneficiary’s illness or injury.Description of ServicesPage 4 of 6Section 23.1

LOUISIANA MEDICAID PROGRAMCHAPTER 23: HOME HEALTHSECTION 23.1: DESCRIPTION OF SERVICESISSUED:REPLACED:08/18/2112/01/18PAGE(S) 6These services are provided with the expectation, based on the physician’s assessment of thebeneficiary’s rehabilitative potential, that: The beneficiary’s condition will improve materially within a reasonable andgenerally predictable period of time; or The services are necessary for the establishment of a safe and effective maintenanceprogram.Physical Therapy AssistantsThe use of Physical Therapy Assistants (PTA) is regulated in the Minimum Standards for HomeHealth Agencies. The PTA must be currently licensed by the Louisiana State Board of PhysicalTherapy Examiners and must be supervised by a licensed physical therapist. The PTA must have,at a minimum, one year of experience as a licensed PTA before assuming responsibility for a homehealth caseload.The PTA’s duties must not include interpretation and implementation of referrals or prescriptions,performance evaluations, or the determination of major modifications of treatment programs.Occupational TherapyOccupational therapy is a medically prescribed treatment to improve or restore a function whichhas been impaired by illness, injury or, when the function has been permanently lost or reduced,to improve the beneficiary’s ability to perform those tasks required for independent functioning.Speech TherapySpeech-Language Therapy Services are those services necessary for the diagnosis and treatmentof speech and language disorders that result in communication disabilities and for the diagnosisand treatment of swallowing disorders (dysphagia), regardless of a communication disability.Medical SuppliesMedical Supplies recommended by the physician, required in the care of the beneficiary andsuitable for use in any setting in which normal life activities take place are covered under the DMEprogram when approved by the PAU.NOTE: HHAs that enroll as DME providers may bill the program for supplies used under thatservice designation using the DME claim form.Description of ServicesPage 5 of 6Section 23.1

LOUISIANA MEDICAID PROGRAMCHAPTER 23: HOME HEALTHSECTION 23.1: DESCRIPTION OF SERVICESISSUED:REPLACED:08/18/2112/01/18PAGE(S) 6Routine supplies, and supplies that are only covered when provided in conjunction with a homehealth visit, are listed in Section 23.5.Chronic Needs CasesChronic needs cases pertain to DME, Extended Home Health, Personal Care Services (PCS), andRehabilitation Services. The PA process has been altered to allow designation of somebeneficiaries as Chronic Needs Case Beneficiaries. Prior authorized services are continuous andexpected to remain at current levels based on their medical condition for these beneficiaries. Oncea beneficiary is deemed a Chronic Needs Case, providers must only submit a PA request formaccompanied by a statement from a physician documenting that the beneficiary’s condition hasnot improved and the services currently approved must be continued at the approved level.Requests for an increase in these services will be treated as a traditional PA request and are subjectto full review.Beneficiaries meeting the Chronic Needs Case status will be notified of the designation and thePAU will send a copy of the letter to the provider of services.Description of ServicesPage 6 of 6Section 23.1

LOUISIANA MEDICAID PROGRAMISSUED:REPLACED:CHAPTER 23: HOME HEALTHSECTION 23.2: SERVICE LIMITATIONS12/01/1801/20/14PAGE(S) 1SERVICE LIMITATIONSService LimitationsHome Health Services include part-time skilled nursing services, home health aide services,physical therapy, speech and occupational therapy, and medical supplies and equipment orderedby a physician as required in the care of the beneficiary and suitable for use in any setting in whichnormal life activities take place.NOTE: Medicaid prohibits multiple professional disciplines in a beneficiary’s residential settingat the same time. This includes but is not limited to nurses, home health aides, and therapists.However, multiple professionals may provide services to multiple beneficiaries in the sameresidential setting when it is medically necessary. The Bureau of Health Services Financing(BHSF) will determine medical necessity for fee-for-service beneficiaries. Medical necessity willbe determined by a beneficiary’s managed care organization (MCO) if the beneficiary is enrolledin an MCO.Service limits for Home Health services are as follows: Birth through age 20: No annual service limits; Prior authorization (PA) is required for multiple visits on the same day whenmedically necessary; and PA is required for extended home health services.Ages 21 or older: Medicaid will reimburse only one visit per profession per day. PA is required for all nursing and rehabilitation services in a residentialsetting: Skilled Nursing and Home Health Aide services; Physical Therapy; Occupational Therapy; and Audiology Services.Page 1 of 1Section 23.2

LOUISIANA MEDICAID PROGRAMISSUED:REPLACED:CHAPTER 23: HOME HEALTHSECTION 23.3: BENEFICIARY REQUIREMENTS12/01/1809/20/10PAGE(S) 2BENEFICIARY REQUIREMENTSThe Medicaid beneficiary must meet all eligibility requirements in order to qualify for home healthservices. The home health agency (HHA) providing the service is required to verify beneficiaryeligibility, other insurance coverage, and living arrangements before providing services.General Beneficiary CriteriaThe beneficiary cannot be in a hospital, nursing facility, or intermediate care facility for individua lswith intellectual disabilities (ICF-IID), or any setting in which payment is or could be made underMedicaid for inpatient services that include room and board.Exception: In accordance with 42 CFR Part 483, Subpart I, there are situations in which abeneficiary residing in an ICF-IID may receive home health services. For example, short-termhome health services may be provided to a beneficiary in an ICF-IID during an acute illness toavoid a beneficiary’s transfer to a nursing facility.Medical Necessity CriteriaMedical necessity for home health services must be determined by medical documentation thatsupports the beneficiary’s illness, injury and/or functional limitations. All home health servicesmust be medically reasonable and appropriate. To be considered medically reasonable andappropriate, the care must be necessary to prevent further deterioration of a beneficiary’s conditionregardless of whether the illness/injury is acute, chronic, or terminal.The services must be reasonably determined to: Diagnose, cure, correct, or ameliorate defects, physical and mental illnesses, anddiagnosed conditions of the effects of such conditions; Prevent the worsening of conditions, or the effects of conditions, that endanger lifeor cause pain; results in illness or infirmity; or have caused, or threatened to causea physical or mental dysfunctional impairment, disability or development delay; Effectively reduce the level of direct medical supervision required or reduce thelevel of medical care or services received in an inpatient or residential care setting;Page 1 of 2Section 23.3

LOUISIANA MEDICAID PROGRAMISSUED:REPLACED:CHAPTER 23: HOME HEALTHSECTION 23.3: BENEFICIARY REQUIREMENTS12/01/1809/20/10PAGE(S) 2 Restore or improve physical or mental functionality, including developmentalfunctioning, lost or delayed as the result of an illness, injury, or other diagnosedcondition or the effects of the illness, injury, or condition; or, Provide assistance in gaining access to needed medical, social, educational, andother services required to diagnose, treat, to support a diagnosed condition or theeffects of the condition, in order that the beneficiary might attain or retainindependence, self-care, dignity, self-determination, personal safety and integrationinto family, community, facility environments and activities.Home health skilled nursing and aide services are considered medically reasonable and appropriatewhen the beneficiary’s medical condition and records accurately justify the medical necessity forservices to be provided in the beneficiary’s residential setting rather than in a physician’s office,clinic, or other outpatient setting.Home health services are appropriate when a beneficiary’s illness, injury, or disability causessignificant medical hardship and will interfere with the effectiveness of the treatment if thebeneficiary has to go to a physician’s office, clinic, or other outpatient setting for the neededservice. Any statement on the plan of care (POC) regarding this medical hardship must besupported by the totality of the beneficiary’s medical records.The following circumstances are not considerations when determining medical necessity for homehealth services: Inconvenience to the beneficiary or the beneficiary’s family; Lack of personal transportation; and, Failure or lack of cooperation by the beneficiary or the beneficiary’s legal guardiansor caretakers to obtain the required medical services in an outpatient setting.Page 2 of 2Section 23.3

LOUISIANA MEDICAID PROGRAMISSUED:REPLACED:CHAPTER 23: HOME HEALTHSECTION 23.4: PROVIDER REQUIREMENTS06/20/1912/01/18PAGE(S) 4PROVIDER REQUIREMENTSTo participate in the Home Health Program the providing agency must be Medicare-certified forMedicare/Medicaid by the Licensing and Certification Unit of the Health Standards Section of theLouisiana Department of Health. All providers enrolled in the Louisiana Medicaid Program mustadhere to the conditions of participation as outlined in the provider agreement.All home health services must be provided by staff employed by or under contract with the homehealth agency (HHA) (see LAC 48:I, Chapter 91. Also, refer to 42 CFR 417.416 and Sec 2194 ofthe State Operations Manual CMS Pub. 7 for specific requirements).All staff must meet all required licensure requirements in accordance with Medicaid policies,federal, state and other applicable laws.Provision of ServicesHome health services include medically necessary skilled nursing, rehabilitation (physical,occupational and speech therapies), home health aide and medical supplies provided tobeneficiaries only if the service is provided in the beneficiary’s residential setting or any noninstitutional setting in which normal life activities take place.NOTE: The beneficiary’s residential setting cannot be a hospital, nursing home, or anintermediate care facility for individuals with intellectual disabilities (ICF-IID, with limitedexceptions), or any setting in which payment is or could be made under Medicaid for inpatientservices that include room and board.Plan of CareThe attending physician must certify that the beneficiary meets the medical criteria to receive theservice in the beneficiary’s residential setting and is in need of the home health services on anintermittent basis. The attending physician must order all home health services and sign a plan ofcare (POC) submitted by the HHA on the CMS-485 form. For more information on the FormCMS-485 visit the Centers for Medicare and Medicaid Services (CMS) website (see Appendix D).This certification and the physician’s POC must be maintained in the beneficiary’s record and onfile at the HHA.Page 1 of 4Section 23.4

LOUISIANA MEDICAID PROGRAMCHAPTER 23: HOME HEALTHSECTION 23.4: PROVIDER ) 4Periodic Review of Plan of CareThe physician must reauthorize the POC every 60 days.Face-to-Face Encounter RequirementsFor the initiation of home health services, a face-to-face encounter with the physician and thebeneficiary, or an allowed non-physician practitioner (NPP) and the beneficiary must occur nosooner than 90 days prior to the start of home health services, or no later than 30 days after thestart of home health services.Evidence of the face-to-face encounter is required by the DXC Technology Prior AuthorizationUnit (PAU) for routine skilled nursing and home health aide services for beneficiaries age 21 andolder. If providers do not have this documentation prior to the initiation of services then the initialPrior Authorization (PA) request must be for 30 days only. Providers must submit documentationof the face-to-face encounter with the new PA request in order for services to be approved.Providers should refer to Section 23.5- Prior Authorization for information related to PArequirements.For the initiation of medical equipment, the face-to-face encounter must be related to the primaryreason the beneficiary requires medical equipment and must occur no more than six months priorto the start of services.Providers should refer to Section 23.5 Prior Authorization for information related to PArequirements.Any of the following will be accepted by the PAU as evidence of a face-to-face encounter betweena physician and the beneficiary, or an allowed NPP and the beneficiary: A written statement on the certifying physician’s letterhead or prescription padattesting to a face-to-face encounter between the physician and the beneficiary oran allowed NPP and the beneficiary; or The HHA’s face-to-face encounter form that the HHA requires the beneficiary’scertifying physician to complete as a routine business practice; or Medical notes or documentation from the physician or an allowed NPPdemonstrating evidence of a face-to-face encounter within the required timeframe.Documentation of a face-to-face encounter as detailed above must be kept in the beneficiary’srecord for ALL home health service related requests, including therapy services, medicalequipment and supplies, and services for beneficiaries under the age of 21.Page 2 of 4Section 23.4

LOUISIANA MEDICAID PROGRAMISSUED:REPLACED:CHAPTER 23: HOME HEALTHSECTION 23.4: PROVIDER REQUIREMENTS06/20/1912/01/18PAGE(S) 4The face-to-face encounter may be conducted by one of the following practitioners: The beneficiary’s physician; A nurse practitioner or clinical nurse specialist, working in collaboration with thebeneficiary’s physician; A physician assistant under the supervision of the beneficiary’s physician; A certified nurse -midwife, as defined in section 1861(gg) of the Social SecurityAct; or The attending acute or post-acute physician for beneficiaries admitted to homehealth immediately after an acute or post-acute stay.The allowed NPP performing the face-to-face encounter must communicate the clinical findingsof the encounter to the ordering physician. Those clinical findings must be incorporated into thebeneficiary’s medical record.The physician responsible for ordering the services must: Document that the face-to-face encounter which is related to the primary reason thebeneficiary requires home health services, occurred within the required andspecified timeframes above; Identify the practitioner who conducted the encounter; and Indicate the date of the face-to-face encounter.Required Assistance to BeneficiariesIn an effort to assist beneficiaries in locating a provider to submit a prior authorization request formedically necessary home health services, the beneficiary may contact Medicaid for assistance(see Contact/Referral Information, Appendix D).In addition, the Bureau of Health Services Financing (BHSF) may conduct surveys withbeneficiaries who have been authorized to receive extended home health services. The purpose ofthese surveys is to ensure that BHSF will contact the appropriate provider to determine whatPage 3 of 4Section 23.4

LOUISIANA MEDICAID PROGRAMISSUED:REPLACED:CHAPTER 23: HOME HEALTHSECTION 23.4: PROVIDER REQUIREMENTS06/20/1912/01/18PAGE(S) 4additional assistance may be required to ensure access to the authorized services.Emergency Preparedness PlanThe HHA must have an emergency preparedness plan that conforms to the current LouisianaOffice of Emergency Preparedness (OEP) model plan. The plan is designed to manage theconsequences of declared disasters or other emergencies that disrupt the HHAs ability to providecare and treatment or threaten the lives or safety of its clients.The HHA is responsible for obtaining a copy of the current Home Health Emergency PreparednessModel Plan from OEP (see Contact/Referral Information, Appendix D).Additionally, per CMS, the HHA must comply with the reporting requirements of the At-RiskRegistry. The HHA shall update the “Louisiana At-risk Registry” or other current state-requiredreporting mechanism as needed or as required.At a minimum, the HHA must have a written plan that includes: The evacuation procedures for agency clients who require community assistance aswell as for those with avai

Medicaid) requires only home health aide visits.Medicare will not pay for this service unless skilled services (sing service, physical therapy, killed nurs or speechoccupational therapy - language therapy) are also required. However, Medicaid will reimburse for home health aide visits if only home health aide visits are required.