DAR File No. 27733

Health, Health Care Financing, Coverage and Reimbursement Policy

R414-14

Home Health Service

NOTICE OF PROPOSED RULE

DAR File No.: 27733
Filed: 02/28/2005, 12:06
Received by: NL

RULE ANALYSIS

Purpose of the rule or reason for the change:

As required by recent legislation found in Subsection 26-18-3(2)(a), this rulemaking is necessary to implement by rule the home health services program that was previously implemented by policy.

Summary of the rule or change:

Section R414-14-0 is renumbered to Section R414-14-1. Also, the words "homebound" or "semi-homebound" are replaced by "eligible" to describe persons who are eligible for home health services. This section also adds language that specifies that these services are provided only when the home is the most appropriate and cost effective setting that is consistent with the client's medical need. In addition, this section states the goals of home health care, which are to minimize the effects of disability, maintain health, and prevent inappropriate institutionalization. The state and federal citations that govern this rulemaking are also included. The old Section R414-14-1 is deleted. In Section R414-14-2, the definition of "Home Health Visit" is deleted. In Section R414-14-3, the title is changed from "Eligibility Requirements/Coverage" to "Client Eligibility Requirements". In Section R414-14-4, language is added that describes the "plan of care" criteria for home health services. In Section R414-14-5, the term "semi-homebound" is removed in reference to supportive maintenance home health care. Also, "plan of care" text is deleted because part of the text already exists in Section R414-14-4. Other "plan of care" text is deleted from Section R414-14-5 and now included in Section R414-14-4. Further, text deleted from Section R414-14-7 is added to Section R414-14-5. Finally, language is added in Subsections R414-14-5(9), (11), and (15) that specifies the limitations of supportive maintenance home health care, makes clear that only one home health provider (agency) is approved to provide service to a patient during any period of time, states that a subcontractor may provide service as long as the original agency bills for services, denies a second provider or agency approval of service, and makes an exception for children to receive occupational therapy who are covered under Child Health Evaluation Care (CHEC) for medically necessary services. Sections R414-14-6, R414-14-7, and R414-14-8 are deleted. Section R414-14-9 is renumbered to R414-14-6.

State statutory or constitutional authorization for this rule:

Sections 26-1-5 and 26-18-3, and 42 CFR 440.70

Anticipated cost or savings to:

the state budget:

There is no impact to the state budget associated with this rulemaking because the policy for service determinations is simply being implemented in rule pursuant to recent legislation found in Subsection 26-18-3(2)(a).

local governments:

There is no budget impact to local governments as a result of this rulemaking because the policy for service determinations is simply being implemented in rule pursuant to recent legislation found in Subsection 26-18-3(2)(a).

other persons:

There is no budget impact to other persons as a result of this rulemaking because the policy for service determinations is simply being implemented in rule pursuant to recent legislation found in Subsection 26-18-3(2)(a).

Compliance costs for affected persons:

There are no compliance costs because the policy for service determinations is simply being implemented in rule pursuant to recent legislation found in Subsection 26-18-3(2)(a).

Comments by the department head on the fiscal impact the rule may have on businesses:

The Department of Health and providers favor this rulemaking because home health is a growing service area and this rule removes restrictive definitions, clarifies eligibility for service, clarifies program goals, and emphasizes medical necessity and appropriateness as the basis for approval of service. No fiscal impact because this rule mirrors current policy on this program area. David N. Sundwall, MD

The full text of this rule may be inspected, during regular business hours, at the Division of Administrative Rules, or at:

Direct questions regarding this rule to:

Craig Devashrayee at the above address, by phone at 801-538-6641, by FAX at 801-538-6099, or by Internet E-mail at cdevashrayee@utah.gov

Interested persons may present their views on this rule by submitting written comments to the address above no later than 5:00 p.m. on:

04/14/2005

This rule may become effective on:

04/15/2005

Authorized by:

David N. Sundwall, Executive Director

RULE TEXT

R414. Health, Health Care Financing, Coverage and Reimbursement Policy.

R414-14. Home Health Service.

R414-14-[0]1. [Policy Statement]Introduction and Authority.

[A.]1. Home health services are part-time intermittent health care services[,] that are based on medical necessity[,] and provided to [homebound or semi-homebound]eligible persons in their [permanent ]places of residence [as an alternative to institutional care]when the home is the most appropriate and cost effective setting that is consistent with the client's medical need. The goals of home health care are to minimize the effects of disability or pain; promote, maintain, or protect health; and prevent premature or inappropriate institutionalization.[ Home health services are provided by a public or private state licensed, Medicare certified home health agency. Home health services are based on physician order and plan of care.]

[B. A hospital, skilled nursing facility, or intermediate care facility does not qualify as a person's place of residence for the purpose of receiving home health service.]2. This rule is authorized under Utah Code 26-18-3 and governs the services allowed under 42 CFR 440.70.

[R414-14-1. Authority and Purpose.

A. Authority

1. Home health service is a required Medicaid, Title XIX program authorized by Section 1901 et seq., of the Social Security Act, Section 1905(a)(7) of the Social Security Act and 42 CFR 440.70.

2. This rule is also authorized by Utah Code Annotated Sections 26-1-4.1, 26-1-5, and 26-18-3.

B. Purpose

The purpose of home health care is to provide skilled or supportive care to patients in their place of residence as an alternative to premature or inappropriate institutionalization. Home health care must minimize the effects of disability or pain and promote, maintain, or protect health while allowing individuals to live at home in personal dignity and independence.

]R414-14-2. Definitions.

[A]1. "Home health agency" means a public agency or private organization[, which]that is licensed by the [Bureau of Health Facility Licensure ]Department as a home health agency under the authority of Utah Code[ Annotated,] Title 26, Chapter 21, and in accordance with Utah Administrative Code [1989, ]R432-700. A home health agency is primarily engaged in providing skilled nursing service and other therapeutic services.[

B. "Home Health Visit" means a personal contact in the place of residence of a patient made for the purpose of providing a covered service by appropriate personnel under the supervision of a home health agency.]

[C]2. "Plan of Care" means a written plan developed cooperatively by home health agency staff and the attending physician. The plan is designed to meet specific needs of an individual, is based on orders written by the attending physician, and is approved and periodically reviewed and updated by the attending physician.

[D]3. "Prior authorization" means that degree of approval for payment of services required to be obtained from Division of Health Care Financing staff by a licensed provider before the service is provided.

R414-14-3. Client Eligibility Requirements[/Coverage].

Home health services are available to categorically eligible and medically needy individuals.

R414-14-4. Program Access Requirements.

[A]1. Home health service shall be provided only to an individual who is under the care of a physician. The attending physician shall write the orders on which a plan of care is established and certify the necessity for home health services.

[B]2. The home health agency [shall ]may accept a recipient for home health care only if there is [basis of ]a reasonable expectation that a recipient's needs can be met adequately by the agency in the recipient's place of residence.

3. The attending physician and home health agency personnel must review and sign a total plan of care shall as often as the severity of the patient's condition requires, but at least once every 60 days in accordance with 42 CFR 440.70.

4. The home health agency must provide quality, cost-effective care and a safe environment in the home through registered or licensed practical nurses who have adequate training, knowledge, judgement, and skill.

5. Home health aide services may only be provided pursuant to written instructions and under the supervision of a registered nurse by a person selected and trained to assist with routine care not requiring specialized nursing skills.

6. Over the long term service period, the cost to provide the required care and service in the patient's home must be no greater than the cost to meet the client's medical needs in an alternative setting.

7. A home health agency may provide an initial assessment visit without prior authorization to assess the patient's needs and establish a plan of care. After the initial visit, all home health care and service must be based on prior authorization.

R414-14-5. Service Coverage.

[A. Home health service shall be provided to a patient who is under the care of a physician who certifies the necessity for home health service and writes orders on which a plan of care can be developed.

B. The total plan of care shall be reviewed and signed by the attending physician and home health agency personnel as often as the severity of the patient's condition requires, but at least once every 60 days in accordance with 42 CFR 440.70.

C]1. Two levels of home health service are covered: Skilled Home Health Care and Supportive Maintenance Home Health Care.

[D]2. Skilled nursing service encompasses the expert application of nursing theory, practice and techniques by a registered professional nurse to meet the needs of patients in their place of residence through professional judgments, through independently solving patient care problems, and through application of standardized procedures and medically delegated techniques.

[E]3. Home health aide service encompasses assistance with, or direct provision of, routine care not requiring specialized nursing skill. The home health aide is closely supervised by a registered, professional nurse to assure competent care. The aide works under written instructions [for care to be provided]and provides necessary care for the patient.

[F]4. Supportive maintenance home health care serves those patients [who are semi-homebound, ]who have a medical condition which has stabilized, but who demonstrate continuing health problems requiring minimal assistance, observation, teaching, or follow-up. This assistance can be provided by a certified home health agency through the knowledge and skill of a licensed practical nurse (LPN) or a home health aide with periodic supervision by a registered nurse. A physician continues to provide direction.

[G]5. IV therapy, enteral and parenteral nutrition therapy are provided as a home health service either in conjunction with skilled or maintenance care or as the only service to be provided. Specific policy is outlined in the medical supplies program[,] and all requirements of the home health program must be met in relation to orders, plan of care, and 60 day review and recertification.

[H]6. [Therapy services: p]Physical therapy and speech pathology services are occasionally indicated and approved for the patient needing home health service. Any therapy services offered by the home health agency directly or under arrangement must be ordered by a physician and provided by a qualified licensed therapist in accordance with the plan of care.

[I]7. Medical supplies utilized for home health service must be suitable for use in the home in providing home health care, consistent with physician orders, and approved as part of the plan of care.

8. Medical supplies provided by the home health agency do not require prior approval, but are limited to:

(a) supplies used during the initial visit to establish the plan of care;

(b) supplies that are consistent with the plan of care; and

(c) non-durable medical equipment.

9. Supportive maintenance home health care is limited in time equal to one visit per day determined by care needs and care giver participation.

10. A registered nurse employed by an approved, certified home health agency must supervise all home health services. Nursing service and all approved therapy services must be provided by the appropriate licensed professional.

11. Only one home health provider (agency) may provide service to a patient during any period of time. However, a subcontractor of a home health provider may provide service if the original agency is the only provider that bills for services. A second provider or agency requesting approval of service will be denied.

12. Home health care provided to a patient capable of self care is not a covered Medicaid benefit.

13. Personal care services, except as determined necessary in providing skilled care, is not a covered home health benefit.

14. Housekeeping or homemaking services are not covered home health benefits.

15. Occupational therapy is not a covered Medicaid benefit except for children covered under CHEC for medically necessary service.

16. Home health nursing service beyond the initial evaluation visit requires prior authorization.

17. All home health service beyond the initial visit, including supplies and therapies, shall be in the plan of care that the home health agency submits for prior authorization. Prior to providing the service, the home health agency must first obtain approval for the level of skilled or maintenance service based on the prior authorization request and a review of the plan of care. If level of service needs change, the home health agency must submit a new prior authorization request.

18. A home health agency may provide therapy services only in accordance with medical necessity and after receiving prior authorization.

[R414-14-6. Standards of Care.

A. Home health service shall be provided in accordance with 42 CFR 440.70, which is hereby adopted and incorporated by reference.

B. Quality, cost-effective care and a safe environment in the home shall be provided through adequate training, knowledge, judgement, and skill of the registered nurse or licensed practical nurse licensed in the State of Utah in accordance with Title 58, Chapter 31 Utah Code Annotated.

C. Home health aide services shall be provided through written instructions and under the supervision of a registered professional nurse by a person selected and trained to assist with routine care not requiring specialized nursing skills.

R414-14-7. Limitations.

A. Home health service must be cost effective. It must cost less, over the long term service period, to provide the required care and service in the patient's home than it would cost to meet the medical needs in an alternative setting.

B. Home health service must be based on physician orders and a plan of care reviewed and recertified every 60 days, or more frequently if patient condition indicates.

C. An initial assessment visit may be provided without prior authorization to assess the patient's needs and establish the plan of care. After the initial visit, all home health care and service must be based on prior authorization.

D. Medical supplies provided by the home health agency do not require prior approval, but are limited to:

1. Supplies used during the initial visit to establish the plan of care.

2. Supplies that are consistent with the plan of care.

3. Non-durable equipment.

E. Supportive maintenance home health care is limited to one visit per day.

F. All home health service must be supervised by a registered nurse employed by an approved, certified home health agency. Nursing service and all approved therapy services must be provided by the appropriate licensed professional.

G. Home health care provided to a patient capable of self care is not a covered Medicaid benefit.

H. Personal care services, except as determined necessary in providing skilled care, is not a covered home health benefit.

I. Housekeeping or homemaking services are not covered home health benefits.

J. Occupational therapy is not a covered Medicaid benefit.

R414-14-8. Prior Authorization.

A. Home health nursing service beyond the initial evaluation visit requires prior authorization.

B. All home health service beyond the initial visit, including supplies and therapies, shall be specified in the plan of care submitted for prior authorization by the home health agency selected by the patient to provide the service. The level of service, e.g., skilled or maintenance service, will be established and approved based on the prior authorization request. When level of service needs change, a new prior authorization request must be submitted.

C. Therapy services shall be supported by medical need and by prior authorization before any service is provided.

]R414-14-[9]6. Reimbursement for Services.

Reimbursement for home health services shall be provided as documented in the Utah State Medicaid Plan, ATTACHMENT 4.19-B. The fee schedule was established after examining usual and customary charges in the industry, applying appropriate discounts, and relying on professional judgment.

KEY: M[m]edicaid

[1989]2005

Notice of Continuation October 6, 2004

[26-1-4.1]

26-1-5

26-18-3

ADDITIONAL INFORMATION

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For questions regarding the content or application of this rule, please contact Craig Devashrayee at the above address, by phone at 801-538-6641, by FAX at 801-538-6099, or by Internet E-mail at cdevashrayee@utah.gov

For questions about the rulemaking process, please contact the Division of Administrative Rules (801-538-3764). Please Note: The Division of Administrative Rules is NOT able to answer questions about the content or application of these administrative rules.