Cal. Code Regs. Tit. 22, § 51337 - Home Health Agency Services
(a) Home health agency services are covered
as specified below when prescribed by a physician and provided at the home of
the beneficiary in accordance with a written treatment plan which the physician
reviews every 60 days. The plan shall indicate a need for one or more of the
following:
(1) Part-time or intermittent
skilled nursing services by licensed nursing personnel.
(2) In-home medical care services as provided
in Section
14132(t)
of the Welfare and Institutions Code.
(3) Physical, occupational, or speech
therapy.
(4) Medical social
services.
(5) The services of a
home health aide.
(6) Provision of
medical supplies, other than drugs and biologicals.
(7) The use of medical appliances, provided
for under an approved treatment plan.
(b) One visit in a six-month period for
evaluation of the patient is covered without prior authorization. More than one
visit in a six-month period is subject to prior authorization. The request for
prior authorization for additional visits shall be accompanied by a written
treatment plan approved and signed by the physician. This shall include the
following:
(1) The principal diagnosis and
significant associated diagnoses.
(2) Prognosis.
(3) Date of onset of the illness.
(4) Specific types of services to be rendered
by each discipline.
(5) The
therapeutic goals to be achieved by each discipline, and anticipated time for
achievement of goals.
(6) The
extent to which home health agency care has been previously provided, and
benefits or improvements demonstrated by prior care.
(7) A description of the home situation, to
include whether assistance is available from household members, homemakers,
attendants, or others.
(8) A
reauthorization request shall include a statement describing the patient's
progress toward achieving the therapeutic goals.
(c) One early discharge visit is covered
without prior authorization when the requirements of Section
51327(b) are
met.
(d) Authorizations may be
granted for home health agency services only when the beneficiary's medical
condition requires either home nursing care or other covered service, exclusive
of physician services.
(e) A
maximum of 30 visits may be authorized at any one time and authorizations shall
be valid for up to 120 days. When the Department contracts with an agency to
provide in-home medical services, the scope, duration, and cost of services
will be defined in a written agreement between the provider agency and the
Department of Health Services.
(f)
In areas serviced by a home health agency, all home health agency services
shall be limited to those provided by approved home health agencies as defined
in Sections
51125,
51145 and
51217.
(g) In areas determined by the Director not
to be serviced by a home health agency, part-time or intermittent skilled
nursing care may be furnished by any qualified provider using the services of a
registered nurse. These services shall be subject to the same limitations as
described in this section and to the same requirements for prior authorization
and reimbursement as home health agency services.
Notes
2. Amendment filed 7-24-79 as an emergency; effective upon filing (Register 79,No. 30).
3. Certificate of Compliance transmitted to OAH 11-20-79 and filed 11-29-79 (Register 79, No. 48).
4. Amendment filed 7-7-86; effective thirtieth day thereafter (Register 86, No. 28).
5. Editorial correction of subsection (c) (Register 95, No. 45).
6. New subsection (c), subsection relettering and amendment of NOTE filed 3-13-2000 as an emergency; operative 3-13-2000 (Register 2000, No. 11). A Certificate of Compliance must be transmitted to OAL by 7-11-2000 or emergency language will be repealed by operation of law on the following day.
7. Certificate of Compliance as to 3-13-2000 order transmitted to OAL 7-5-2000 and filed 8-14-2000 (Register 2000, No. 33).
Note: Authority cited: Sections 10725, 14105 and 14124.5, Welfare and Institutions Code; and Section 100275, Health and Safety Code. Reference: Sections 14132 and 14132.42, Welfare and Institutions Code; and Section 1727, Health and Safety Code.
2. Amendment filed 7-24-79 as an emergency; effective upon filing (Register 79,No. 30).
3. Certificate of Compliance transmitted to OAH 11-20-79 and filed 11-29-79 (Register 79, No. 48).
4. Amendment filed 7-7-86; effective thirtieth day thereafter (Register 86, No. 28).
5. Editorial correction of subsection (c) (Register 95, No. 45).
6. New subsection (c), subsection relettering and amendment of Note filed 3-13-2000 as an emergency; operative 3-13-2000 (Register 2000, No. 11). A Certificate of Compliance must be transmitted to OAL by 7-11-2000 or emergency language will be repealed by operation of law on the following day.
7. Certificate of Compliance as to 3-13-2000 order transmitted to OAL 7-5-2000 and filed 8-14-2000 (Register 2000, No. 33).
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