405 IAC 5-16-3.1 - Home health agency services; limitations
Authority: IC 12-15
Affected: IC 12-13-7-3; IC 12-15-13-6
Sec. 3.1.
(a) In
addition to the prior authorization requirements as outlined in section 3 of
this rule, services provided by a registered nurse, licensed practical nurse,
home health aide, or renal dialysis aide employed by a home health agency must
be as follows:
(1) Prescribed or ordered in
writing by a physician.
(2)
Provided in accordance with a written plan of treatment developed by the
attending physician.
(3)
Intermittent or part time, except for ventilator-dependent patients who have a
developed plan of home health care.
(4) Health-related nursing care. Homemaker,
chore services, and sitter/companion service are not covered, except as
specified under applicable Medicaid waiver programs.
(5) Medically necessary.
(6) Less expensive than any alternate modes
of care.
(b) In addition
to the prior authorization requirements as outlined in section 3 of this rule,
physical therapy, occupational therapy, respiratory therapy, and speech
pathology must be as follows:
(1) Provided by
an appropriately licensed, certified, or registered therapist employed or
contracted by the home health agency.
(2) Ordered or prescribed in writing by a
provider in accordance with
405 IAC
5-22-6(b)(1).
(3) Provided in accordance with a written
plan of treatment developed cooperatively between the therapist and the
attending physician.
(4) Medically
necessary. Educational activities, such as the remediation of learning
disabilities, are not covered by Medicaid.
(5) Provided in accordance with
405 IAC 5-22.
(c) Nursing services, which do not meet the
definition of emergency services at
405 IAC 5-2-9, are covered
without prior authorization when provided to a member for whom home health
services have been currently authorized when the attending physician orders a
one (1) time home visit due to a change in the patient's medical condition to
prevent deterioration of the patient's medical condition, for example,
reanchoring a foley catheter, obtaining a laboratory specimen, administering an
injection, or assessing a reported change with signs and symptoms of potential
for serious deterioration.
(d) In
addition to the limitations as outlined in subsection (a) and section 3 of this
rule, telehealth services provided by a home health agency are subject to the
following requirements:
(1) The member must
be receiving home health services.
(2) To initially qualify for telehealth
services, the member must have had two (2) or more of the following events
related to one (1) of the conditions listed in subdivision (3) within the
previous twelve (12) months:
(A) An emergency
room visit.
(B) An inpatient
hospital stay.
(3) The
member must have one (1) or more of the following conditions:
(A) Chronic obstructive pulmonary
disease.
(B) Congestive heart
failure.
(C) Diabetes.
Additional qualifying conditions may be added by the office upon satisfying the notice requirements set forth in IC 12-15-13-6.
(4) An emergency room
visit resulting in an inpatient hospital admission does not constitute two (2)
separate events for purposes of meeting the requirements of subdivision
(2).
(5) In any telehealth
encounter, a licensed registered nurse must perform the reading of transmitted
health information provided to the member in accordance with the written order
of the physician.
(e)
Home health services are reimbursable only if the treating physician certifying
the need for home health services documents that there was a face-to-face
encounter with the individual as outlined in section 2(b) of this rule.
Notes
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