RELATES TO:
KRS
205.622,
216.935,
216.936,
216.937,
216.9375,
216.939,
369.101369.120,
42 C.F.R.
431.17,
440.70,
447.325,
484.115,
45 C.F.R.
164.316,
42 U.S.C.
1396a -d
NECESSITY, FUNCTION, AND CONFORMITY: The Cabinet for Health and
Family Services, Department for Medicaid Services, has responsibility to
administer the Medicaid Program.
KRS
205.520(3) authorizes the
cabinet, by administrative regulation, to comply with any requirement that may
be imposed or opportunity presented by federal law to qualify for federal
Medicaid funds. This administrative regulation establishes the coverage
provisions and requirements relating to Medicaid Program home health care
services.
Section 1. Definitions.
(1) "Department" means the Department for
Medicaid Services or its designee.
(2) "Electronic signature" is defined by
KRS
369.102(8).
(3) "Enrollee" means a recipient who is
enrolled with a managed care organization.
(4) "Federal financial participation" is
defined by
42 C.F.R.
400.203.
(5) "Home health agency" or "HHA" means:
(a) An agency defined pursuant to
42 C.F.R.
440.70(d); and
(b) A Medicare and Medicaid-certified agency
licensed in accordance with
902 KAR
20:081.
(6) "Home health aide" is defined by
KRS
216.935(3).
(7) "Licensed practical nurse" or "LPN" means
a person who is licensed in accordance with
KRS
314.051.
(8) "Managed care organization" means an
entity for which the Department for Medicaid Services has contracted to serve
as a managed care organization as defined in
42
C.F.R.
438.2.
(9) "Medical social worker" means a person
who meets the medical social worker requirements as established in
902 KAR
20:081.
(10) "Medically necessary" or "medical
necessity" means that a covered benefit is determined to be needed in
accordance with
907
KAR 3:130.
(11) "Nursing service" means the delivery of
medication, or treatment by a registered nurse or a licensed practical nurse
supervised by a registered nurse, consistent with KRS Chapter 314 scope of
practice provisions and the Kentucky Board of Nursing scope of practice
determination guidelines.
(12)
"Occupational therapist" is defined by
KRS
319A.010(3).
(13) "Occupational therapy assistant" is
defined by
KRS
319A.010(4).
(14) "Physical therapist" is defined by
KRS
327.010(2).
(15) "Physical therapist assistant" means a
skilled health care worker who:
(a) Is
certified by the Kentucky Board of Physical Therapy; and
(b) Performs physical therapy services and
related duties as assigned by the supervising physical therapist.
(16) "Place of residence" means,
excluding a hospital or nursing facility, the location at which a recipient
resides.
(17) "Plan of care" means
a written plan which shall:
(a) Stipulate the
type, nature, frequency and duration of a service; and
(b) At least every sixty (60) days, be
reviewed and signed by a HHA staff person and physician, advanced practice
registered nurse, or physician assistant.
(18) "Provider" is defined by
KRS
205.8451(7).
(19) "Qualified medical social worker" means
a person who meets the qualified medical social worker requirements as
established in
902 KAR
20:081.
(20) "Qualified social work assistant" means
a social work assistant as defined in
42 C.F.R.
484.115.
(21) "Recipient" is defined by
KRS
205.8451(9).
(22) "Registered nurse" or "RN" is defined by
KRS
314.011(5).
(23) "Speech-language pathologist" is defined
by
KRS
334A.020(3).
(24) "Speech-language pathology assistant" is
defined by
KRS
334A.020(8).
Section 2. Conditions of
Participation.
(1) In order to provide home
health services, a provider shall:
(a) Be an
HHA; and
(b) Comply with:
4.
All applicable state and federal laws; and
5. The Home Health Services Manual.
(2)
(a) A home health provider shall maintain a
medical record for each recipient for whom services are provided.
(b) A medical record shall:
1. Document each service provided to the
recipient including the date of the service and the signature of the individual
who provided the service;
2.
Contain a copy of the plan of care;
3. Document verbal orders from the physician,
advanced practice registered nurse, or physician assistant, if
applicable;
4. Except as
established in paragraph (d) of this subsection, be retained for a minimum of
five (5) years from the date a covered service is provided or until any audit
dispute or issue is resolved beyond five (5) years;
5. Be kept in an organized central file
within the HHA; and
6. Be made
available to the department upon request.
(c) The individual who provided a service
shall date and sign the health record on the date that the individual provided
the service.
(d)
1. If the secretary of the United States
Department of Health and Human Services requires a longer document retention
period than the period referenced in paragraph (b)4. of this section, pursuant
to
42 C.F.R.
431.17, the period established by the
secretary shall be the required period.
2. In the case of a recipient who is a minor,
the recipient's medical record shall be retained for three (3) years after the
recipient reaches the age of majority under state law or the length established
in paragraph (b)4 of this subsection or subparagraph 1 of this paragraph,
whichever is longest.
(3) A provider shall comply with 45 C.F.R.
Part
164 .
(4)
(a) If a provider receives any duplicate
payment or overpayment from the department, regardless of reason, the provider
shall return the payment to the department.
(b) Failure to return a payment to the
department in accordance with paragraph (a) of this section may be:
1. Interpreted to be fraud or abuse;
and
2. Prosecuted in accordance
with applicable federal or state law.
Section 3. Covered Services.
(1) A home health service shall be:
(a) Prior authorized by the department to
ensure that the service or modification of the service is medically necessary
and adequate for the needs of the recipient;
(b) Provided pursuant to a plan of care;
and
(c) Provided in a recipient's
place of residence.
(2)
The following services provided to a recipient by a home health provider who
meets the requirements in Section 2 of this administrative regulation shall be
covered by the department:
(a) A nursing
service which shall:
1. Include part-time or
intermittent nursing services; and
2. If provided daily, be limited to thirty
(30) days unless additional days are prior authorized by the
department;
(b) A
therapy service which shall:
1. Include
physical therapy services provided by a physical therapist or a physical
therapist assistant who is under the supervision of a physical
therapist;
2. Include occupational
therapy services provided by an occupational therapist or an occupational
therapy assistant who is under the supervision of an occupational
therapist;
3. Include
speech-language pathology services provided by a speech-language pathologist or
a speech-language pathology assistant who is under the supervision of a
speech-language pathologist;
4. Be
provided pursuant to a plan of treatment which shall be developed by the
appropriate therapist and physician, advanced practice registered nurse, or
physician assistant;
6. Comply with the:
a. Physical therapy service requirements
established in the:
(i) Technical Criteria for
Reviewing Ancillary Services for Adults if the therapy service is a physical
therapy service provided to an adult; or
(ii) Technical Criteria for Reviewing
Ancillary Services for Pediatrics if the therapy service is a physical therapy
service provided to a child;
b. Occupational therapy requirements
established in the:
(i) Technical Criteria for
Reviewing Ancillary Services for Adults if the therapy service is an
occupational therapy service provided to an adult; or
(ii) Technical Criteria for Reviewing
Ancillary Services for Pediatrics if the therapy service is an occupational
therapy service provided to a child; or
c. Speech-language pathology service
requirements established in the:
(i) Technical
Criteria for Reviewing Ancillary Services for Adults if the service is a
speechlanguage pathology service provided to an adult; or
(ii) Technical Criteria for Reviewing
Ancillary Services for Pediatrics if the service is a speechlanguage pathology
service provided to a child;
(c) A home health aide service which shall:
1. Include the performance of simple
procedures as an extension of therapy services, personal care, range of motion
exercises and ambulation, assistance with medications that are ordinarily
self-administered, reporting a change in the recipient's condition and needs,
incidental household services which are essential to the recipient's health
care at home when provided in the course of a regular visit, and completing
appropriate records;
2. Be provided
by a home health aide who is supervised at least every fourteen (14) days by:
a. An RN;
b. A physical therapist, for any physical
therapy services that are provided by the home health aide;
c. An occupational therapist, for any
occupational therapy services that are provided by the home health aide;
or
d. A speech-language
pathologist, for any speech-language pathology services that are provided by
the home health aide; and
3. Be a service that the recipient is either
physically or mentally unable to perform;
(d) A medical social service which shall:
1. Be provided by a qualified medical social
worker or qualified social work assistant; and
2. Be provided in conjunction with at least
one (1) other service listed in this section;
(e) A supply listed on the Home Health
Schedule of Supplies, which shall be covered if provided to a recipient
pursuant to the recipient's plan of care; or
(f) A supplemental nutritional product listed
on the Home Health Schedule of Supplies, which shall:
1. Be ingested orally or delivered by tube
into the gastrointestinal tract;
2.
Provide for the supplemental nutrition of a recipient; and
3. Require a completed MAP-248 signed by a
physician, advanced practice registered nurse, or physician assistant
certifying the medical necessity of the supplemental nutritional
product.
Section 4. Limitations and Exclusions from
Coverage.
(1) A domestic or housekeeping
service which is unrelated to the health care of a recipient shall not be
covered.
(2) A medical social
service shall not be covered unless provided in conjunction with another
service pursuant to Section 3 of this administrative regulation.
(3) Supplies for personal hygiene shall not
be covered.
(4) Drugs shall not be
covered.
(5) Disposable diapers
shall not be covered for a recipient age three (3) years and under, regardless
of the recipient's medical condition.
(6) Except for the first week following a
home delivery, a newborn or postpartum service without the presence of a
medical complication shall not be covered.
(7) A recipient who has elected to receive
hospice care shall not be eligible to receive coverage under the home health
program.
(8)
(a) There shall be an annual limit of twenty
(20):
1. Occupational therapy service visits
per recipient per calendar year except as established in paragraph (b) of this
subsection;
2. Physical therapy
service visits per recipient per calendar year except as established in
paragraph (b) of this subsection; and
3. Speech-language pathology service visits
per recipient per calendar year except as established in paragraph (b) of this
subsection.
(b) The
limits established in paragraph (a) of this subsection may be exceeded if
services in excess of the limits are determined to be medically necessary by
the:
1. Department if the recipient is not
enrolled with a managed care organization; or
2. Managed care organization in which the
enrollee is enrolled if the recipient is an enrollee.
(c) Prior authorization by the department
shall be required for each visit that exceeds the limit established in
paragraph (a) of this subsection for a recipient who is not enrolled with a
managed care organization.
Section 5. No Duplication of Service.
(1) The department shall not reimburse for a
service provided to a recipient by more than one (1) provider of any program in
which the service is covered during the same time period.
(2) For example, if a recipient is receiving
a speech-language pathology service from a speech-language pathologist enrolled
with the Medicaid Program, the department shall not reimburse for a
speech-language pathology service provided to the same recipient during the
same time period via the home health services program.
Section 6. Third Party Liability. A provider
shall comply with
KRS
205.622.
Section 7. Use of Electronic Signatures.
(1) The creation, transmission, storage, and
other use of electronic signatures and documents shall comply with the
requirements established in
KRS
369.101 to
369.120.
(2) A provider that chooses to use electronic
signatures shall:
(a) Develop and implement a
written security policy that shall:
1. Be
adhered to by each of the provider's employees, officers, agents, or
contractors;
2. Identify each
electronic signature for which an individual has access; and
3. Ensure that each electronic signature is
created, transmitted, and stored in a secure fashion;
(b) Develop a consent form that shall:
1. Be completed and executed by each
individual using an electronic signature;
2. Attest to the signature's authenticity;
and
3. Include a statement
indicating that the individual has been notified of his or her responsibility
in allowing the use of the electronic signature; and
(c) Provide the department, immediately upon
request, with:
1. A copy of the provider's
electronic signature policy;
2. The
signed consent form; and
3. The
original filed signature.
Section 8. Auditing Authority. The department
shall have the authority to audit any claim, medical record, or documentation
associated with any claim or medical record.
Section 9. Federal Approval and Federal
Financial Participation. The department's coverage of services pursuant to this
administrative regulation shall be contingent upon:
(1) Receipt of federal financial
participation for the coverage; and
(2) Centers for Medicare and Medicaid
Services' approval for the coverage.
Section 10. Appeal Rights.
(1) An appeal of an adverse action taken by
the department regarding a service and a recipient who is not enrolled with a
managed care organization shall be in accordance with
907
KAR 1:563.
(2) An appeal of an adverse action by a
managed care organization regarding a service and an enrollee shall be in
accordance with
907
KAR 17:010.
Section 11. Incorporation by Reference.
(1) The following material is incorporated by
reference:
(a) "MAP-248", August
2021;
(b) "Home Health Services
Manual", May 2014;
(c) "Technical
Criteria for Reviewing Ancillary Services for Adults", February 2000;
(d) "Technical Criteria for Reviewing
Ancillary Services for Pediatrics", April 2000; and
(e) "Home Health Schedule of Supplies", May
2014.
(2) This material
may be inspected, copied, or obtained, subject to applicable copyright law, at:
(a) The Department for Medicaid Services, 275
East Main Street, Frankfort, Kentucky 40621, Monday through Friday 8 a.m. to
4:30 p.m.; or