Ohio Admin. Code 4123-6-38.1 - Payment for nursing and caregiver services provided by persons other than home health agency employees
(A) Nursing services provided prior to
December 14, 1992.
(1) Registered nurses and
licensed practical nurses who are not employed by a
medicare certified, joint commission accredited, or community health
accreditation program (CHAP) accredited home health agency, or a home
health agency accredited through an organization
that has been granted deeming authority by the centers for medicare and
medicaid services (CMS)
a home health agency
certified in accordance with rule 4123-6-02.2 of the Administrative Code
may continue to provide authorized services to a
claimant
an injured worker if the
services began prior to December 14, 1992.
(2) The need for nursing services must be the
direct result of an allowed injury or
occupational disease.
(3) In the
event the registered nurse or licensed practical nurse is no longer able to
provide approved services or if services are stopped and later restarted,
nursing services shall be provided only by an employee of a
medicare certified, joint commission accredited, or
community health accreditation program (CHAP) accredited home health
agency, or a home health agency accredited through
an organization that has been granted deeming authority by the centers for
medicare and medicaid services (CMS)
certified
in accordance with rule 4123-6-02.2 of the Administrative Code .
(B) Non-licensed caregiver
services.
(1) Requests for extension of
non-licensed caregiver services initially
provided prior to December 14, 1992.
(a) Prior
to December 14, 1992, caregiver services provided by a nonlicensed person
including claimant's
injured worker's spouse, friend or family member
were considered for reimbursement in cases where the claimant
injured
worker , as a direct result of an
allowed injury or occupational disease, was bedfast, confined to a wheelchair,
had a disability of two or more extremities which prevented the
claimant
injured
worker from caring for his/her
their own body needs or was otherwise unable to
take care of his/her
their own bodily functions. Services include, but
are not limited to, feeding, bathing, dressing, providing personal hygiene, and
transferring from bed to chair. Household, personal or other duties related to
maintaining a household, including but not limited to care or upkeep to the
inside or outside of the residence, washing clothes, preparing meals, or
running errands, are not considered nursing services, and will not be
reimbursed, except to the extent such services are incidental to care of the
claimant
injured
worker .
(b) Requests for an
extension of caregiver services initially
approved prior to December 14, 1992, delivered by a non-licensed person, other
than an attendant, aide, or claimant's
injured worker's spouse, but including other
family members or friends, will be approved only if:
(i) The claimant
injured
worker does not have a spouse because the claimant
injured
worker is not married, or the claimant's
injured
worker's spouse is deceased, or the claimant's spouse is physically or
mentally incapable of caring for the claimant
injured
worker ; and,
(ii) The
approved home health agency is greater than thirty-five miles from the
claimant's
injured
worker's location and the home health agency refuses to provide services
to the claimant
injured worker .
(c) In the event the caregiver is no longer
able to provide approved services or if services are stopped and later
restarted, services shall be provided only by an employee of a
medicare certified, joint commission accredited, or
community health accreditation program (CHAP) accredited home health agency,
or a home health agency accredited through
an organization that has been granted deeming authority by the centers for
medicare and medicaid services (CMS)
certified
in accordance with rule 4123-6-02.2 of the Administrative Code .
(2) Requests for extension of
caregiver services initially provided on or after December 14, 1992 and prior
to January 9, 1995.
(a) Requests for approval
of caregiver services delivered by a non-licensed person, other than an
attendant, aide, or claimant's
injured worker's spouse were considered for
reimbursement only if the claimant
injured worker did not have a spouse or the
spouse was physically or mentally incapable of caring for the
claimant
injured
worker , or an approved home health agency was greater than thirty-five
miles from the claimant's
injured worker's location and the home health agency
refused to provide services to the claimant.
(b) Criteria for approval of caregiver
services were as indicated in paragraph (B)(1)(a) of this rule.
(c) After January 9, 1995, persons who are
not home health agency home health aides or attendants, but who are currently
approved to provide caregiver services to a
claimant
an injured worker , may continue
to do so until services are no longer medically necessary or unless services
are not authorized. After January 9, 1995, approval of caregiver services shall
only be considered when services are rendered by a home health agency home
health aide or attendant.
(d) In
the event the caregiver is no longer able to provide approved services or if
services are stopped and later restarted, services shall be provided only by an
employee of a medicare certified, joint commission
accredited, or community health accreditation program (CHAP) accredited home
health agency, or a home health agency accredited through an organization that has been granted
deeming authority by the centers for medicare and medicaid services
(CMS)
certified in accordance with rule
4123-6-02.2 of the Administrative Code .
(C) All covered home health services must
be rendered on a part-time or intermittent care
basis, in accordance with the written treatment plan and the bureau standard of
care. Part-time or intermittent care means that services are generally rendered
for no more than eight hours per day. Home health services rendered on a full
time or continuous care basis are not covered. More appropriate alternative
settings will be considered for claimants requiring more than eight hours per
day of care, where medical necessity is documented. Exceptional cases may be
reviewed by the bureau
comply with rule
4123-6-38
of the Administrative Code, except as otherwise provided in this
rule .
(D) A review of the
claim or assessment of the injured worker will be conducted at least annually
to ensure that nursing or caregiver services are
necessary as a direct result of the allowed
injury or occupational disease.
Notes
Promulgated Under: 119.03
Statutory Authority: 4121.12, 4121.121, 4121.30, 4121.31, 4121.44, 4121.441, 4123.05, 4123.66
Rule Amplifies: 4121.12, 4121.121, 4121.44, 4121.441, 4123.66
Prior Effective Dates: 02/12/1997, 02/14/2005, 02/01/2010, 11/13/2015
State regulations are updated quarterly; we currently have two versions available. Below is a comparison between our most recent version and the prior quarterly release. More comparison features will be added as we have more versions to compare.
(A) Nursing services provided prior to December 14, 1992.
(1) Registered nurses and licensed practical nurses who are not employed by a medicare certified, joint commission accredited, or community health accreditation program (CHAP) accredited home health agency, or a home health agency accredited through an organization that has been granted deeming authority by the centers for medicare and medicaid services (CMS) a home health agency certified in accordance with rule 4123-6-02.2 of the Administrative Code may continue to provide authorized services to a claimant an injured worker if the services began prior to December 14, 1992.
(2) The need for nursing services must be the direct result of an allowed injury or occupational disease.
(3) In the event the registered nurse or licensed practical nurse is no longer able to provide approved services or if services are stopped and later restarted, nursing services shall be provided only by an employee of a medicare certified, joint commission accredited, or community health accreditation program (CHAP) accredited home health agency, or a home health agency accredited through an organization that has been granted deeming authority by the centers for medicare and medicaid services (CMS) certified in accordance with rule 4123-6-02.2 of the Administrative Code .
(B) Non-licensed caregiver services.
(1) Requests for extension of non-licensed caregiver services initially provided prior to December 14, 1992.
(a) Prior to December 14, 1992, caregiver services provided by a nonlicensed person including claimant's injured worker's spouse, friend or family member were considered for reimbursement in cases where the claimant injured worker , as a direct result of an allowed injury or occupational disease, was bedfast, confined to a wheelchair, had a disability of two or more extremities which prevented the claimant injured worker from caring for his/her their own body needs or was otherwise unable to take care of his/her their own bodily functions. Services include, but are not limited to, feeding, bathing, dressing, providing personal hygiene, and transferring from bed to chair. Household, personal or other duties related to maintaining a household, including but not limited to care or upkeep to the inside or outside of the residence, washing clothes, preparing meals, or running errands, are not considered nursing services, and will not be reimbursed, except to the extent such services are incidental to care of the claimant injured worker .
(b) Requests for an extension of caregiver services initially approved prior to December 14, 1992, delivered by a non-licensed person, other than an attendant, aide, or claimant's injured worker's spouse, but including other family members or friends, will be approved only if:
(i) The claimant injured worker does not have a spouse because the claimant injured worker is not married, or the claimant's injured worker's spouse is deceased, or the claimant's spouse is physically or mentally incapable of caring for the claimant injured worker ; and,
(ii) The approved home health agency is greater than thirty-five miles from the claimant's injured worker's location and the home health agency refuses to provide services to the claimant injured worker .
(c) In the event the caregiver is no longer able to provide approved services or if services are stopped and later restarted, services shall be provided only by an employee of a medicare certified, joint commission accredited, or community health accreditation program (CHAP) accredited home health agency, or a home health agency accredited through an organization that has been granted deeming authority by the centers for medicare and medicaid services (CMS) certified in accordance with rule 4123-6-02.2 of the Administrative Code .
(2) Requests for extension of caregiver services initially provided on or after December 14, 1992 and prior to January 9, 1995.
(a) Requests for approval of caregiver services delivered by a non-licensed person, other than an attendant, aide, or claimant's injured worker's spouse were considered for reimbursement only if the claimant injured worker did not have a spouse or the spouse was physically or mentally incapable of caring for the claimant injured worker , or an approved home health agency was greater than thirty-five miles from the claimant's injured worker's location and the home health agency refused to provide services to the claimant.
(b) Criteria for approval of caregiver services were as indicated in paragraph (B)(1)(a) of this rule.
(c) After January 9, 1995, persons who are not home health agency home health aides or attendants, but who are currently approved to provide caregiver services to a claimant an injured worker , may continue to do so until services are no longer medically necessary or unless services are not authorized. After January 9, 1995, approval of caregiver services shall only be considered when services are rendered by a home health agency home health aide or attendant.
(d) In the event the caregiver is no longer able to provide approved services or if services are stopped and later restarted, services shall be provided only by an employee of a medicare certified, joint commission accredited, or community health accreditation program (CHAP) accredited home health agency, or a home health agency accredited through an organization that has been granted deeming authority by the centers for medicare and medicaid services (CMS) certified in accordance with rule 4123-6-02.2 of the Administrative Code .
(C) All covered home health services must be rendered on a part-time or intermittent care basis, in accordance with the written treatment plan and the bureau standard of care. Part-time or intermittent care means that services are generally rendered for no more than eight hours per day. Home health services rendered on a full time or continuous care basis are not covered. More appropriate alternative settings will be considered for claimants requiring more than eight hours per day of care, where medical necessity is documented. Exceptional cases may be reviewed by the bureau comply with rule 4123-6-38 of the Administrative Code, except as otherwise provided in this rule .
(D) A review of the claim or assessment of the injured worker will be conducted at least annually to ensure that nursing or caregiver services are necessary as a direct result of the allowed injury or occupational disease.
Notes
Promulgated Under: 119.03
Statutory Authority: 4121.12, 4121.121, 4121.30, 4121.31, 4121.44, 4121.441, 4123.05, 4123.66
Rule Amplifies: 4121.12, 4121.121, 4121.44, 4121.441, 4123.66
Prior Effective Dates: 02/12/1997, 02/14/2005, 02/01/2010, 11/13/2015