reglab/statecodes huggingface dataset:
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment of Personal Care Assistance Services for Adults › Section 17b-262-588 - Definitions

Current through July 10, 2024
For the purposes of sections 17b-262-587 through 17b-262-596 b, inclusive, of the Regulations of Connecticut State Agencies, the following definitions shall apply:
(1)
"Activities of Daily Living"
means hands-on activities or tasks, which are essential for a consumer's healthful and safe existence and include, but are not limited to: bathing, dressing, eating, transfers, and bowel and bladder care.
(2)
"Adult"
means a person 18 through 64 years of age inclusive.
(3)
"Applicant"
means a person who directly or through a representative completes a Personal Care Assistance Request Form and submits it to the department.
(4)
"Assessment"
means a comprehensive written evaluation conducted by non-medical department personnel which uses a standard assessment form and which consists of:
(A) an identification of the consumer's limitations in activities of daily living;
(B) the identification of the personal care assistance services required by the consumer and a determination that such services are appropriate for the consumer and, in the non-medical opinion of the department can reasonably be expected to meet the health and safety needs of the consumer;
(C) identification of the training and support needs of the consumer for personal care assistance services;
(D) a face-to-face interview with the consumer;
(E) documentation of the number of hours needed by the consumer to complete the activities of daily living and instrumental activities of daily living with the help of a personal care assistant;
(F) a determination confirming that the consumer would otherwise require institutional care in a nursing facility;
(G) development of a total cost of care plan for the consumer; and
(H) development of a consumer personal care services plan.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment of Personal Care Assistance Services for Adults › Section 17b-262-589 - Eligibility and determination of need

Current through July 10, 2024
(a) In order to be eligible to receive coverage for the cost of personal care assistance services under the Department's Personal Care Assistance Waiver Program, an individual shall either have already been determined eligible to participate in the Department's Title XIX medical assistance program and also be determined to meet the additional programmatic requirements for coverage of personal care assistance services that are specified in this section or qualify for personal care assistance services by meeting all of the technical, special financial, and programmatic requirements stated in this section.
(b) An individual who has not previously been determined eligible for medical assistance and who receives personal care assistance services after meeting the requirements of this section is thereby automatically determined eligible for the medical assistance program and for all other medically necessary services that are covered by the program.
(c) The technical requirements for eligibility are:
(1) A recipient of medical assistance benefits who applies for coverage of personal care assistance services and applicants for personal care assistance services shall meet all requirements for eligibility in the Department's medical assistance program that are applicable to disabled adults as stated in the regulations promulgated by the Department and contained in its Uniform Policy Manual pursuant to Section 17b-10 of the Connecticut General Statutes, including, without limitation, all regulations establishing medical assistance eligibility requirements related to the filing of applications for assistance, verifications, redeterminations, existence of a disabling condition, citizenship status, residency, institutional status, assistance unit composition and income and asset limits.
(2) Applicants for personal care assistance services are treated as if they were institutionalized and all medical assistance eligibility rules that apply to institutionalized applicants or recipients of medical assistance benefits are also applied in the same way to applicants or recipients of personal care assistance services. Specifically, without limiting the scope of this subsection, applicants and recipients for personal care assistance services are subject to the same rules that govern eligibility related to the transfer of assets and to the treatment of the resources and income of spouses of institutionalized applicants for assistance.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment of Personal Care Assistance Services for Adults › Section 17b-262-590 - Application process

Current through July 10, 2024
(a) The application process consists of:
(1) a financial eligibility determination by the Department in accordance with the eligibility standards for participation in the Department's Title XIX medical assistance program that are contained in the Uniform Policy Manual;
(2) a preliminary determination by central office administrative staff as to the consumer's needs and financial eligibility based on a review of the information provided on the "Personal Care Assistance Request" form; and
(3) a referral to the appropriate regional office when an assessment for services is indicated to determine if a cost effective plan of services can be developed to provide services to the person in the community.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment of Personal Care Assistance Services for Adults › Section 17b-262-591 - Waiting list

Current through July 10, 2024
(a) As a result of the limitation of the number of slots and/or funding, the Department shall establish and maintain a statewide waiting list for the Personal Care Assistance Waiver program when the Department has filled its maximum allocation of slots or reached the funding level in the approved waiver. Names shall be placed on the waiting list in the same order as the "Personal Care Assistance Request" form is received in Central Office.
(b) When an opening occurs, applications shall be solicited by contacting consumers in the order their names appear on the waiting list.
(c) A consumer is removed from the waiting list if he or she:
(1) asks to be removed;
(2) moves out of state;
(3) reaches age 65; or
(4) is deceased.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment of Personal Care Assistance Services for Adults › Section 17b-262-592 - Limitations

Current through July 10, 2024
(a) The Department does not offer Personal Care Assistance Waiver services to more than the number of consumers specified in the federally approved Personal Care Assistance Waiver or to more than the number of consumers who can be served within the funding limitations established in the approved waiver.
(b) In order to be eligible for a personal care services plan that, combined with all other state administered home care and community based services, exceeds 60% of the average nursing facility cost, the consumer shall require physical assistance with three or more of the following activities of daily living: bathing, dressing, eating, transferring and bowel and bladder care.
(c) In order to be eligible for a personal care services plan that, combined with all other state administered home care and community based services, exceeds 80% of the average nursing facility cost, the consumer shall require assistance with all of the following activities of daily living: bathing, dressing, eating, transferring and bowel and bladder care.
(d) In addition, any plan exceeding 60% of the average nursing facility cost shall meet the following requirements:
(1) there shall be documentation of any changes in the consumer's needs or other circumstances which affect the plan if the cost of care plan exceeds the costs of services provided prior to application to this program; and
(2) the projected overall program costs for the total personal care assistance services population shall not be exceeded as a result of the approval of this consumer's personal care services plan; and
(3) all informal and family supports shall have been explored and documented in the record. It is not the intent of the program to displace services that have been provided free of charge by family members and relatives, and may reasonably be expected to continue in the future, and a personal care services plan shall not be developed which substitutes the paid services of a personal care assistant for voluntary services provided by family members.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment of Personal Care Assistance Services for Adults › Section 17b-262-593 - Services covered

Current through July 10, 2024
(a) Services covered are:
(1) personal care assistance services provided in accordance with a personal care services plan which enable the consumer to carry out activities of daily living and instrumental activities of daily living in a community living arrangement; and
(2) as a result of being determined eligible for Medicaid, any other covered service to the extent that it is necessary, in accordance with Title XIX contained in the Social Security Amendments of 1965 and state and federal regulations adopted pursuant thereto.
(3) personal care assistance services up to 25.75 hours per week provided by a single personal care assistant and up to 40 hours per week provided by a single personal care assistant if the consumer documents, to the department's satisfaction, that the consumer has obtained and maintained worker's compensation insurance for the single personal care assistant and that such insurance shall remain in full force and effect for at least one year from the date the personal care assistant begins providing personal care assistance services to the consumer. Personal care assistance services beyond 25.75 hours per week shall not be covered without the submission of such documentation. The social worker shall verify the continuation of the worker's compensation insurance coverage at the time of the annual review.
(4) up to 10 additional hours of personal care assistance services beyond those already included in the approved service plan for the purpose of communicating with medical providers during a crisis or an emergency for those consumers who have difficulty communicating verbally their needs to medical providers, as determined by the social worker during the assessment process.
(5) for those consumers who either live alone or who remain at home alone with no available caregiver, a personal emergency response system (PERS) may be provided. The department social worker shall determine the need for the PERS as part of the assessment process.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment of Personal Care Assistance Services for Adults › Section 17b-262-594 - Determining the cost effectiveness of the service plan

Current through July 10, 2024
In order to determine the cost effectiveness of the consumer's service plan, the Department shall do all of the following:
(1) Obtain the monthly average nursing facility cost; and
(2) Determine the monthly cost of the service plan; and
(3) Determine the monthly cost of other medical services that the consumer will require in order to live in the community. These other medical services include: home health care, nursing services, physical therapy, occupational therapy and/or speech therapy. These costs are based on the consumer's expected utilization of these services, multiplied by the Medicaid rates established by the Department for such services; and
(4) Determine the monthly cost of other state administered home and community based services. These other home and community based services costs include but are not limited to those services provided by the department's Community Based Services Program and all funds provided by programs administered by any other state agency which help to maintain the consumer in the community; and
(5) Add the cost of other medical services and other state administered home and community based services to the costs of the service plan to obtain the consumer's total cost of care; and
(6) Compare the consumer's total cost of care to the average nursing facility cost.
The Department may not approve a personal care assistance plan when the cost of all of the foregoing services exceeds the cost of care in a nursing facility.
If due to a temporary acute condition the consumer requires personal care assistance services that exceed the monthly average nursing facility cost for a period that is not expected to exceed four months, the Department, at its discretion, may approve a plan that provides such additional personal care assistance services provided that the annualized cost of personal care assistance services and other services does not exceed the annualized cost of nursing facility services.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment of Personal Care Assistance Services for Adults › Section 17b-262-595 - Payment

Current through July 10, 2024
(a) Payment for personal care assistance services for adults is made at the lowest of:
(1) the maximum rate determined by the department for personal care assistance services;
(2) a rate below the maximum based on an amount the consumer has negotiated with the personal care assistant; or
(3) the amount billed.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment of Personal Care Assistance Services for Adults › Section 17b-262-596 - Personal care assistant qualifications

Current through July 10, 2024
(a) The consumer is responsible for ensuring that his or her personal care assistants meet all of the following qualifications:
(1) be at least 16 years of age except that, if the consumer chooses to hire an individual who is 16 or 17 years old, the consumer shall comply with specific standards and restrictions imposed by state and federal law;
(2) be able to understand and carry out directions given by the consumer or conservator;
(3) be physically able to perform all duties delineated in the service plan;
(4) be willing to receive training from the consumer or conservator in performance of all personal care assistance services delineated in the service plan;
(5) be able to handle emergencies; and
(6) demonstrate competencies in effective employer/employee relationships, disability awareness, use of equipment, and activities of daily living.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment of Personal Care Assistance Services for Adults › Section 17b-262-596a - Fair hearings

Current through July 10, 2024
Applicants for and recipients of services under the Personal Care Assistance program may request and receive a fair hearing, in accordance with the rules of the Department's Medicaid program when the Department:
(1) did not offer the choice of home and community-based services as an alternative to institutional care in a nursing facility; or
(2) does not reach a determination of financial eligibility within the Department's standard of promptness; or
(3) denies the application for any reason other than the limitations on the number of individuals who can be served and/or funding limitations as established in the approved waiver; or
(4) disapproves the consumer's service plan; or
(5) denies or terminates payment to a qualified personal care assistant of the consumer's choice; or
(6) discharges the consumer from the waiver program.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment for Early Intervention Services to Children Age Birth to Three Years with Developmental Delays › Section 17b-262-597 - Scope

Current through July 10, 2024
Sections 17b-262-597 through 17b-262-605 inclusive set forth the Department of Social Services (DSS) requirements for payment of early intervention services provided by the Department of Mental Retardation (DMR), or another state agency, and their funded contractors, to children age Birth to Three years with developmental delays who are determined eligible for Connecticut's Medical Assistance Program pursuant to section 17b-262 of the Connecticut General Statutes.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment for Early Intervention Services to Children Age Birth to Three Years with Developmental Delays › Section 17b-262-598 - Definitions

Current through July 10, 2024
For the purposes of section 17b-262-597 through 17b-262-605 the following definitions shall apply:
(1) "Allied Health Professional or AHP" means an individual who is licensed or certified or who is qualified by special training, education, skills, and experience to provide early intervention services. Such individuals include, but are not limited to: nurses, physician assistants, masters level social workers, special education teachers, speech therapy assistants, nutritionists, and family therapists.
(2) "Assessment" means the definition contained in Part H of the Individuals with Disabilities Education Act (IDEA), Title 20 United States Code (USC), section 1477(a), and at Title 34 Code of Federal Regulations (CFR), Part 303, subdivisions (1) and (2) of subsection (a) of section 303.322, and at subdivision (2) of subsection (b) of section 303.322.
(3) "Assessment Team" means a multidisciplinary team of qualified, as defined in Title 34 CFR, Part 303, section 303.21, service providers selected by the performing provider, based on results of the child's evaluation, to perform an assessment to determine the service needs of the child based on the diagnosis of the evaluation team.
(4) "Assistive Technology Devices" means the assistive technology devices as defined in Part H of IDEA, Title 20 USC 1471 et seq., and at Title 34 CFR, Part 303, subdivision (1) of subsection (d) of section 303.12.
(5) "Assistive Technology Services" means the assistive technology services defined in Part H of IDEA, 20 USC et seq., and at Title 34 CFR, Part 303, subdivision (1) of subsection (d) of section 303.12.
(6) "Audiology" means the definition contained in Part H of IDEA, Title 20 USC et seq., and at Title 34 CFR, Part 303, subdivision (2) of subsection (d) of section 303.12.
(7) "Audiologist" means one who is licensed to practice audiology pursuant to Chapter 399 of the Connecticut General Statutes.
(8) "Billing Provider" means DMR or another state agency responsible for coordinating and delivering early intervention services to Birth to Three eligible children. Billing providers may also be responsible for service coordination and may be a performing provider.
(9) "Birth to Three Eligible Child" means a child from birth to age three who is:
(A) experiencing a significant developmental delay as measured by standardized diagnostic test or clinical opinion in one or more of the following areas:
(i) cognitive development;
(ii) physical development, including vision or hearing;
(iii) communication development; or
(iv) adaptive skills; or
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment for Early Intervention Services to Children Age Birth to Three Years with Developmental Delays › Section 17b-262-599 - Provider participation

Current through July 10, 2024
(a)
Billing Provider
In order to enroll in the Medical Assistance Program and receive payment from the department for early intervention services rendered, the billing provider shall:
(1) meet and maintain all departmental enrollment requirements;
(2) have a valid billing provider agreement on file which is signed by the billing provider and the department upon application for enrollment into the Medical Assistance Program. This agreement, which shall be periodically updated, shall continue to be in effect for the duration of the agreement or for the stated period in the agreement. The provider agreement specifies conditions and terms which govern the program and to which the billing provider is mandated to adhere in order to participate in the program;
(3) ensure that an individual employed or contracted by the performing provider shall be selected as service coordinator for each child to serve as the person responsible for compliance with the duties as defined in Title 34 CFR, Part 303, section 303.22;
(4) provide early intervention services directly or by means of a contract with qualified allied health professionals pursuant to all applicable federal and state statutes and regulations and ensure that all performing providers are enrolled with the Medical Assistance Program prior to provision of service;
(5) select one or more performing providers through a competitive or non-competitive bidding process;
(6) process all claims submitted by all other performing providers under contract for provision of early intervention services in the Birth to Three System; and
(7) comply with all Medical Assistance Program documentation and other requirements.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment for Early Intervention Services to Children Age Birth to Three Years with Developmental Delays › Section 17b-262-600 - Eligibility

Current through July 10, 2024
(a) Payment for early intervention services shall be available for all children eligible for the Medical Assistance Program subject to the conditions and limitations which apply to early intervention services as provided by these regulations.
(b) Payment for early intervention services shall be available only for evaluations, assessments, and services that are contained in an IFSP and by consent of a parent or other person authorized to consent to such activities on behalf of an eligible child.
(c) Significant delay shall be demonstrated with scores on an appropriate norm-referenced standardized diagnostic instrument or other procedures, such as formal observations and informed clinical opinion, to substantiate:
(1) a score two standard deviations below the mean in one area of development; or
(2) scores one and one-half standard deviations below the mean in two areas of development.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment for Early Intervention Services to Children Age Birth to Three Years with Developmental Delays › Section 17b-262-601 - Services covered and limitations

Current through July 10, 2024
(a) The department shall pay for the following:
(1) evaluations and assessments;
(2) early intervention services, which are medically appropriate and medically necessary as follows:
(A) assistive technology devices and assistive technology services;
(B) audiology;
(C) family training, counseling, and home visits;
(D) health services;
(E) medical services;
(F) nursing services;
(G) nutrition services;
(H) occupational therapy;
(I) physical therapy;
(J) psychological services;
(H) service coordination;
(I) social work services;
(J) special instruction;
(K) speech-language pathology;
(L) transportation and related costs; and
(M) vision services; and
(3) services provided in the child's natural environment to the maximum extent appropriate to the needs of the child.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment for Early Intervention Services to Children Age Birth to Three Years with Developmental Delays › Section 17b-262-602 - Billing procedures

Current through July 10, 2024
All claims submitted to the department for payment of evaluation and early intervention services including assessments and assistive technology devices, shall be substantiated by documentation in the Birth to Three eligible child's early intervention record.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment for Early Intervention Services to Children Age Birth to Three Years with Developmental Delays › Section 17b-262-603 - Payment

Current through July 10, 2024
(a) The department shall establish payment rates effective July 1, 1996.
(b) The rate period shall be the state fiscal year.
(c) Interim rates shall be issued for each rate period and such rates shall be replaced by rates computed on the basis of actual cost and service volume submitted to the department by the billing provider by December 31 each year for the immediately preceding state fiscal year.
(d) Payment shall not be made directly to AHPs or organizations under contract to a performing provider or a billing provider.
(e) Payment limitations shall be as follows:
(1) payment for evaluations; early intervention services, which includes assessments; and assistive technology devices shall not duplicate payments made under the Medical Assistance Program for other services which are covered under the Program;
(2) any Medical Assistance Program Birth to Three eligible child is qualified to be evaluated for eligibility for Part H of IDEA;
(3) payment shall be made for early intervention services only for the period covered by the written authorized IFSP;
(4) once a child is determined ineligible for Part H of IDEA, payment shall not be made for assessment and early intervention services;
(5) claims for payment shall be submitted to the department only by the billing provider or its designated agent;
(6) payment for early intervention services, excluding evaluations, shall not be made unless one or more of the individual services pursuant to section 17b-262-601 are rendered in a calendar month;
(7) payment shall be made for evaluations regardless of whether the child becomes eligible for the Birth to Three System;
(8) evaluations shall be based on a cost per evaluation basis;
(9) other early intervention services, including assessments, shall be no more than two units per child per calendar month;
(10) rates for early intervention services shall include assistive technology devices having a cost equal to or less than two hundred and fifty dollars; and
(11) rates for assistive technology devices having a cost of more than two hundred and fifty dollars, shall be based on the applicable Medical Assistance Program durable medical equipment fee schedule.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment for Early Intervention Services to Children Age Birth to Three Years with Developmental Delays › Section 17b-262-604 - Documentation requirements

Current through July 10, 2024
Early intervention services shall be paid by the department only when the lead agency ensures compliance of the following documentation requirements on file with the performing provider, as appropriate:
(a)
Evaluation
(1) A copy of the evaluation report which shall meet the requirements of Part H of IDEA, Title 20 USC 1471 et seq., Title 20 USC section 1477(a), and at Title 34 CFR, Part 303, subdivision (1) of subsection (b) of section 303.322, shall be on file, recommending the specific medical diagnosis or diagnoses according to the International Classification of Diseases (ICD) in a form and manner specified by the department, and signed by all members of the evaluation team.
(2) The evaluation shall include:
(A) for eligible Birth to Three children, a signature on a form and manner to be specified by the department, by the physician who recommended the evaluation and stated diagnosis or diagnoses; which authorizes the development of the IFSP, and
(B) for ineligible children, a signature by a physician within forty-five days of the date the evaluation was completed and signed.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment for Early Intervention Services to Children Age Birth to Three Years with Developmental Delays › Section 17b-262-605 - Audit and record retention

Current through July 10, 2024
(a) All supporting accounting and business records, statistical data, early intervention records, and other records relating to the provision of evaluation, assessment, service coordination, and early intervention services paid for by the department shall be subject to audit.
(b) Documentation as required for the Birth to Three System, including census and accounting records, shall be maintained for the longer of:
(1) six years from the end of the billing period; or
(2) six years from the date of services by the performing provider; or
(3) until such time as the department audit of documented services is completed and said audit is approved or disallowed as the case may be by the commissioner.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment of Nurse Practitioner Services › Section 17b-262-607 - Scope

Current through July 10, 2024
Sections 17b-262-607 through 17b-262-618 inclusive set forth the Department of Social Services requirements for payment of nurse practitioner services provided by licensed advanced practice registered nurses for clients who are determined eligible to receive services under Connecticut's Medical Assistance Program pursuant to section 17b-262 of the Connecticut General Statutes (CGS).
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment of Nurse Practitioner Services › Section 17b-262-608 - Definitions

Current through July 10, 2024
For the purposes of sections 17b-262-607 through 17b-262-618 the following definitions shall apply:
(1) "Acute" means having rapid onset, severe symptoms, and a short course.
(2) "Allied Health Professional (AHP)" means a professional or paraprofessional individual who is qualified by special training, education, skills, and experience in providing health care and treatment and shall include, but shall not be limited to: licensed practical nurses, certified nurse assistants, and other qualified therapists.
(3) "By or Under the Supervision" means the nurse practitioner shall assume professional responsibility for the service performed by the allied health professional, overseeing or participating in the work of the allied health professional including, but not limited to:
(A) availability of the nurse practitioner to the allied health professional in person and within five minutes;
(B) availability of the nurse practitioner on a regularly scheduled basis to review the practice, charts, and records of the allied health professional and to support the allied health professional in the performance of services; and
(C) a predetermined plan for emergency situations, including the designation of an alternate nurse practitioner in the absence of the regular nurse practitioner.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment of Nurse Practitioner Services › Section 17b-262-609 - Provider participation

Current through July 10, 2024
In order to enroll in the Medical Assistance Program and receive payment from the department, providers shall meet the following requirements:
(a)
General:
(1) meet and maintain all applicable licensing, accreditation, and certification requirements;
(2) meet and maintain all departmental enrollment requirements; and
(3) have a valid provider agreement on file which is signed by the provider and the department upon application for enrollment into the Medical Assistance Program. This agreement, which shall be periodically updated, shall continue to be in effect for the duration of the agreement or for the stated period in the agreement. The provider agreement specifies conditions and terms which govern the program and to which the provider is mandated to adhere in order to participate in the program.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment of Nurse Practitioner Services › Section 17b-262-611 - Services covered and limitations

Current through July 10, 2024
(a) Except for the limitations and exclusions listed below, the department shall pay for:
(1) medically necessary and medically appropriate professional services of a nurse practitioner which conform to accepted methods of diagnosis and treatment;
(2) services provided in the practitioner's office, client's home, hospital, long-term care facility, or other medical care facility;
(3) family planning services as described in the Regulations of Connecticut State Agencies;
(4) unless defined elsewhere, CPT descriptive terms used by the department as standards;
(5) medical and surgical supplies used by the provider in the course of treatment of a client;
(6) injectable drugs which are payable by the department and administered by a provider; and
(7) HealthTrack Services and HealthTrack Special Services.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment of Nurse Practitioner Services › Section 17b-262-612 - Services not covered

Current through July 10, 2024
The department shall not pay for the following:
(a) Any procedures or services of an unproven, educational, social, research, experimental or cosmetic nature; for any diagnostic, therapeutic or treatment procedures in excess of those deemed medically necessary by the department to treat the client's condition; or for services not directly related tothe client's diagnosis, symptoms or medical history;
(b) Any examinations, laboratory tests, biological products, immunizations or other products which are furnished free of charge;
(c) Information or services provided to a client by a provider over the telephone;
(d) An office visit for the sole purpose of the client obtaining a prescription where the need for the prescription has already been determined;
(e) Cancelled office visits and appointments not kept;
(f) Cosmetic surgery;
(g) Services provided in an acute care hospital if the department determines the admission does not, or retrospectively did not, fit the department's utilization review requirements pursuant to section 17-134d-80 of the Regulations of Connecticut State Agencies;
(h) Services provided by the admitting provider in an acute care hospital shall not be made or costs for such services may be recouped if it is determined by the department's utilization review, either prospectively or retrospectively, that the admission did not fulfill the accepted professional criteria for medical necessity, appropriateness of setting or quality of care;
(i) A laboratory charge for laboratory services performed by a laboratory outside of the nurse practitioner's office. The laboratory shall bill the department for services rendered when a nurse practitioner refers a client to a private laboratory; and
(j) The following routine laboratory tests which shall be included in the fee for an office visit and shall not be billed on the same date of service: urinalysis without microscopy,hemoglobin determination and urine glucose.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment of Nurse Practitioner Services › Section 17b-262-613 - Need for service

Current through July 10, 2024
The department shall pay for an initial office visit and continuing services which the department deems are medically necessary and medically appropriate, in relation to the diagnosis for which care is required, provided that:
(a) the services are within the scope of the provider's practice, and
(b) the services are made part of the client's medical record.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment of Nurse Practitioner Services › Section 17b-262-614 - Prior authorization

Current through July 10, 2024
(a) Prior authorization, on forms and in a manner as specified by the department, is required for the following services:
(1) more than one visit on the same day for the same client by the same provider. Authorization for additional visits need not be submitted in advance of the service, but providers shall submit the authorization request prior to billing for the second or subsequent visits;
(2) admissions to acute care hospitals pursuant to section 17-134d-80 of the Regulations of Connecticut State Agencies;
(3) electrolysis epilation;
(4) physical therapy services in excess of two treatments per calendar week per client per provider;
(5) physical therapy services in excess of nine treatments per calendar year per client per provider, involving the following primary diagnoses:
(A) all mental disorders including diagnoses related to mental retardation and specific delays in development covered by the International Classification of Diseases (ICD), as amended from time to time;
(B) cases involving musculoskeletal system disorders covered by ICD, as amended from time to time; and
(C) cases involving symptoms related to nutrition, metabolism, and development covered by ICD, as amended from time to time;
(6) reconstructive surgery, including breast reconstruction following mastectomy;
(7) plastic surgery;
(8) transplant procedures; and
(9) HealthTrack Special Services.
(A) HealthTrack Special Services are determined medically necessary and medically appropriate on a case-by-case basis; and
(B) the request for HealthTrack Special Services shall include:
(i) a written statement from the prescribing physician, or other licensed practitioner of the healing arts, performing such services within his or her respective scope of practice as defined under state law, justifying the need for the item or service required;
(ii) a description of the outcomes of any alternative measures tried; and
(iii) if applicable and requested by the department, any other documentation required in order to render a decision.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment of Nurse Practitioner Services › Section 17b-262-615 - Billing procedures

Current through July 10, 2024
(a) Claims from nurse practitioners shall be submitted on the department's designated form or electronically transmitted to the department's fiscal agent and shall include all information required by the department to process the claim for payment.
(b) The amount billed to the department shall represent the nurse practitioner's usual and customary charge for the services delivered.
(c) When a Medical Assistance Program client is referred to a provider for consultation, the consultant provider shall include the referring practitioner's provider number and name. If no provider number has been assigned, the consultant provider shall enter the entire name as well as the state license number of the referring provider on the billing form.
(d) Injectables shall be billed according to the number of units administered to the client by the nurse practitioner.
(e) When billing for anesthesia services, providers shall include the name of the primary surgeon on the bill and enter the total number of minutes in units.
(f) Providers shall bill for drugs or devices which are dispensed directly to the client as separate line items.
(g) All charges billed for supplies and materials provided by a provider, except glasses, shall be reviewed by the department.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment of Nurse Practitioner Services › Section 17b-262-616 - Payment

Current through July 10, 2024
(a) Payment rates shall be the same for in-state and out-of-state providers.
(b) Payment shall be made at the lowest of:
(1) the provider's usual and customary charge to the general public;
(2) the lowest Medicare rate;
(3) the amount in the applicable fee schedule as published by the department;
(4) the amount billed by the provider; or
(5) the lowest price charged or accepted for the same or substantially similar goods or services by the provider from any person or entity.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment of Nurse Practitioner Services › Section 17b-262-617 - Payment rate and limitations

Current through July 10, 2024
(a) The commissioner establishes the fees contained in the department's fee schedule pursuant to section 4-67c of the Connecticut General Statutes.
(b) Nurse practitioner rates for each procedure shall be set at 90% of the department's fees for physician procedure codes.
(c) The fees listed apply only when services are directly performed by the nurse practitioner or provided under the supervision of the nurse practitioner.
(d) Payment shall be made for panel or profile tests according to the fees listed in the department's fee schedule for panel tests and not at the rate for each separate test included in the panel or profile.
(e) Fees for surgical and medical procedures shall include the fee for an emergency room visit. The department shall not pay a provider at a higher rate for any surgical or medical procedure which is performed in an emergency room.
(f) The department shall pay nonhospital based providers for evaluation and management services provided to the provider's private practice clients in the emergency room.
(g) If a client is referred to a provider for advice and treatment of a condition which the referring provider does not usually treat, the fee for a consultation shall not be paid.
(h) If a client's medical condition necessitates the concurrent services and skills of two or more providers, each nurse practitioner provider shall be entitled to the listed fee for the service.
(i) When a Medical Assistance Program applicant visits a provider for the purpose of determining eligibility, the department shall pay only for the test required to establish eligibility as requested by the department. No other procedures shall be paid.
(j) Newborn resuscitation may be billed in addition to billing for routine care of a newborn or billing for critical care.
(k) The admission and annual comprehensive medical examination, in a long-term care facility, shall be performed by or under the direct supervision of a provider.
(l) The admission examination, in a long-term care facility, shall be performed within forty-eight hours of admission to the long-term care facility and shall be limited to one per client, per provider, regardless of the number of admissions.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment of Nurse Practitioner Services › Section 17b-262-618 - Documentation

Current through July 10, 2024
(a) Nurse Practitioners shall maintain a specific record for all services rendered for each client eligible for Medical Assistance Program payment including, but not limited to: name, address, birth date, Medical Assistance Program identification number, pertinent diagnostic information, a current treatment plan signed by the nurse practitioner, documentation of services provided, and the dates the services were provided.
(b) All required documentation shall be maintained for at least five years in the nurse practitioner's file subject to review by authorized department personnel. In the event of a dispute concerning a service provided, documentation shall be maintained until the end of the dispute or five years, whichever is greater.
(c) Failure to maintain all required documentation shall result in the disallowance and recovery by the department of any amounts paid to the nurse practitioner for which the required documentation is not maintained or provided to the department upon request.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment of Podiatric Services › Section 17b-262-619 - Scope

Current through July 10, 2024
Sections 17b-262-619 to 17b-262-629, inclusive, of the Regulations of Connecticut State Agencies set forth the Department of Social Services requirements for payment of podiatric services on behalf of clients who are determined eligible to receive services under the Connecticut Medicaid program pursuant to section 17b-261 of the Connecticut General Statutes.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment of Podiatric Services › Section 17b-262-621 - Provider participation

Current through July 10, 2024
To enroll in Medicaid and receive payment from the department, providers shall comply with sections 17b-262-522 to 17b-262-533, inclusive, of the Regulations of Connecticut State Agencies.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment of Podiatric Services › Section 17b-262-623 - Services covered and limitations

Current through July 10, 2024
Subject to the limitations and exclusions identified in sections 17b-262-619 to 17b-262-629, inclusive, of the Regulations of Connecticut State Agencies, the department shall pay providers for podiatric services provided by podiatrists:
(1) for only for those procedures listed in the provider's fee schedule that are medically necessary and medically appropriate to treat the client's condition;
(2) for podiatric services provided in an office, a general hospital, the client's home, a chronic disease hospital, nursing facility, ICF/MR or other medical care facility;
(3) for laboratory services provided by a podiatrist in compliance with the provisions of the Clinical Laboratory Improvement Amendments (CLIA) of 1988;
(4) for medical and surgical supplies used by the podiatrist in the course of treatment of a client;
(5) for drugs and supplies administered by a podiatrist;
(6) for a second opinion for surgery when requested voluntarily by the client or when required by the department. The department shall pay for a second opinion according to the established fees for consultation; and
(7) for EPSDT services including, but not limited to, treatment services which are indicated following screening but not otherwise covered, provided that prior authorization is obtained.