reglab/statecodes huggingface dataset:
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment Under the Connecticut Pharmaceutical Assistance Contract to the Elderly and the Disabled (ConnPACE) › Section 17b-262-690 - Payment rate (Repealed)

Current through July 10, 2024
For 2014 repeal, see Sec. 54 of Public Act 14-187. (June 11, 2014)
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment Under the Connecticut Pharmaceutical Assistance Contract to the Elderly and the Disabled (ConnPACE) › Section 17b-262-691 - Documentation (Repealed)

Current through July 10, 2024
For 2014 repeal, see Sec. 54 of Public Act 14-187. (June 11, 2014)
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment Under the Connecticut Pharmaceutical Assistance Contract to the Elderly and the Disabled (ConnPACE) › Section 17b-262-692 - Manufacturer rebate program (Repealed)

Current through July 10, 2024
For 2014 repeal, see Sec. 54 of Public Act 14-187. (June 11, 2014)
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment of Public Health Dental Hygienist Services › Section 17b-262-693 - Scope

Current through July 10, 2024
Sections 17b-262-693 to 17b-262-700, inclusive, set forth the requirements for payment of public health dental hygienist services for persons determined eligible for Connecticut's Medicaid 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 of Public Health Dental Hygienist Services › Section 17b-262-695 - Provider participation

Current through July 10, 2024
(a) In order to participate in Medicaid and receive payment from the department, all providers shall meet and maintain all departmental enrollment requirements as set forth in sections 17b-262-522 to 17b-262-533, inclusive, of the Regulations of Connecticut State Agencies.
(b) All dental hygienists who participate in Medicaid shall be public health dental hygienists.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment of Public Health Dental Hygienist Services › Section 17b-262-697 - Services covered and limitations

Current through July 10, 2024
(a)
Services Covered
(1) The department shall pay for medically necessary and medically appropriate public health dental hygienist services provided to clients subject to the limitations listed in subsection (b) of this section.
(2) The department shall pay providers only for those procedures listed in the provider's fee schedule.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment of Public Health Dental Hygienist Services › Section 17b-262-698 - Services not covered

Current through July 10, 2024
The department shall not pay for:
(1) anything not explicitly allowed pursuant to section 17b-262-697 of the Regulations of Connecticut State Agencies;
(2) information provided to the client over the telephone;
(3) cancelled visits or services not provided;
(4) any services provided by a public health dental hygienist free of charge to non-Medicaid clients;
(5) anything of an unproven, experimental or research nature, or for services in excess of those deemed medically necessary or medically appropriate by the department to treat a client's condition, or for services not directly related to the client's diagnosis, symptoms, or medical history; or
(6) any services provided by a public health dental hygienist in a dental office, a dental clinic or a location other than those set forth in section 17b-262-697(b)(5) 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 Public Health Dental Hygienist Services › Section 17b-262-699 - Payment rate and billing procedure

Current through July 10, 2024
(a) The provider may sign claims and bill directly and shall submit claims to the department in accordance with the procedures set forth in section 17b-262-529 of the Regulations of Connecticut State Agencies and the billing instructions specific to a public health dental hygienist.
(b) The commissioner shall establish the fees for dental hygienist services performed by the public health dental hygienist pursuant to section 4-67c of the Connecticut General Statutes;
(c) The provider shall bill the usual and customary charge and the department shall pay the lowest of:
(1) the usual and customary charge;
(2) the amount billed by the provider to the department; or
(3) the amount in the applicable fee schedule as published by the department.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment of Public Health Dental Hygienist Services › Section 17b-262-700 - Documentation

Current through July 10, 2024
(a) The provider shall maintain a client file that shall include, but not be limited to, the following information:
(1) identifying data:
(A) name of client;
(B) address;
(C) date of birth;
(D) gender; and
(E) Medicaid identification number;
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment of Nursing Facilities › Section 17b-262-701 - Scope

Current through July 10, 2024
Sections 17b-262-701 to 17b-262-711, inclusive, set forth the Department of Social Services requirements for payment to nursing facilities for services to clients eligible to receive such services under Connecticut's Medicaid 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 of Nursing Facilities › Section 17b-262-703 - Provider participation

Current through July 10, 2024
In order to enroll in the Medicaid program and receive payment from the department, a nursing facility shall comply with sections 17b-262-522 through 17b-262-533, inclusive, of the Regulations of Connecticut State Agencies. Licensing and certification requirements for nursing facilities referenced in sections 17b-262-701 to 17b-262-711, inclusive, of the Regulations of Connecticut State Agencies include, but are not limited to, the criteria described in section 19-13-D8t of the Regulations of Connecticut State Agencies and the criteria described in 42 CFR Part 483, subpart B, as amended from time to time.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment of Nursing Facilities › Section 17b-262-705 - Services covered and limitations

Current through July 10, 2024
The department shall pay an all-inclusive per diem rate, computed in accordance with section 17b-340 of the Connecticut General Statutes and sections 17-311-1 to 17-311-120, inclusive, and sections 17-311-200 to 17-311-209, inclusive, of the Regulations of Connecticut State Agencies, to the provider for each Medicaid resident. This rate represents payment for the following goods and services:
(a) all services as required by section 19-13-D8t of the Regulations of Connecticut State Agencies and 42 CFR Part 483, subpart B, as amended from time to time, including, but not limited to:
(1) medical direction in accordance with sections 19-13-D8t(h) and (i) of the Regulations of Connecticut State Agencies;
(2) nursing service in accordance with 42 CFR 483.30, as amended from time to time, and sections 19-13-D8t(j),(k),(m) and (n) of the Regulations of Connecticut State Agencies;
(3) social services in accordance with 42 CFR 483.15(g), as amended from time to time, and section 19-13-D8t(s) of the Regulations of Connecticut State Agencies;
(4) therapeutic recreation in accordance with 42 CFR 483.15(f), as amended from time to time, and section 19-13-D8t(r) of the Regulations of Connecticut State Agencies;
(5) specialized rehabilitative services in accordance with 42 CFR 483.45, as amended from time to time;
(6) room and board in accordance with 42 CFR 483.10(c)(8)(i)(D), 42 CFR 483.35, and 42 CFR 483.70, as amended from time to time, and sections 19-13-D8t(q) and 19-13-D8t(v) of the Regulations of Connecticut State Agencies;
(7) consultation and assistance to residents in obtaining other needed services including:
(A) vision and hearing services in accordance with 42 CFR 483.25(b), as amended from time to time;
(B) services to address mental and psychosocial functioning in accordance with 42 CFR 483.25(f), as amended from time to time;
(C) dental services in accordance with 42 CFR 483.55, as amended from time to time; and
(D) pharmacy services in accordance with 42 CFR 483.60(b) and (c), as amended from time to time;
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment of Nursing Facilities › Section 17b-262-706 - Service limitations

Current through July 10, 2024
(a) the department shall pay to reserve a bed in a nursing facility for a Medicaid resident during a temporary absence in a hospital or a temporary absence for home leave in accordance with the provisions of section 19a-537 of the Connecticut General Statutes.
(b) Payment shall be made for the date of admission and not for the date of discharge. Exceptions to this are:
(1) Payment may be made for the date of death when the resident dies in the nursing facility. If the resident dies while in the hospital or on home leave, the date of death may be paid as a reserve bed day, provided all other bed reservation requirements as described in section 19a-537 of the Connecticut General Statutes are met; and
(2) In the case of a resident admitted and discharged on the same day, payment shall be made for one day of care.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment of Nursing Facilities › Section 17b-262-707 - Need for service and authorization process

Current through July 10, 2024
(a) The department shall pay for an admission that is medically necessary and medically appropriate as evidenced by the following:
(1) certification by a licensed practitioner that a client admitted to a nursing facility meets the criteria outlined in section 19-13-D8t(d)(1) of the Regulations of Connecticut State Agencies. This certification of the need for care shall be made prior to the department's authorization of payment. The licensed practitioner shall use and sign all forms specified by the department;
(2) the department's evaluation and written authorization of the client's need for nursing facility services as ordered by the licensed practitioner;
(3) a health screen for clients eligible for the Connecticut Home Care Program for Elders as described in section 17b-342-4(a) of the Regulations of Connecticut State Agencies;
(4) a preadmission MI/MR screen signed by the department; or an exemption form, in accordance with 42 CFR 483.106(b), as amended from time to time, for any hospital discharge, readmission or transfer for which a preadmission MI/MR screen was not completed; and
(5) a preadmission screening level II evaluation for any individual suspected of having mental illness or mental retardation as identified by the preadmission MI/MR screen.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment of Nursing Facilities › Section 17b-262-708 - Applied income

Current through July 10, 2024
(a) The department is responsible for calculating the applied income. The department shall notify the nursing facility of the amount of any applied income that the nursing facility is responsible for collecting. Applied income shall be deducted from what otherwise would have been the department's monthly payment to the nursing facility.
(b) The nursing facility shall notify the department's caseworker of any errors in the amount of applied income processed against the claim using the form specified by the department. Payment adjustments resulting from retroactive applied income corrections shall be processed periodically.
(c) In any month that a resident returns to the community or dies, and the cost of care is less than the applied income, the department shall adjust the applied income as follows: the applied income shall equal the number of days that the resident was in the nursing facility multiplied by the per diem rate.
(d) Applied income is not pro rated. It is used to cover the cost of care until it is expended.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment of Nursing Facilities › Section 17b-262-709 - Billing and payment procedures

Current through July 10, 2024
(a) The nursing facility shall submit claims to the department as described in section 17b-262-529 of the Regulations of Connecticut State Agencies and the billing instructions specific to nursing facilities established by the department.
(b) The nursing facility is responsible for:
(1) completing the daily admission and discharge forms in accordance with the department's instructions;
(2) notifying the department caseworker if the nursing facility is aware that the Medicaid resident's asset level exceeds the established resource limit. The report shall be made on the form specified by the department;
(3) notifying the convalescent payment unit of the department of any and all credits due the department on the form specified by the department; and
(4) exhausting other payment sources of which the nursing facility is aware before billing the department.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment of Nursing Facilities › Section 17b-262-710 - Rates

Current through July 10, 2024
(a) The per diem rates for nursing facilities services are determined annually pursuant to section 17b-340 of the Connecticut general statutes and sections 17-311-1 to 17-311-209, inclusive, of the Regulations of Connecticut State Agencies.
(b) the department shall reimburse the nursing facility at the lower of:
(1) the per diem rate minus the applied income; or
(2) the usual and customary charge minus the applied income.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment of Nursing Facilities › Section 17b-262-711 - Documentation

Current through July 10, 2024
(a) The nursing facility shall maintain all documentation required for rate setting purposes in accordance with section 17-311-56 of the Regulations of Connecticut State Agencies, including all documentation required to support the billing for bed reserve days described in subsection (e)(5) of this section. This documentation is subject to review and audit by the department.
(b) The nursing facility shall maintain all other documentation required by this section for at least five (5) years or longer as required by statute or regulation, subject to review by authorized department personnel. In the event of a dispute concerning a service provided, the nursing facility shall maintain all documentation until the end of the dispute, for five (5) years, or for the length of time required by statute or regulation, whichever is longest.
(c) Failure to maintain all required documentation may result in the disallowance and recovery by the department of any amounts paid to the nursing facility for which the required documentation is not maintained and provided to the department upon request. Documentation requirements are described in detail in the Provider Agreement for Nursing Facilities and sections 17b-262-522 to 17b-262-533, inclusive, of the Regulations of Connecticut State Agencies.
(d) The department requires that nursing facilities maintain fiscal and medical records to fully disclose services and goods rendered or delivered to Medicaid residents. Records shall be maintained in accordance with the department's Provider Agreement for nursing facilities.
(e) Required documentation includes:
(1) certification for nursing facility admission as required by the department. The form shall be signed by the licensed practitioner;
(2) the department's written authorization of the client's need for nursing facility care;
(3) a health screen signed by the department for clients eligible for the Connecticut Home Care Program for Elders;
(4) all admission and discharge forms supporting the claim;
(5) all documentation required to support the nursing facility's billing for and the department's payment of bed reserve days as described in section 19a-537 of the Connecticut General Statutes;
(6) all documentation required by the PASRR process including:
(A) a preadmission MI/MR screen signed by the department or an exemption letter, in the form and manner prescribed by the department, for any hospital discharge, readmission or transfer for which a preadmission MI/MR screen is not on file; and
(B) a preadmission screening level II evaluation, signed by DMHAS or DMR, for any resident suspected of having mental illness or mental retardation, respectively, as identified on the preadmission MI/MR screen.
(7) medical records in accordance with section 19-13-D8t(o) 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 for Medical and Surgical Supplies › Section 17b-262-712 - Scope

Current through July 10, 2024
Sections 17b-262-712 to 17b-262-722, inclusive, of the Regulations of Connecticut State Agencies set forth the Department of Social Services' requirements for payment to providers of medical and surgical supplies provided to eligible Medicaid clients residing at home.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment for Medical and Surgical Supplies › Section 17b-262-713 - Definitions

Current through July 10, 2024
As used in sections 17b-262-712 to 17b-262-722, inclusive, of the Regulations of Connecticut State Agencies:
(1) "Chronic disease hospital" means "chronic disease hospital" as defined in section 19-13-D1 of the Regulations of Connecticut State Agencies;
(2) "Client" means a person eligible for goods or services under the Medicaid program;
(3) "Commissioner" means the Commissioner of Social Services or his or her designee;
(4) "Department" means the Department of Social Services or its agent;
(5) "Documented in writing" means handwritten, typed or computer printed;
(6) "EPSDT (Early & Periodic Screening & Diagnostic Treatment) special services" means services provided in accordance with subdivision 1905 (r) of the Social Security Act;
(7) "Home" means the client's place of residence, including a boarding home, community living arrangement or residential care home. Home does not include facilities such as hospitals, chronic disease hospitals, nursing facilities, intermediate care facilities for the mentally retarded or other facilities that are paid an all-inclusive rate directly by Medicaid for the care of the client;
(8) "Hospital" means "short-term hospital" as defined in section 19-13-D1(b)(1) of the Regulations of Connecticut State Agencies;
(9) "Intermediate care facility for the mentally retarded" or "ICF/MR" means a residential facility for the mentally retarded licensed pursuant to section 17a-227 of the Connecticut General Statutes and certified to participate in the Medicaid program as an intermediate care facility for the mentally retarded pursuant to 42 CFR 442.101, as amended from time to time;
(10) "Licensed practitioner" means an individual who is licensed by the Connecticut Department of Public Health, another state, District of Columbia or the Commonwealth of Puerto Rico and is acting within his or her scope of practice under Connecticut state law in prescribing a medical or surgical supply;
(11) "Medical and surgical supplies" or "supply" means treatment products that:
(A) are fabricated primarily and customarily to fulfill a medical or surgical purpose;
(B) are used in the treatment or diagnosis of specific medical conditions;
(C) are generally not useful in the absence of illness or injury; and
(D) are generally not reusable and are disposable.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment for Medical and Surgical Supplies › Section 17b-262-714 - 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 for Medical and Surgical Supplies › Section 17b-262-715 - Eligibility

Current through July 10, 2024
Payment for medical and surgical supplies is available for clients who have a medical necessity for such supplies, when the supplies are prescribed by a licensed practitioner, subject to the conditions and limitations set forth in sections 17b-262-712 to 17b-262-722, 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 for Medical and Surgical Supplies › Section 17b-262-716 - Supplies covered and limitations

Current through July 10, 2024
(a)
Supplies covered
(1) The department shall pay for the purchase of medical and surgical supplies, except as limited by sections 17b-262-712 to 17b-262-722, inclusive, of the Regulations of Connecticut State Agencies, that conform to accepted methods of diagnosis and treatment and are medically necessary and medically appropriate.
(2) Payment for medical and surgical supplies is available only to clients who live at home.
(3) The department shall maintain a non-exclusive fee schedule of supplies which it has determined meet the department's definition of medical and surgical supplies and for which coverage shall be provided to eligible clients, subject to the conditions and limitations set forth in sections 17b-262-712 to 17b-262-722, inclusive, of the Regulations of Connecticut State Agencies.
(4) When the supply for which coverage is requested is not on the department's fee schedule, prior authorization is required for that supply. The provider requesting coverage for a prescribed supply not on the list shall submit a prior authorization request to the department through an enrolled provider of medical and surgical supplies. Such request shall include a prescription and documentation showing the client's medical necessity for the prescribed supply. The provider also shall include documentation showing that the supply meets the department's definition of a medical and surgical supply and is medically appropriate for the client requesting coverage of such supply.
(5) The department shall pay for medical and surgical supplies for EPSDT special services.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment for Medical and Surgical Supplies › Section 17b-262-717 - Supplies not covered

Current through July 10, 2024
The department shall not pay providers for:
(1) standard or stock medical and surgical supplies prescribed and ordered for a client who:
(A) dies prior to delivery of the supply; or
(B) is not otherwise eligible on the date of delivery. It shall be the provider's responsibility to verify that the client is eligible on the date the supply is delivered;
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment for Medical and Surgical Supplies › Section 17b-262-718 - Prior authorization

Current through July 10, 2024
(a) To receive payment from the department, providers shall comply with all prior authorization requirements. The department in its sole discretion determines what information is necessary in order to approve a prior authorization request. Prior authorization does not guarantee payment unless all other requirements are met.
(b) The department requires prior authorization for any supply identified on the department's published fee schedule as requiring prior authorization or any supply not on the department's fee schedule.
(c) A prior authorization request, on forms and in a manner as specified by the department, shall include documentation of medical necessity and shall be signed by the prescribing licensed practitioner and the supplier. A copy of the prescription from the licensed practitioner may be attached to the completed PA request in lieu of the actual signature of the licensed practitioner on the PA request form. The licensed practitioner's original prescription shall be on file with the provider and be subject to review by the department.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment for Medical and Surgical Supplies › Section 17b-262-719 - Billing procedure

Current through July 10, 2024
(a) Claims from providers shall be submitted on a hard copy invoice or electronically transmitted to the department or its agent, in a form and manner that the department shall specify and shall include all information that the department shall require to process the claim for payment.
(b) Claims submitted for medical and surgical supplies not requiring prior authorization shall include the name of the licensed practitioner prescribing the supplies. A licensed practitioner's original prescription for the supplies shall be on file in the client's record with the provider and shall be subject to review by the department.
(c) Providers shall use the Healthcare Common Procedure Coding System (HCPCS), as maintained and distributed by the United States Department of Health and Human Services, for billing for medical and surgical supplies. Providers shall consult the Medicare SADMERC (Statistical Analysis Durable Medical Equipment Regional Carrier) if necessary to determine the proper billing code. A miscellaneous HCPCS code shall not be used unless a specific HCPCS code is not available for a supply. If a provider submits a prior authorization request to the department using a miscellaneous code for a supply that has a specific HCPCS code, the authorization request shall be denied.
(d) Providers shall bill the usual and customary charge.
(e) The department shall pay the lowest of:
(1) the lowest Medicare rate;
(2) the amount in the applicable fee schedule as published by the department;
(3) the provider's usual and customary charge; or
(4) the amount previously authorized in writing by the department.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment for Medical and Surgical Supplies › Section 17b-262-720 - Payment limitations

Current through July 10, 2024
The price for any supply listed in the fee schedule published by the department shall include and the department shall pay the lowest:
(1) fees for initial measurements, fittings and adjustments and related transportation costs;
(2) labor charges;
(3) delivery costs, fully prepaid by the provider, including any and all manufacturer's delivery charges with no additional charges to be made for packing or shipping;
(4) travel to the client's home;
(5) technical assistance to the client to teach the client, or his or her family, the proper use and care of the supplies;
(6) information furnished by the provider to the client over the telephone; and
(7) the provider shall accept the department's payment as payment in full.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment for Medical and Surgical Supplies › Section 17b-262-721 - Documentation

Current through July 10, 2024
(a) All required documentation shall be maintained for at least five years or the length of time required by statute in the provider's file subject to review by the department. In the event of a dispute concerning a service or a supply provided, documentation shall be maintained until the end of the dispute, five years or the length of time required by statute, whichever is longest.
(b) Failure to maintain all required documentation shall result in the disallowance of payment and recovery by the department of any amounts paid to the provider for supplies for which the required documentation is not maintained or provided to the department upon request.
(c) The licensed practitioner's original prescription for medical and surgical supplies shall be on file with the provider and shall be subject to review by the department.
(d) The department requires that providers maintain fiscal and medical records to fully disclose services and goods rendered or delivered to clients.
(e) A signed receipt is required for all deliveries of medical and surgical supplies documenting that the client or, if the client is unable to sign, a designated representative or adult other than the provider or the provider's employee, took delivery of the supply. The receipt for medical and surgical supplies, regardless of format used, shall, at a minimum, contain the following elements:
(1) provider's name;
(2) client's name;
(3) delivery address;
(4) date of delivery; and
(5) itemization of the medical and surgical supplies delivered, including:
(A) product description;
(B) brand name;
(C) quantity delivered; and
(D) amount billed per supply.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment for Medical and Surgical Supplies › Section 17b-262-722 - Other

Current through July 10, 2024
(a) Where brand names or stock numbers are specified on the prescription or the PA, no substitution shall be permitted without the written approval of the department.
(b) The provider shall instruct the client or his or her family, designated representative or adult, on the proper use and care of the supply. This instruction shall be provided as a part of the cost of the supply.
(c) Providers shall notify the department of returns of medical and surgical supplies delivered to a client. Providers shall initiate necessary reimbursement adjustments resulting from such returns.
(d) The provider shall maintain a current usual and customary price list.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment of Home Health Care Services › Section 17b-262-724 - Scope

Current through July 10, 2024
Sections 17b-262-724 to 17b-262-735, inclusive, of the Regulations of Connecticut State Agencies set forth the Department of Social Services requirements for the payment of home health care services on behalf of clients who are determined eligible to receive services under the Connecticut Medicaid 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 of Home Health Care Services › Section 17b-262-725 - Definitions

Current through July 10, 2024
As used in section 17b-262-724 to section 17b-262-735, inclusive, of the Regulations of Connecticut State Agencies:
(1) "Activity of daily living" or "ADL" means any activity necessary for self care including bathing, dressing, toileting, transferring and feeding;
(2) "Acute" means symptoms that are severe and have a rapid onset and a short course;
(3) "Care plan" means the patient care plan as set forth in section 19-13-D73 of the Regulations of Connecticut State Agencies;
(4) "Chronic disease hospital" means "chronic disease hospital" as defined in section 19-13-D1(b)(2) of the Regulations of Connecticut State Agencies;
(5) "Client" means a person eligible for goods or services under Medicaid;
(6) "Commissioner" means the Commissioner of Social Services or his or her designee;
(7) "Concurrent" means in the same time period covered by the care plan;
(8) "Department" means the Department of Social Services or its agent;
(9) "Early and periodic screening, diagnostic, and treatment services" or "EPSDT" means the services provided in accordance with section 1905(r) of the Social Security Act, as amended from time to time;
(10) "Emergency" means a medical condition, including labor and delivery, manifesting itself by acute symptoms of sufficient severity, including severe pain, such that the absence of immediate medical attention could reasonably be expected to result in placing the client's health in serious jeopardy, serious impairment to bodily functions or serious dysfunction of any bodily organ or part;
(11) "Extended nursing services" means nursing care services that are required for more than two continuous, consecutive hours on any given day;
(12) "Hands on care" means the assistance with activities of daily living provided most often, but not exclusively, by home health aides. The assistance includes the prompting and cueing necessary for a client to perform an activity of daily living;
(13) "Home" means the client's place of residence, including, but not limited to, a boarding home, residential care home or community living arrangement. "Home" does not include facilities such as hospitals, nursing facilities, chronic disease hospitals, intermediate care facilities for the mentally retarded (ICFs/MR) or other facilities that are paid an all-inclusive rate directly by Medicaid for the care of the client;
(14) "Home health aide" means "homemaker-home health aide" as defined in section 19-13-D66 of the Regulations of Connecticut State Agencies;
(15) "Home health care agency" means "home health care agency" as defined in section 19a-490 of the Connecticut General Statutes and which:
(A) is licensed by the Department of Public Health pursuant to sections 19-13-D66 to 19-13-D79, inclusive, of the Regulations of Connecticut State Agencies;
(B) meets the requirements of 42 CFR Parts 440, 441 and 484, as amended from time to time; and
(C) is enrolled in Medicaid;
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment of Home Health Care Services › Section 17b-262-726 - 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, and sections 17b-262-1 to 17b-262-9, 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 Home Health Care Services › Section 17b-262-727 - Eligibility

Current through July 10, 2024
Payment for home health care services provided to persons eligible for Medicaid shall be available subject to the conditions and limitations that apply to these services as identified in sections 17b-262-724 to 17b-262-735, 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 Home Health Care Services › Section 17b-262-728 - Services covered and limitations

Current through July 10, 2024
(a) Subject to the limitations and exclusions identified in sections 17b-262-724 to 17b-262-735, inclusive, of the Regulations of Connecticut State Agencies, the department shall pay for medically necessary and medically appropriate home health care services provided by home health care agencies that are directly related to the client's diagnosis, symptoms or medical history. These services include:
(1) nursing care services limited to the following:
(A) physical nursing care or the teaching of nursing care, including, but not limited to, direct services such as enemas, irrigations, dressing changes, treatments and administration and supervision of medication;
(B) admission of clients to agency services; development of the initial care plan; and subsequent reviews of the care plan, no more than one every 60 days;
(C) diabetic teaching for thirty consecutive days per diabetic client;
(D) pregnancy-related preventive prenatal and postpartum nursing care services to women at high risk of negative pregnancy outcome that are performed during the prenatal or postpartum period of pregnancy for the purpose of, but not limited to:
(i) evaluation of medical health status, obstetrical history, present and past pregnancy related problems and psychosocial factors such as emotional status, inadequate resources, supportive helping networks and parenting skills; and
(ii) the provision of general health education and counseling, referral, instruction, suggestions, support or observation to monitor for any untoward changes in the condition of a prenatal or postpartum woman at high risk so that other medical or social services, if necessary, can be instituted during the prenatal or postpartum stage of childbearing;
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment of Home Health Care Services › Section 17b-262-729 - Services not covered

Current through July 10, 2024
The department shall not pay a home health care agency:
(1) for services provided to a client who is receiving the same service concurrently from an individual therapist, clinic, hospital, practitioner, rehabilitation center or other health care provider;
(2) for services provided by or through another agency or facility as part of its licensing requirements. For example, the department shall not pay for home health aide services if the client lives in a facility that provides home health aide services as part of its licensing requirements;
(3) when the client is in a hospital, nursing facility, chronic disease hospital, ICF/MR or other facility that is paid an all-inclusive rate directly by Medicaid for the care of the client;
(4) when the client is receiving the same home health care services concurrently from another home health care agency. This limitation does not preclude a home health care agency from contracting with another agency as described in section 19-13-D70 of the Regulations of Connecticut State Agencies;
(5) for well child care or for prenatal or postpartum care that is not high risk;
(6) for medical and surgical supplies or durable medical equipment used by the nurse, home health aide or therapist as part of the course of treatment for a client;
(7) for cancelled visits, appointments not kept or services not provided;
(8) for information or services provided to a client over the telephone; or
(9) for anything of an unproven, experimental or research nature or for services in excess of those deemed medically necessary and medically appropriate by the department to treat the client's condition or for services not directly related to the client's diagnosis, symptoms or medical history.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment of Home Health Care Services › Section 17b-262-730 - Cost effectiveness test

Current through July 10, 2024
(a) The department shall apply a cost effectiveness test for all prior authorization requests for:
(1) home health aide services in excess of fourteen hours per week; and
(2) all extended nursing services. The purpose of said test is to ensure that the services requiring PA, when combined with other services provided and within the home health care agency's scope of practice, whether or not provided by the home health agency, are not more expensive than the cost of the care would be for the client if the client were to be placed in the appropriate institution.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment of Home Health Care Services › Section 17b-262-731 - Need for service

Current through July 10, 2024
(a) The department shall pay for medically necessary and medically appropriate home health care services only under orders of a licensed practitioner as part of a care plan.
(b) The department shall pay for pregnancy-related preventive prenatal or postpartum nursing care services only if the woman has one, or a combination of, high risk indicators including, but not limited to, the following, which, in the opinion of her licensed practitioner, places the woman at high risk for negative pregnancy outcomes:
(1) an age under 20;
(2) an age over 39;
(3) a late registration for prenatal care that starts after the sixteenth week of gestation;
(4) no prenatal care;
(5) a serious weight loss or inadequate weight gain of seven pounds or less;
(6) a prenatal weight of more than eighty percent above the standard for height and age;
(7) more than one abortion, or an abortion within three months before the current pregnancy;
(8) a previous neonatal or fetal death;
(9) a previous preterm birth;
(10) an infant with a significant congenital anomaly or central nervous system damage;
(11) violence or deprivation that was abusive or damaging to the woman or her children;
(12) active substance abuse or an addiction, or a history of substance abuse or addiction, such as alcohol, drugs or nicotine;
(13) an active sexually transmitted disease or a history of such a disease;
(14) diseases or conditions including, but not limited to:
(A) human immunodeficiency virus (HIV), including related conditions such as acquired immune deficiency syndrome (AIDS) or AIDS related complex (ARC);
(B) cancer;
(C) acute or chronic cardiac disease;
(D) chronic renal disease;
(E) a seizure disorder;
(F) hypertension, either pre-existing or gestational;
(G) mental disorder without social or psychiatric supervision;
(H) mental retardation without supervision or support;
(I) endocrine or metabolic disorder;
(J) hepatitis;
(K) multiple sclerosis; or
(L) nutritional deficiency; and
(15) an infant up to sixty days of age with one or a combination of diseases or conditions such as:
(A) HIV, including related conditions such as AIDS or ARC;
(B) a birth before thirty-six weeks of gestation or a birth weight under two thousand five hundred grams;
(C) central nervous system damage;
(D) a failure to thrive or a significant infant feeding problem;
(E) an admission to a neonatal intensive care unit;
(F) a sibling who required treatment for recurring apnea or had sudden infant death syndrome;
(G) mental retardation;
(H) neonatal asphyxia;
(I) a seizure disorder;
(J) a significant congenital anomaly; or
(K) a supervising relative under sixteen years of age.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment of Home Health Care Services › Section 17b-262-732 - Prior authorization

Current through July 10, 2024
(a) To receive payment from the department the provider shall comply with the prior authorization requirements described in section 17b-262-528 of the Regulations of Connecticut State Agencies and this section. The department, in its sole discretion, shall determine what information is necessary to approve a prior authorization request. Prior authorization does not, however, guarantee payment unless all other requirements for payment are met.
(b) Prior authorization, on forms and in a manner as specified by the department, shall be required for:
(1) nursing care services in excess of an initial evaluation and two visits per week;
(2) all extended nursing services;
(3) pregnancy-related preventive prenatal nursing care services in excess of two visits during the prenatal period;
(4) pregnancy-related preventive postpartum nursing care services in excess of two visits during the postpartum period;
(5) home health aide services in excess of fourteen hours per week;
(6) physical therapy services in excess of an initial evaluation and two visits per week;
(7) speech therapy services in excess of an initial evaluation and two visits per week;
(8) occupational therapy services in excess of an initial evaluation and one visit per week;
(9) physical therapy, occupational therapy or speech therapy services in excess of nine visits per therapy type per calendar year per provider per client, when the therapy is for the treatment of the following diagnoses:
(A) all mental disorders including diagnoses relating 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 of the spine covered by the ICD, as amended from time to time; or
(C) cases involving symptoms related to nutrition, metabolism and development covered by the ICD, as amended from time to time; and
(10) Early and periodic screening, diagnostic and treatment services requested under section 1905(r)(5) of the Social Security Act, as amended from time to time.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment of Home Health Care Services › Section 17b-262-733 - Billing procedures

Current through July 10, 2024
(a) Claims from home health care agencies shall be submitted on the department's designated form or electronically transmitted to the department or its agent, in a form and manner as specified by the department, and shall include all information required by the department to process the claim for payment.
(b) The provider shall bill the usual and customary charge and the department shall pay the lowest of:
(1) the provider's usual and customary charge;
(2) the lowest non-managed care Medicare rate;
(3) the amount in the applicable fee schedule as published by the department; or
(4) the amount billed by the provider to the department.
Connecticut Administrative Code › Title 17b - Social Services › 262 - Requirements for Payment of Home Health Agencies › Requirements for Payment of Home Health Care Services › Section 17b-262-734 - Payment

Current through July 10, 2024
(a)
Payment
(1) The commissioner shall establish the fees for home health care services in the department's fee schedule pursuant to section 17b-242 of the Connecticut General Statutes.
(2) The department shall pay for home health aide services based on each unit of service the aide spends providing the services as described in the fee schedule.
(3) The department shall pay therapists as described in the fee schedule.
(4) The department shall pay for nursing services based on each visit or unit of service the nurse spends providing the services as described in the fee schedule.