Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 78 - Amount, Duration and Scope of Medical and Remedial Services › Rule 441-78.9 - Home Health Agencies

Current through Register Vol. 47, No. 3, July 24, 2024
Payment shall be approved for medically necessary home health
				  agency services prescribed by a physician, nurse practitioner, clinical nurse
				  specialist, or physician assistant in a plan of home health care provided by a
				  Medicare-certified home health agency.
The number of hours of home health agency services shall be
				  reasonable and appropriate to meet an established medical need of the member
				  that cannot be met by a family member, significant other, friend, or neighbor.
				  Services must be medically necessary in the individual case and be related to a
				  diagnosed medical impairment or disability.
The member need not be homebound to be eligible for home
				  health agency services; however, the services provided by a home health agency
				  shall only be covered when provided in the member's residence with the
				  following exception. Private duty nursing and personal care services for
				  persons aged 20 and under as described at 78.9(10)
"a"
may be
				  provided in settings other than the member's residence when medically
				  necessary.
Medicaid members of home health agency services need not
				  first require skilled nursing care to be entitled to home health aide
				  services.
Further limitations related to specific components of home
				  health agency services are noted in subrules 78.9(3) to 78.9(10).
Payment shall be made on an encounter basis. An encounter is
				  defined as separately identifiable hours in which home health agency staff
				  provide continuous service to a member.
Payment for supplies shall be approved when the supplies are
				  incidental to the patient's care, e.g., syringes for injections, and do not
				  exceed $15 per month. Dressings, durable medical equipment, and other supplies
				  shall be obtained from a durable medical equipment dealer or pharmacy. Payment
				  of supplies may be made to home health agencies when a durable medical
				  equipment dealer or pharmacy is not available in the member's community.
Payment may be made for restorative and maintenance home
				  health agency services.
Payment may be made for teaching, training, and counseling in
				  the provision of health care services.
Treatment plans for these services shall additionally
				  reflect: to whom the services are to be provided (patient, family member,
				  etc.); prior teaching training, or counseling provided; medical necessity for
				  the rendered service; identification of specific services and goals; date of
				  onset of the teaching, training, or counseling; frequency of services; progress
				  of member in response to treatment; and estimated length of time these services
				  will be needed.
The following are not covered: services provided in the home
				  health agency office, homemaker services, well child care and supervision, and
				  medical equipment rental or purchase.
Services shall be authorized by a physician, nurse
				  practitioner, clinical nurse specialist, or physician assistant, evidenced by
				  the physician's, nurse practitioner's, clinical nurse specialist's, or
				  physician assistant's signature and date on a plan of treatment.
(1)
Treatment plan.
A plan
				of treatment shall be completed prior to the start of care and at a minimum
				reviewed every 60 days thereafter. There must be a face-to-face encounter
				between a physician, a nurse practitioner, a clinical nurse specialist, a
				certified nurse-midwife, or a physician assistant and the Medicaid member no
				more than 90 days before or 30 days after the start of service. The plan of
				care shall support the medical necessity and intensity of services to be
				provided by reflecting the following information:
a. Place of service.
b. Type of service to be rendered and the
				treatment modalities being used.
c.
				Frequency of the services.
d.
				Assistance devices to be used.
e.
				Date home health services were initiated.
f. Progress of member in response to
				treatment.
g. Medical supplies to
				be furnished.
h. Member's medical
				condition as reflected by the following information, if applicable:
(1) Dates of prior hospitalization.
(2) Dates of prior surgery.
(3) Date last seen by a physician, nurse
				practitioner, clinical nurse specialist, or physician assistant.
(4) Diagnoses and dates of onset of diagnoses
				for which treatment is being rendered.
(5) Prognosis.
(6) Functional limitations.
(7) Vital signs reading.
(8) Date of last episode of
				instability.
(9) Date of last
				episode of acute recurrence of illness or symptoms.
(10) Medications.
i. Discipline of the person providing the
				service.
j. Certification period
				(no more than 60 days).
k.
				Estimated date of discharge from the hospital or home health agency services,
				if applicable.
l. Physician's,
				nurse practitioner's, clinical nurse specialist's, or physician assistant's
				signature and date. The plan of care must be signed and dated by the physician,
				nurse practitioner, clinical nurse specialist, or physician assistant before
				the claim for service is submitted for reimbursement.