reglab/statecodes huggingface dataset:
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 30 - Transportation Services › Section 30-1.5 - Reimbursement rates for transportation services

Current through July 10, 2024
Authority: IC 12-15
Affected: IC
				  12-13-7-3; IC
				  12-15-6; IC
				  12-15-13-6
Sec. 1.5.
(a)
				Reimbursement rates for ambulance transportation services shall be the rates
				listed in this subsection. Updates to covered procedure codes and rates shall
				be published as a provider bulletin by the office as needed. Any such updates
				shall be made effective no earlier than permitted under IC
				12-15-13-6(a).
				The reimbursement rates for ambulance transportation services are as follows:
Procedure Code
Rate
A0140
Ticket Price
A0225
$160.84
A0420 U1
$20.00
A0420 U2
$20.00
A0422
$15.00
A0424
$5.00
A0425 U1
$4.41
A0425 U2
$3.31
A0426
$95.84
A0427
$160.84
A0428
$95.84
A0429
$110.84
A0430
$2,788.24
A0431
$3,172.27
A0431 QL
$3,172.27
A0433
$160.84
A0435
$8.07
A0436 A0999
$21.53 Manual Pricing
(b)
				Reimbursement rates for nonemergency (nonambulance) transportation services
				shall be the rates listed in this subsection. Updates to covered procedure
				codes and rates shall be published as a provider bulletin by the office as
				needed. Any such updates shall be made effective no earlier than permitted
				under IC 12-15-13-6(a).
				The reimbursement rates for nonemergency (nonambulance) transportation services
				are as follows:
Procedure Code
Rate
A0100 UA
$6.00
A0100 UB
$10.00
A0100 UC
$15.00
A0100 U4
$15.00
A0100 TK UA
$3.00
A0100 TK UB
$5.00
A0100 TK UC
$7.50
A0100 TT UA
$3.00
A0100 TT UB
$5.00
A0100 TT UC
$7.50
A0110
Ticket Price
A0130
$20.00
A0130 TK
$10.00
A0130 TT
$10.00
A0130 U6
$5.00
A0425 U3
$1.25
A0425 U5
$1.25
T2001
$5.00
T2003
$10.00
T2004
$5.00
T2007 U3
$4.25
T2007 U5
$4.25
(c)
				Notwithstanding all other provisions of this rule, the fee schedule rates
				listed in this section will be reduced by five percent (5%) for emergency
				transportation services (ambulance services) and by ten percent (10%) for
				nonemergency transportation services (nonambulance services). These rate
				reductions will be in effect for the period beginning upon the later of the
				effective date of LSA Document #10-792 or June 27, 2011, and continuing through
				June 30, 2013.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 30 - Transportation Services › Section 30-2 - Copayments for transportation services

Current through July 10, 2024
Authority: IC 12-15-1-10; IC 12-15-6-5; IC 12-15-21-2; IC
				  12-15-21-3
Affected: IC 12-13-7-3; IC 12-15-6
Sec. 2.
In accordance with IC 12-15-6, a copayment will be required
				  for transportation services as follows:
(1) The copayment shall be made by the member
				and collected by the provider at the time the service is rendered. Medicaid
				reimbursement to the provider shall be adjusted to reflect the copayment amount
				for which the member is liable.
(2)
				In accordance with 42 CFR
				447.15, effective October 1, 1991, not
				including tertiary citations therein, the provider may not deny services to any
				eligible individual on account of the individual's inability to pay the
				copayment amount. Under this federal requirement, this service guarantee does
				not apply to an individual who is able to pay, nor does an individual's
				inability to pay eliminate his or her liability for the copayment.
(3) The provider shall collect from the
				member a copayment amount equal to the following:
(A) Fifty cents ($0.50) for services for
				which Medicaid pays ten dollars ($10) or less.
(B) One dollar ($1) for services for which
				Medicaid pays ten dollars and one cent ($10.01) to fifty dollars
				($50).
(C) Two dollars ($2) for
				services for which Medicaid pays fifty dollars and one cent ($50.01) or
				more.
(D) No copayment will be
				required for an accompanying adult traveling with a minor member or for an
				attendant.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 30 - Transportation Services › Section 30-3 - Noncovered transportation services

Current through July 10, 2024
Authority: IC
				  12-15-1-10; IC
				  12-15-6-5; IC
				  12-15-21-2; IC
				  12-15-21-3
Affected: IC
				  12-13-7-3; IC
				  12-15-6
Sec. 3.
Medicaid reimbursement is not available for the following
				  transportation services:
(1) One-way
				trips exceeding twenty (20) per member, per rolling twelve (12) month period of
				time, except when additional trips are medically necessary and the same is
				demonstrated and documented through the prior authorization process. The
				services identified in section 1(1) of this rule are exempt from the numeric
				cap and do not require prior authorization, except as specified in section 1(2)
				of this rule.
(2) Trips of fifty
				(50) miles or more one (1) way unless prior authorization is
				obtained.
(3) The first thirty (30)
				minutes of waiting time for any type of Medicaid covered conveyance, including
				ambulance.
(4) Nonemergency
				transportation provided by any of the following:
(A) A volunteer with no vested or personal
				interest in the member.
(B) An
				interested individual or neighbor of the member.
(C) A case worker or social worker.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 30 - Transportation Services › Section 30-4 - Prior authorization

Current through July 10, 2024
Authority: IC
				  12-15-1-10; IC
				  12-15-6-5; IC
				  12-15-21-2; IC
				  12-15-21-3
Affected: IC
				  12-13-7-3; IC
				  12-15-6
Sec. 4.
Prior authorization is required for the following
				  transportation services:
(1) Train or
				bus services.
(2) Family member
				services.
(3) Airline or air
				ambulance and transportation services rendered by a provider located
				out-of-state in a nondesignated area.
(4) Transportation rendered by any provider
				to or from an out-of-state nondesignated area.
(5) Trips exceeding twenty (20) one-way trips
				per member, per rolling twelve (12) month period of time, except as specified
				in section 1 of this rule.
(6)
				Trips of fifty (50) miles or more one (1) way.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 30 - Transportation Services › Section 30-5 - Ambulance services

Current through July 10, 2024
Authority: IC
				  12-15-1-10; IC
				  12-15-6-5; IC
				  12-15-21-2; IC
				  12-15-21-3
Affected: IC
				  12-13-7-3; IC
				  12-15-6
Sec. 5.
Medicaid reimbursement is available for medically necessary
				  emergency and nonemergency ambulance services subject to the following:
(1) Medicaid will reimburse both basic and
				advanced life support emergency ambulance services; however, advanced life
				support ambulance services are covered only when such level of service is
				medically necessary, and a basic emergency ambulance is not appropriate due to
				the medical condition of the member being transported.
(2) Medicaid reimbursement is available for
				specialized neonatal ambulance services used exclusively for interhospital
				transfers of high risk and premature infants only when the member has been
				discharged from one (1) hospital for the purpose of admission to another
				hospital and only when such neonatal ambulances are recognized by emergency
				medical services.
(3) Ambulance
				services are subject to maximum allowable fees. Medicaid reimbursement is
				available for the following ambulance services:
(A) Loading fee.
(B) Loaded mileage, which shall be paid for
				each mile of the trip.
(C)
				Oxygen.
(D) Waiting time, except
				for the first thirty (30) minutes, and only when the trip exceeds fifty (50)
				miles one (1) way and prior authorization has been obtained from the Medicaid
				contractor.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 30 - Transportation Services › Section 30-6 - Intrastate wheelchair/nonambulatory services

Current through July 10, 2024
Authority: IC
				  12-15-1-10; IC
				  12-15-6-5; IC
				  12-15-21-2; IC
				  12-15-21-3
Affected: IC
				  12-13-7-3; IC
				  12-15-6
Sec. 6.
Intrastate wheelchair/nonambulatory services are
				  reimbursable when a member must travel in a wheelchair to or from an Indiana
				  Medicaid covered service. Wheelchair/nonambulatory services are subject to
				  maximum allowable fees. Reimbursement is available as follows:
(1) Base rate means the flat fee paid by
				Medicaid for all trips, regardless of trip length.
(2) In addition to the base rate, mileage
				payments are available for loaded miles in excess of a specified number of
				miles as determined by the state.
(3) Waiting time is reimbursable only when
				the member must travel fifty (50) miles or more one (1) way and prior
				authorization has been obtained from the Medicaid contractor. Waiting time is
				reimbursable only for those cases in which the vehicle is parked outside the
				provider of medical service awaiting the return of the member to the vehicle.
				The first thirty (30) minutes of waiting time are not covered by
				Medicaid.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 30 - Transportation Services › Section 30-7 - Intrastate commercial ambulatory services

Current through July 10, 2024
Authority: IC
				  12-15-1-10; IC
				  12-15-6-5; IC
				  12-15-21-2; IC
				  12-15-21-3
Affected: IC
				  12-13-7-3; IC
				  12-15-6
Sec. 7.
Intrastate commercial ambulatory services are reimbursable
				  when an ambulatory member must travel to or from an Indiana Medicaid covered
				  service. Commercial ambulatory services are those services provided to
				  ambulatory members by any means other than the services described in sections 8
				  through 10 of this rule. This classification includes profit and not-for-profit
				  entities using van, taxi, or bus type vehicles. Commercial ambulatory services
				  are subject to maximum allowable fees. Reimbursement is available as
				  follows:
(1) Taxi providers operating
				within their legal boundaries in accordance with state law whose rates are
				regulated by local ordinance must bill the lower of their metered or zoned
				rate, as established by local ordinance, or the maximum allowed rate.
(2) Taxi providers operating within their
				legal boundaries in accordance with state law whose rates are not regulated by
				local ordinance are reimbursed the lower of their submitted charge or a maximum
				allowable fee based on trip length.
(3) No additional mileage payments above the
				maximum rate are available for taxi services.
(4) Nontaxi commercial ambulatory service
				providers are reimbursed a base rate for all trips regardless of trip length,
				plus mileage payments for loaded miles in excess of a specified number of miles
				as determined by the state.
(5) The
				first thirty (30) minutes of waiting time is not covered by Medicaid. Waiting
				time is covered only when the member must travel fifty (50) miles or more one
				(1) way and prior authorization has been obtained from the Medicaid contractor.
				Waiting time is reimbursable only for those cases in which the vehicle is
				parked outside the provider of medical service awaiting the return of the
				member to the vehicle.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 30 - Transportation Services › Section 30-8 - Reimbursement for additional passengers

Current through July 10, 2024
Authority: IC
				  12-15-1-10; IC
				  12-15-6-5; IC
				  12-15-21-2; IC
				  12-15-21-3
Affected: IC
				  12-13-7-3; IC
				  12-15-6
Sec. 8.
Medicaid reimbursement is available for second or subsequent
				  passengers in a single vehicle at one-half (1/2) the base rate allowance for
				  wheelchair/nonambulatory services and commercial ambulatory services when
				  provided in such vehicles. No additional payment will be made for mileage or
				  waiting time for second or subsequent passengers. Additional Medicaid
				  reimbursement is not available for multiple passengers when the provider
				  involved does not bill non-Medicaid customers for like services. Medicaid will
				  not make additional payment for multiple passengers in ambulance or family
				  member vehicles. The following are the circumstances under which providers may
				  bill for multiple passengers in a single vehicle:
(1) When a minor member is in need of medical
				services and an adult must accompany him or her, payment will be made under the
				commercial ambulatory services or nonambulatory services base code for the
				member and under the appropriate multiple passenger code for the accompanying
				adult. Payment will not be made for the transportation of an individual to
				accompany a competent adult to obtain medical services.
(2) When an adult member is in need of
				medical services and because of his or her condition must have an assistant to
				travel with him or her and/or stay with him or her in the place of medical
				service, the commercial ambulatory services or the nonambulatory services base
				code will be reimbursed for the member and the accompanying multiple passenger
				code will be reimbursed for the assistant.
(3) When more than one (1) member is
				transported simultaneously from the same county to the same vicinity for
				medical services, the full base code (commercial ambulatory services or
				nonambulatory services) will be reimbursed for the first member, plus mileage
				and waiting codes, where appropriate. Payment for the second and subsequent
				members is available for one-half (1/2) the base rate allowance. Mileage and
				waiting codes may not be billed.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 30 - Transportation Services › Section 30-9 - Reimbursement for family member transportation services

Current through July 10, 2024
Authority: IC 12-15
Affected: IC 12-13-7-3; IC 12-15-6
Sec. 9.
Family members enrolled as transportation providers under
				  405 IAC 5-4-3 are eligible for
				  reimbursement for mileage only. Reimbursement is determined by the actual
				  loaded mileage multiplied by the rate per mile established by the Indiana
				  legislature for state employees. The office must authorize all family member
				  transportation. Notwithstanding all other provisions of this rule, beginning
				  upon the later of the effective date of LSA Document #10-792 or June 27, 2011,
				  and continuing through June 30, 2013, rates calculated under this section shall
				  be reduced by ten percent (10%).
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 30 - Transportation Services › Section 30-10 - Reimbursement for other transportation services

Current through July 10, 2024
Authority: IC
				  12-15-1-10; IC
				  12-15-6-5; IC
				  12-15-21-2; IC
				  12-15-21-3
Affected: IC
				  12-13-7-3; IC
				  12-15-6
Sec. 10.
Medicaid reimbursement is available for other transportation
				  services, including, but not limited to, intrastate bus or train
				  transportation. Medicaid payment for other transportation services will be that
				  fee usually and customarily charged the general public, subject to federal,
				  state, or local law, rule, or ordinance. Intrastate bus or train services
				  (including services provided in designated areas) require authorization by the
				  office, and interstate bus or train services require authorization from the
				  contractor. Authorization may be given for use of monthly bus passes in
				  situations where a member has an ongoing medical need so that purchase of the
				  bus pass is cost effective when compared to the cost of other modes of
				  transportation. Such authorization shall be given only if the member has agreed
				  to the use of this mode of transportation. To be reimbursed, the bus or train
				  company providing services must be enrolled as a provider.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 30 - Transportation Services › Section 30-11 - IEP transportation services

Current through July 10, 2024
Authority: IC 12-15
Affected: IC 12-13-7-3; IC 20-27
Sec. 11.
Medicaid reimbursement is available for IEP transportation
				  services subject to the following limitations:
(1) Services are consistent with the
				definition set forth in
				405 IAC 5-2-13.3.
(2) IEP transportation services must be
				listed in a Medicaid enrolled student's IEP and must be necessary to enable the
				student to receive other Medicaid covered services listed in the student's
				IEP.
(3) IEP transportation
				services:
(A) must be rendered by school
				corporation personnel or their contractor; and
(B) are not covered when provided by a member
				of the student's family if the person is not an employee of the school
				corporation.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 31 - Nursing Facility Services › Section 31-1 - Reimbursement

Current through July 10, 2024
Authority: IC 12-15-1-10; IC 12-15-21-2
Affected: IC 12-13-7-3; IC 12-15
Sec. 1.
Medicaid reimbursement is available for nursing facility
				  services provided by a licensed and certified nursing facility in accordance
				  with 405 IAC 1-14.6 or
				  405 IAC 1-17 when rendered to a
				  member whose level of care has been approved by the office.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 31 - Nursing Facility Services › Section 31-1.1 - "Nursing facility services" defined

Current through July 10, 2024
Authority: IC 12-15-1-10; IC 12-15-1-15; IC 12-15-21-2
Affected: IC 12-13-7-3; IC 12-15
Sec. 1.1.
As used in this rule, "nursing facility services" means
				  services ordered by and under the direction of a physician, which can only be
				  provided on an inpatient basis in a certified nursing facility that meets
				  conditions of participation in
				  42 CFR
				  440.150,
				  42 CFR 440.155, and
				  42 CFR
				  483. Members requiring nursing facility level
				  of care are those who do not require the degree of care and treatment that a
				  hospital provides, but who, because of their mental or physical condition,
				  require care and services above the level of room and board.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 31 - Nursing Facility Services › Section 31-4 - Per diem services

Current through July 10, 2024
Authority: IC 12-15-1-10; IC 12-15-1-15; IC 12-15-21-2
Affected: IC 12-13-7-3; IC 12-15
Sec. 4.
Those services and products furnished by the facility for
				  the usual care and treatment of patients are reimbursed in the per diem rate in
				  accordance with
				  405 IAC 1-14.6. The per diem rate
				  for nursing facilities includes the following services:
(1) Room and board (room accommodations, all
				dietary services, and laundry services). The per diem rate includes
				accommodations for semiprivate rooms. Medicaid reimbursement is available for
				medically necessary private rooms. Private rooms will be considered medically
				necessary only under one (1) or both of the following circumstances:
(A) The member's condition requires isolation
				for health reasons, such as communicable disease.
(B) The member exhibits behavior that is or
				may be physically harmful to self or others in the
				facility.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 31 - Nursing Facility Services › Section 31-4.5 - Per diem services, state nursing facility

Current through July 10, 2024
Authority: IC 12-15-1-10; IC 12-15-21-2
Affected: IC 12-13-7-3; IC 12-15
Sec. 4.5.
(a) Those
				services and products furnished by a state nursing facility for the usual care
				and treatment of patients are reimbursed in the per diem rate in accordance
				with 405 IAC 1-17. The per diem rate
				for state nursing facilities includes the following services:
(1) Room and board:
(A) room accommodations;
(B) all dietary services; and
(C) laundry services.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 31 - Nursing Facility Services › Section 31-5 - Legend and prescription items

Current through July 10, 2024
Authority: IC
				  12-15-1-10; IC
				  12-15-1-15; IC
				  12-15-21-2
Affected: IC
				  12-13-7-3; IC 12-15
Sec. 5.
(a) All
				covered legend and nonlegend drugs must be prescribed by a physician.
				Facilities cannot require members to purchase covered legend and nonlegend drug
				items with their personal funds.
(b) Anorectics (except amphetamines), both
				legend and nonlegend, are not covered by Medicaid. Amphetamines are not covered
				services for weight control or treatment of obesity.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 31 - Nursing Facility Services › Section 31-6 - Personal care items

Current through July 10, 2024
Authority: IC 12-15-1-10; IC 12-15-1-15; IC 12-15-21-2
Affected: IC 12-13-7-3; IC 12-15
Sec. 6.
Personal care or comfort items as defined in
				  42 CFR
				  483.10(c)(8)(ii) and
				  42 CFR 483.10(c)(8)(iii) are not
				  covered under Medicaid.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 31 - Nursing Facility Services › Section 31-7 - Limitations on nursing services

Current through July 10, 2024
Authority: IC
				  12-15-1-10; IC
				  12-15-1-15; IC
				  12-15-21-2
Affected: IC
				  12-13-7-3; IC 12-15
Sec. 7.
Routine nursing services are reimbursed by Medicaid within
				  the per diem rate. Such services must be provided by a registered nurse, a
				  licensed practical nurse, or a nurse's aide.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 31 - Nursing Facility Services › Section 31-9 - Prior authorization for services rendered outside the state nursing facility

Current through July 10, 2024
Authority: IC
				  12-15-1-10; IC
				  12-15-21-2; IC
				  12-15-21-3
Affected: IC
				  12-13-7-3; IC 12-15
Sec. 9.
(a) Medical
				care rendered by practitioners outside the state nursing facility requires
				prior authorization.
(b) Prior
				authorization will not be given for medical services included in the per diem
				rate.
(c) Written evidence of
				physician involvement and personal patient evaluation in the progress notes and
				attached to the prior authorization form is required to document that the
				service is medically necessary.
(d)
				Prior authorization will include consideration of the following:
(1) Review of the properly completed Medicaid
				prior authorization request form substantiating both of the following:
(A) The service is medically
				necessary.
(B) Explanation of why
				the service cannot be rendered at the facility.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 32 - Rehabilitation Unit › Section 32-1 - Severity of illness criteria

Current through July 10, 2024
Authority: IC
				  12-15-1-10; IC
				  12-15-1-15; IC
				  12-15-21-2
Affected: IC
				  12-13-7-3; IC 12-15
Sec. 1.
The following criteria shall demonstrate the inability to
				  function independently with demonstrated impairment:
(1) Cognitive function (attention span,
				memory, or intelligence).
(2)
				Communication (aphasia with major receptive or expressive
				dysfunction).
(3) Continence
				(bladder or bowel).
(4) Mobility
				(transfer, walk, climb stairs, or wheelchair).
(5) Pain management (pain behavior limits
				functional performance).
(6)
				Perceptual motor function (spatial orientation or depth or distance
				perception).
(7) Self-care
				activities (drink or feed, dress, maintain personal hygiene, brace or
				prosthesis).
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 32 - Rehabilitation Unit › Section 32-2 - Intensity of service criteria

Current through July 10, 2024
Authority: IC
				  12-15-1-10; IC
				  12-15-1-15; IC
				  12-15-21-2
Affected: IC
				  12-13-7-3; IC 12-15
Sec. 2.
Intensity of service criteria shall be as follows:
(1) Multidisciplinary team evaluation at
				least every two (2) weeks.
(2)
				Physical therapy and at least one (1) of the following therapies (totaling a
				minimum of three (3) hours daily):
(A)
				Occupational therapy.
(B) Speech
				therapy.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 32 - Rehabilitation Unit › Section 32-3 - Discharge criteria

Current through July 10, 2024
Authority: IC
				  12-15-1-10; IC
				  12-15-1-15; IC
				  12-15-21-2
Affected: IC
				  12-13-7-3; IC 12-15
Sec. 3.
Discharge criteria for consideration may include the
				  following:
(1) Evidence in record that
				patient has achieved stated goals.
(2) Medical complications preclude intensive
				rehabilitative effort.
(3)
				Multidisciplinary therapy no longer needed.
(4) No additional functional improvement is
				anticipated.
(5) Patient's
				functional status has remained unchanged for fourteen (14) days.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 33 - Acute Care Hospital Admission › Section 33-1 - Adult medical surgical criteria

Current through July 10, 2024
Authority: IC
				  12-15-1-10; IC
				  12-15-1-15; IC
				  12-15-21-2
Affected: IC
				  12-13-7-3; IC 12-15
Sec. 1.
Day of admission appropriateness shall be as follows:
(1) Severity of illness criteria:
(A) sudden onset of unconsciousness or
				disorientation (coma or unresponsiveness);
(B) pulse rate:
(i) less than fifty (50) per minute;
				or
(ii) greater than one hundred
				forty (140) per minute;
(C) blood pressure:
(i) systolic less than ninety (90) or greater
				than two hundred (200) millimeters mercury; or
(ii) diastolic less than sixty (60) or
				greater than one hundred twenty (120) millimeters mercury;
(D) acute loss of sight or hearing;
(E) acute loss of ability to move body
				part;
(F) persistent fever equal to
				or greater than one hundred (100) (p.o) or greater than one hundred one (101)
				(R) for more than five (5) days;
(G) active bleeding;
(H) severe electrolyte/blood gas abnormality,
				including any of the following:
(i) Na <
				123 mEq/L
Na > 156 mEq/L
(ii) K < 2.5 mEq/L
K > 6.0 mEq/L
(iii) CO2 combining
				power (unless chronically abnormal) < 20 mEq/L
CO2 combining power (unless
				  chronically abnormal) > 36 mEq/L
(iv) Blood pH < 7.30
Blood pH > 7.45;
(I) acute or progressive sensory, motor,
				circulatory, or respiratory embarrassment sufficient to incapacitate the
				patient (inability to move, feed, or breathe); must also meet intensity of
				service criterion simultaneously in order to certify; do not use for back
				pain;
(J) EKG evidence of acute
				ischemia; must be suspicion of a new MI; or
(K) wound dehiscence of
				evisceration.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 33 - Acute Care Hospital Admission › Section 33-2 - Pediatric AEP admission criteria

Current through July 10, 2024
Authority: IC
				  12-15-1-10; IC
				  12-15-1-15; IC
				  12-15-21-2
Affected: IC
				  12-13-7-3; IC 12-15
Sec. 2.
Day of admission appropriateness shall be as follows:
(1) Severity of illness criteria:
(A) sudden onset of unconsciousness (coma or
				unresponsiveness) or disorientation;
(B) acute or progressive sensory, motor,
				circulatory, or respiratory embarrassment sufficient to incapacitate the
				patient (inability to move, feed, breathe, or urinate);
(C) acute loss of sight or hearing;
(D) acute loss of ability to move body
				part;
(E) persistent fever (>
				one hundred (100) degrees orally or > one hundred one (101) degrees
				rectally) for more than ten (10) days;
(F) active bleeding;
(G) wound dehiscence or
				evisceration;
(H) severe
				electrolyte/acid-base abnormality, including any of the following:
(i) Na < 123 mEq/L
Na > 156 mEq/L
(ii) K < 2.5 mEq/L
K > 6.0 mEq/L
(iii) CO2 combining
				power (unless chronically abnormal) [LESS THAN] 20 mEq/L
CO2 combining power (unless
				  chronically abnormal) > 36 mEq/L
(iv) Arterial pH < 7.30
Arterial pH > 7.45;
(I) hematocrit < thirty percent (30%);
(J) pulse rate outside following
				ranges (optimally a sleeping pulse for < twelve (12) years old):
2-6 years old
70-200/minute
7-11 years old
60-180/minute
> 12 years old
50-140/minute
(K)
				blood pressure outside following ranges:
Systolic
Diastolic
2-6 years old
75-125 mm Hg
40-90 mm Hg
7-11 years old
80-130 mm Hg
45-90 mm Hg
< 12 years old
90-200 mm Hg
60-120 mm Hg
(L)
				need for lumbar puncture, where this procedure is not done routinely on an
				outpatient basis;
(M) any conditions
				not responding to outpatient, including emergency room:
(i) seizures;
(ii) cardiac arrhythmia;
(iii) bronchial asthma or croup;
(iv) dehydration;
(v) encopresis (for clean-out); or
(vi) other physiologic problem (specify);
(N) special pediatric
				problems:
(i) child abuse;
(ii) noncompliance with necessary therapeutic
				regimen; or
(iii) need for special
				observation or close monitoring of behavior, including calorie intake in cases
				of failure to thrive.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 34 - Hospice Services › Section 34-1 - Policy

Current through July 10, 2024
Authority: IC 12-15-1-10; IC 12-15-21-2; IC 12-15-40
Affected: IC 12-15
Sec. 1.
(a) Medicaid
				reimbursement is available for hospice services subject to the limitations in
				this rule and
				405 IAC 1-16. Hospice services
				consist of the following:
(1) Palliative care
				for the physical, psychological, social, spiritual, and other special needs of
				a hospice program patient during the final stages of the patient's terminal
				illness.
(2) Care for the
				psychological, social, spiritual, and other needs of the hospice program
				patient's family before and after the patient's death.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 34 - Hospice Services › Section 34-2 - Provider enrollment

Current through July 10, 2024
Authority: IC 12-15-1-10; IC 12-15-21-2; IC 12-15-40
Affected: IC 12-15; IC 16-25-3
Sec. 2.
(a) In order
				to enroll as a hospice provider in Medicaid a provider must submit a provider
				enrollment agreement as specified in
				405 IAC 5-4. A separate provider
				agreement for hospice services must be completed even if the provider currently
				participates in Medicaid as a provider of another service.
(b) A hospice provider must be certified as a
				hospice provider in the Medicare program. A copy of the provider's Medicare
				Certification Letter from the Centers for Medicare and Medicaid Services (CMS),
				formerly the Health Care Financing Administration, must be submitted with the
				Medicaid provider enrollment agreement. The hospice provider who operates at
				more than one (1) location must provide a copy of the Medicare Certification
				Letter from CMS that demonstrates that the regional office has approved each
				additional office location to be Medicare-certified as a either a satellite
				office of the home office location or as a separate hospice with its unique
				Medicare provider number.
(c) The
				provider must comply with all state and federal requirements for Medicaid and
				Medicare providers in addition to the requirements in this section. The hospice
				and all hospice employees must be licensed in accordance with applicable
				federal, state, and local laws and regulations as required under federal
				regulations at 42 CFR
				418.72 and Indiana state hospice licensure at
				IC 16-25-3.
(d) The hospice provider must designate an
				interdisciplinary group composed of individuals who are employees of the
				hospice and who provide or supervise care and services offered by the hospice
				provider. At a minimum, this group must include all of the following persons:
(1) A medical director, who must be a doctor
				of medicine or osteopathy.
(2) A
				registered nurse.
(3) A social
				worker.
(4) A pastoral or other
				counselor.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 34 - Hospice Services › Section 34-3 - Out-of-state providers

Current through July 10, 2024
Authority: IC 12-15-1-10; IC 12-15-21-2; IC 12-15-40
Affected: IC 12-15
Sec. 3.
(a) Subject
				to the conditions in this section and section 2 of this rule, and any
				applicable state or federal licensing laws or regulations, an Indiana resident
				may receive hospice services from an out-of-state hospice provider if the
				provider is:
(1) located in a designated
				out-of-state area pursuant to
				405 IAC 5-5-1; and
(2) enrolled in Medicaid.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 34 - Hospice Services › Section 34-4 - Hospice authorization and benefit periods

Current through July 10, 2024
Authority: IC
				  12-15-1-10; IC
				  12-15-21-2; IC
				  12-15-40
Affected: IC 12-15
Sec. 4.
(a) Hospice
				services require Medicaid hospice authorization by the office or its
				contractor. Medicaid reimbursement is not available for hospice services
				furnished without authorization.
(b) To request hospice authorization for
				Medicaid-only eligible members for each hospice benefit period, the provider
				must submit all of the following documentation on forms approved by the office:
(1) Member election statement.
(2) Medicaid physician
				certification.
(3) Medicaid plan of
				care.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 34 - Hospice Services › Section 34-4.1 - Appeals of hospice authorization determinations

Current through July 10, 2024
Authority: IC 12-15-1-10; IC 12-15-21-2; IC 12-15-40-8
Affected: IC 12-15
Sec. 4.1.
(a) Members
				may appeal the denial or modification of hospice authorization under 405 IAC
				1.1.
(b) Any provider submitting a
				request for hospice authorization under this rule, which has been denied either
				in whole or in part, may appeal the decision under 405 IAC 1.1 after first
				submitting a request for reconsideration of the hospice authorization in
				accordance with the procedures set out in
				405 IAC 5-7-2 and
				405 IAC 5-7-3 for administrative
				reconsideration of prior authorization decisions.
(c) When there is insufficient information
				submitted to render a decision, or the documentation contains errors, a hospice
				authorization request will be suspended pursuant to section 4 of this rule, and
				the office or its contractor will request additional information from the
				provider. Suspension is not a final decision on the merits of the request and
				is not appealable. If the provider does not submit sufficient information
				within the time frames set out in section 4(h) of this rule, the request shall
				be denied. Denial is a final decision and may be appealed pursuant to
				subsections (a) and (b).
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 34 - Hospice Services › Section 34-4.2 - Audit

Current through July 10, 2024
Authority: IC
				  12-15-1-10; IC
				  12-15-21-2; IC
				  12-15-40-8
Affected: IC 12-15
Sec. 4.2.
(a) The
				office may conduct audits of hospice services, including services for which
				hospice authorization has been granted. Audit of hospice services shall include
				review of the medical record to determine the services are medically necessary
				based upon applicable current professional guidelines, including the local
				Medicare medical review policies for hospice services.
(b) If the office determines that hospice
				services for a member are not medically necessary, hospice authorization will
				be revoked for the dates during which hospice services did not meet medically
				necessary criteria for hospice care. Medicaid payment for hospice services is
				not available for services that the office determines are not medically
				necessary.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 34 - Hospice Services › Section 34-5 - Physician certification

Current through July 10, 2024
Authority: IC
				  12-8-6.5-5; IC 12-15
Affected: IC 12-15
Sec. 5.
(a) In order
				for an individual to receive Medicaid-covered hospice services, a physician
				must certify in writing that the individual is terminally ill and expected to
				die from that illness within six (6) months. For a dually-eligible
				Medicaid/Medicare member, the hospice provider must comply with Medicare
				physician certification requirements, but the provider is not required to
				complete the Medicaid physician certification form or to submit the physician
				certification to the office. For a Medicaid-only hospice member, the Medicaid
				physician certification form must be completed and submitted to office as set
				out in this section.
(b) As
				required by federal regulations, the certification in subsection (a) must:
(1) be completed for the first period of
				ninety (90) days by the:
(A) medical director
				of the hospice program or the physician member of the hospice interdisciplinary
				group; and
(B) member's attending
				physician if the member has an attending physician;
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 34 - Hospice Services › Section 34-6 - Election of hospice services

Current through July 10, 2024
Authority: IC
				  12-8-6.5-5; IC 12-15
Affected: IC 12-15
Sec. 6.
(a) In order
				to receive hospice services, a member must elect hospice services by filing an
				election statement with the hospice provider on forms specified by the
				office.
(b) For members at least
				twenty-one (21) years of age, election of the hospice benefit requires the
				member to waive Medicaid coverage for the following services:
(1) Other forms of health care for the
				treatment of the terminal illness for which hospice care was elected, or for
				treatment of a condition related to the terminal illness.
(2) Services provided by another provider
				that are equivalent to the care provided by the elected hospice
				provider.
(3) Hospice services
				other than those provided by the elected hospice provider or its
				contractors.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 34 - Hospice Services › Section 34-7 - Plan of care

Current through July 10, 2024
Authority: IC
				  12-8-6.5-5; IC 12-15
Affected: IC 12-15
Sec. 7.
(a) When an
				eligible member elects to receive services from a certified hospice provider,
				the provider shall develop a plan of care. For the Medicaid-only hospice
				members, the provider must submit the Medicaid plan of care form to the office
				or the office's contractor with the Medicaid physician certification and the
				Medicaid election statement. For members less than twenty-one (21) years of age
				concurrently receiving hospice and curative care services, the providers
				rendering those services must submit an updated coordinated plan of care,
				including delineation of hospice and curative care services, to the office or
				the office's contractor.
(b) In
				developing the plan of care, the provider must comply with the following
				procedures:
(1) The interdisciplinary team
				member who drafts the plan must confer with at least one (1) other member of
				the interdisciplinary team.
(2) One
				(1) of the conferees must be a physician or nurse, and all other team members
				must review the plan of care.
(3)
				All services stipulated within the plan of care must be reasonable and
				necessary for the palliation or management of the terminal illness and related
				conditions.
(4) For the
				Medicaid-only hospice member, the Medicaid hospice plan of care must be
				included in the member's medical chart at the hospice agency. If the
				Medicaid-only member resides in a nursing facility, the Medicaid plan of care
				must also be included in the member's nursing facility medical chart.
(5) For the dually-eligible Medicare/Medicaid
				hospice member residing in a nursing facility, a coordinated plan of care
				prepared and agreed upon by the hospice and nursing facility must be included
				in the member's nursing facility medical chart.
(6) For members less than twenty-one (21)
				years of age concurrently receiving hospice and curative care services, the
				Medicaid plan of care must include the information identified previously in
				this section, and a coordinated plan of care must be prepared and agreed upon
				by the hospice interdisciplinary team and the provider or providers rendering
				the curative care services. The plan of care must include the following:
(A) An assessment of the member's
				needs.
(B) The curative care and
				hospice services the member is receiving along with the scope and frequency of
				these services and the manner in which the services and assessments are
				coordinated.
The plan of care must be included in the member's medical
				  charts of both the hospice and curative care providers. The advanced directive,
				  if applicable, must be included in the member's medical charts of both the
				  hospice and curative care providers.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 34 - Hospice Services › Section 34-8 - Covered services

Current through July 10, 2024
Authority: IC 12-15-1-10; IC 12-15-21-2; IC 12-15-40
Affected: IC 12-15
Sec. 8.
Services covered within the hospice per diem reimbursement
				  rates include the following:
(1)
				Nursing care provided by or under the supervision of a registered
				nurse.
(2) Medical social services
				provided by a social worker who has at least a bachelor's degree and who is
				working under the supervision of a physician.
(3) Physicians' services provided by the
				medical director or physician member of the interdisciplinary team that may be
				characterized as follows:
(A) General
				supervisory services.
(B)
				Participation in the establishment of the plan of care.
(C) Supervision of the plan of
				care.
(D) Periodic
				review.
(E) Establishment of
				governing policies.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 34 - Hospice Services › Section 34-9 - Levels of care

Current through July 10, 2024
Authority: IC 12-15-1-10; IC 12-15-21-2; IC 12-15-40
Affected: IC 12-15
Sec. 9.
(a) Covered
				hospice services will be delivered and reimbursed at one (1) of four (4)
				levels, the utilization of which shall be determined by the hospice provider
				within the context of the overall utilization and reimbursement limitations
				contained in this rule and
				405 IAC 1-16.
(b) The levels of care are as follows:
(1) Routine home hospice care.
(2) Continuous home hospice care.
(3) Inpatient respite care.
(4) General inpatient hospice care.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 34 - Hospice Services › Section 34-10 - Location of care

Current through July 10, 2024
Authority: IC 12-15-1-10; IC 12-15-21-2; IC 12-15-40
Affected: IC 12-15
Sec. 10.
(a) The
				usual home of the hospice member determines the location of care for that
				member. For purposes of this rule and
				405 IAC 1-16, hospice location of
				care will be categorized according to one (1) of two (2) locations.
(b) Private home location of care applies if
				the member usually lives in his or her private home.
(c) Nursing facility location of care applies
				if the member usually lives in a nursing facility.
(d) The additional room and board amount
				available for nursing facility residents under
				405 IAC 1-16-4 is available only
				if the hospice member meets the criteria for nursing facility level of care
				under 405 IAC 1-3.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 5 - MEDICAID SERVICES › Rule 34 - Hospice Services › Section 34-11 - Prior authorization for nonhospice services

Current through July 10, 2024
Authority: IC
				  12-15-1-10; IC
				  12-15-21-2; IC
				  12-15-40
Affected: IC 12-15
Sec. 11.
(a) Except
				as provided in subsection (b), prior authorization is required for any
				Medicaid-covered service not related to the hospice member's terminal condition
				if prior authorization is otherwise required under this article.
(b) Notwithstanding any other provision of
				this article, prior authorization is not required for the following services
				when provided to hospice patients:
(1)
				Pharmacy services, for conditions not related to the patient's terminal
				condition. Pharmacy services related to the patient's terminal condition do not
				require prior authorization because they are included in the hospice per
				diem.
(2) Dental
				services.
(3) Vision care
				services.