|(a) The Health and Human Services Commission or its
designee (HHSC) determines authorization requirements and limitations
for covered home health service benefits. The home health agency is
responsible for obtaining prior authorization where specified for
the healthcare service, supply, equipment, or appliance. Home health
service benefits include the following:
(1) Skilled nursing. Nursing services provided by a
registered nurse (RN) or licensed vocational nurse (LVN) licensed
by the Texas Board of Nursing provided on a part-time or intermittent
basis and furnished through an enrolled home health agency are covered
benefits. Billable nursing visits may also include:
(A) nursing visits required to teach the recipient,
the primary caregiver, a family member and/or neighbor how to administer
or assist in a service or activity that is necessary to the care and/or
treatment of the recipient in a home setting;
(B) RN visits for skilled nursing observation, assessment,
and evaluation, provided a physician specifically requests that a
nurse visit the recipient for this purpose.
(i) The physician's request must reflect the need for
the assessment visit.
(ii) Nursing visits for the primary purpose of assessing
a recipient's care needs to develop a plan of care are considered
administrative and are not billable; and
(C) RN visits for general supervision of nursing care
provided by a home health aide and/or others over whom the RN is administratively
or professionally responsible.
(2) Home health aide services. Home health aide services
to provide personal care under the supervision of an RN, a licensed
physical therapist (PT), or an occupational therapist (OT) employed
by the home health agency are covered benefits.
(A) The primary purpose of a home health aide visit
must be to provide personal care services.
(B) Duties of a home health aide include the performance
of simple procedures such as personal care, ambulation, exercise,
range of motion, safe transfer, positioning, and household services
essential to health care at home; assistance with medications that
are ordinarily self-administered; reporting changes in the patient's
condition and needs; and completing appropriate records.
(C) Written instructions for home health aide services
must be prepared by an RN or therapist as appropriate.
(D) The requirements for home health aide supervision
are as follows.
(i) When only home health aide services are being furnished
to a recipient, an RN must make a supervisory visit to the recipient's
residence at least once every 60 days. These supervisory visits must
occur when the aide is furnishing patient care.
(ii) When skilled nursing care, PT, or OT are also
being furnished to a recipient, an RN must make a supervisory visit
to the recipient's residence at least every two weeks.
(iii) When only PT or OT is furnished in addition to
the home health aide services, the appropriate skilled therapist may
make the supervisory visits in place of an RN.
(E) Visits made primarily for performing housekeeping
services are not covered services.
(3) Medical supplies. Medical supplies are covered
benefits if they meet the following criteria.
(A) Medical supplies must be:
(i) documented in the recipient's plan of care as medically
necessary and used for medical or therapeutic purposes;
(I) through an enrolled home health agency in compliance
with the recipient's plan of care; or
(II) by an enrolled medical supplier under written,
signed, and dated physician's prescription; and
(iii) prior authorized unless otherwise specified by
(B) Items which are not listed in subparagraph (C)
of this paragraph may be medically necessary for the treatment or
therapy of qualified recipients. If a prior authorization request
is received for these items, consideration will be given to the request.
Approval for reasonable amounts of the requested items may be given
if circumstances justify the exception and the need is documented.
(C) Covered items include:
(i) colostomy and ileostomy care supplies;
(ii) urinary catheters, appliances and related supplies;
(iii) pressure pads including elbow and heel protectors;
(iv) incontinent supplies to include incontinent pads
or diapers for clients over the age of four for medical necessity
as determined by the physician;
(v) crutch and cane tips;
(vi) irrigation sets;
(vii) supports and abdominal binders (not to include
braces, orthotics, or prosthetics);
(viii) medicine chest supplies not requiring a prescription
(not to include vitamins or personal care items such as soap or shampoos);
(ix) syringes, needles, IV tubing and/or IV administration
setups including IV solutions generally used for hydration or prescriptive
(x) dressing supplies;
(xii) suction catheters;
(xiii) oxygen and related respiratory care supplies;
(xiv) feeding related supplies.
(4) Durable medical equipment (DME). Durable Medical
Equipment must meet the following requirements to qualify for reimbursement
under Medicaid home health services.
(A) DME must:
(i) be medically necessary and the appropriateness
of the health care service, supply, equipment, or appliance prescribed
by the physician for the treatment of the individual recipient and
delivered in his place of residence must be documented in the plan
of care and/or the request form;
(ii) be prior authorized unless otherwise specified
(iii) meet the recipient's existing medical and treatment
(iv) be considered safe for use in the home; and
(v) be provided through an:
(I) enrolled home health agency under a current physician's
plan of care; or
(II) enrolled DME supplier under a written, signed,
and dated physician's prescription.
(B) HHSC will determine whether DME will be rented,
purchased, or repaired based upon the duration and use needs of the
(i) Periodic rental payments are made only for the
(I) the period of time the equipment is medically necessary;
(II) when the total monthly rental payments equal the
reasonable purchase cost for the equipment.
(ii) Purchase is justified when the estimated duration
of need multiplied by the rental payments would exceed the reasonable
purchase cost of the equipment or it is otherwise more practical to
purchase the equipment.
(iii) Repair of durable medical equipment and appliances
will be considered based on the age of the item and the cost to repair
(I) A request for repair of durable medical equipment
or appliances must include an itemized estimated cost list of the
repairs. Rental equipment may be provided to replace purchased medical
equipment or appliances for the period of time it will take to make
necessary repairs to purchased medical equipment or appliances.
(II) Repairs will not be authorized in situations where
the equipment has been abused or neglected by the patient, patient's
family, or caregiver.
(III) Routine maintenance of rental equipment is the
responsibility of the provider.
(C) Covered medical appliances and equipment (rental,
purchase, or repairs) include:
(i) manual or powered wheelchairs;
(I) non-customized including medically justified seating,
supports, and equipment; or
(II) customized, specifically tailored or individualized,
powered wheelchairs including appropriate medically justified seating,
supports and equipment not to exceed an amount specified by HHSC.
(ii) canes, crutches, walkers, and trapeze bars;
(iii) bed pans, urinals, bedside commode chairs, elevated
commode seats, bath chairs/benches/seats;
(iv) electric and non-electric hospital beds and mattresses;
(v) air flotation or air pressure mattresses and cushions;
(vi) bed side rails and bed trays;
(vii) reasonable and appropriate appliances for measuring
blood pressure and blood glucose suitable to the recipient's medical
situation to include replacement parts and supplies;
(viii) lifts for assisting recipient to ambulate within
(ix) pumps for feeding tubes and IV administration;
(x) respiratory or oxygen related equipment.
(D) Medical equipment or appliances not listed in subparagraph
(C) of this paragraph may, in exceptional circumstances, be considered
for payment when it can be medically substantiated as a part of the
treatment plan that such service would serve a specific medical purpose
on an individual case basis.
(5) Physical therapy. To be payable as a home health
benefit, physical therapy services must:
(A) be provided by a physical therapist who is currently
licensed by the Texas Board of Physical Therapy Examiners, or physical
therapist assistant who is licensed by the Texas Board of Physical
Therapy Examiners who assists and is supervised by a licensed physical
(B) be for the treatment of an acute musculoskeletal
or neuromuscular condition or an acute exacerbation of a chronic musculoskeletal
or neuromuscular condition;
(C) be expected to improve the patient's condition
in a reasonable and generally predictable period of time, based on
the physician's assessment of the patient's restorative potential
after any needed consultation with the therapist; and
(D) not be provided when the patient has reached the
maximum level of improvement. Repetitive services designed to maintain
function once the maximum level of improvement has been reached are
not a benefit. Services related to activities for the general good
and welfare of patients such as general exercises to promote overall
fitness and flexibility and activities to provide diversion or general
motivation are not reimbursable.
(6) Occupational therapy. To be payable as a home health
benefit, occupational therapy services must be:
(A) provided by one who is currently registered and
licensed by the Texas Board of Occupational Therapy Examiners or by
an occupational therapist assistant who is licensed to assist in the
practice of occupational therapy and is supervised by an occupational
(B) for the evaluation and function-oriented treatment
of individuals whose ability to function in life roles is impaired
by recent or current physical illness, injury or condition; and
(C) specific goal directed activities to achieve a
functional level of mobility and communication and to prevent further
dysfunction within a reasonable length of time based on the therapist's
evaluation and physician's assessment and plan of care.
(7) Insulin syringes and needles. Insulin syringes
and needles must meet the following requirements to qualify for reimbursement
under Medicaid home health services.
(A) Pharmacies enrolled in the Medicaid Vendor Drug
Program may dispense insulin syringes and needles to eligible Medicaid
recipients with a physician's prescription.
(B) Prior authorization is not required for an eligible
recipient to obtain insulin syringes and needles.
(C) Insulin syringes and needles obtained in accordance
with this section will be reimbursed through the Medicaid Vendor Drug
(D) A physician's plan of care is not required for
an eligible recipient to obtain insulin syringes and needles under
(8) Diabetic supplies and related testing equipment.
Diabetic supplies and related testing equipment must meet the following
requirements to qualify for reimbursement under Medicaid home health
(A) Diabetic supplies and related testing equipment
must be prescribed by a physician.
(B) Prior authorization is required unless otherwise
specified by HHSC.
(b) Home health service limitations include the following.
(1) Patient supervision.
(A) Patients must be seen by their physician or, if
consistent with subparagraph (C) of this paragraph, a nurse practitioner,
clinical nurse specialist, or physician assistant, within 30 days
prior to the start of home health services. This physician visit may
be waived when a diagnosis has already been established by the attending
physician and the patient is currently undergoing active medical care
and treatment. Such a waiver is based on the physician's statement
that an additional evaluation visit is not medically necessary.
(B) Patients receiving home health care services must
remain under the care and supervision of a physician who reviews and
revises the plan of care at least every 60 days or more frequently
as the physician determines necessary.