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RULE §354.1039Home Health Services Benefits and Limitations

(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;

      (ii) supplied:

        (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 HHSC.

    (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 additives;

      (x) dressing supplies;

      (xi) thermometers;

      (xii) suction catheters;

      (xiii) oxygen and related respiratory care supplies; or

      (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 by HHSC;

      (iii) meet the recipient's existing medical and treatment needs;

      (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 recipient.

      (i) Periodic rental payments are made only for the lesser of:

        (I) the period of time the equipment is medically necessary; or

        (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 the item.

        (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 residence;

      (ix) pumps for feeding tubes and IV administration; and

      (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 therapist;

    (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 therapist;

    (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 Program.

    (D) A physician's plan of care is not required for an eligible recipient to obtain insulin syringes and needles under this section.

  (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 services.

    (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.


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