| (a) HHSC determines authorization requirements and
limitations for covered home health services. The home health agency
is responsible for obtaining prior authorization where specified for
the home health service, supply, or item of durable medical equipment
(DME). Home health services 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
home health services. Billable nursing visits may include:
(A) nursing visits required to teach the recipient,
the primary caregiver, a family member, or a neighbor how to administer
or assist in a service or activity that is necessary to the care and
treatment of the recipient in a home setting; and
(B) RN visits for skilled nursing observation, assessment,
and evaluation, provided:
(i) a physician or an allowed practitioner specifically
requests that an RN visits the recipient for this purpose; and
(ii) the request reflects the need for the assessment
visit.
(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 a licensed occupational therapist (OT)
employed by the home health agency are covered home health services.
(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:
(i) 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;
(ii) assistance with medications that are ordinarily
self-administered;
(iii) reporting changes in the recipient's condition
and needs; and
(iv) completing appropriate records.
(C) Written instructions for home health aide services
must be prepared by an RN, a PT, or an OT, 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) Supplies. Supplies are a covered home health services
benefit if they meet the following criteria.
(A) 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 or allowed practitioner'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 a qualified recipient. 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 a recipient over the age of four for medical necessity
as determined by the physician or allowed practitioner;
(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, 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) DME. DME 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 medical equipment or appliance prescribed by the physician
or allowed practitioner for the treatment of the individual recipient
in the recipient's place of residence must be documented in:
(I) the plan of care; or
(II) the request form described in subsection (b)(2)
of this section;
(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
or allowed practitioner's plan of care; or
(II) enrolled DME supplier under a written, signed,
and dated physician's or allowed practitioner'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 DME will be considered based on the
age of the item and the cost to repair the item.
(I) A request for repair of DME must include an itemized
estimated cost list of the repairs. Rental equipment may be provided
to replace purchased DME for the period of time it will take to make
necessary repairs to purchased DME.
(II) Repairs will not be authorized in situations where
the equipment has been abused or neglected by the recipient or the
recipient's legally authorized representative (LAR), court appointed
guardian, family, or caregiver.
(III) Routine maintenance of rental equipment is the
responsibility of the provider.
(C) Covered DME that may be rented, purchased, or repaired
includes:
(i) non-customized manual or powered wheelchairs, including
medically justified seating, supports, and equipment;
(ii) customized manual or power wheelchairs, specifically
tailored or individualized, powered wheelchairs, including appropriate
medically justified seating, supports, and equipment not to exceed
an amount specified by HHSC;
(iii) canes, crutches, walkers, and trapeze bars;
(iv) bed pans, urinals, bedside commode chairs, elevated
commode seats, and bath chairs/benches/seats;
(v) electric and non-electric hospital beds and mattresses;
(vi) air flotation or air pressure mattresses and cushions;
(vii) bed side rails and bed trays;
(viii) reasonable and appropriate appliances for measuring
blood pressure and blood glucose suitable to the recipient's medical
situation to include replacement parts and supplies;
(ix) lifts for assisting recipient to ambulate within
residence;
(x) pumps for feeding tubes and IV administration;
and
Cont'd... |
