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RULE §354.1039Benefits and Limitations of Home Health Services

(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


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