| (xi) respiratory or oxygen related equipment.
(D) DME 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 recipient's condition
in a reasonable and generally predictable period of time, based on
the physician's or allowed practitioner's assessment of the recipient's
restorative potential after any needed consultation with the physical
therapist; and
(D) not be provided when the recipient 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 a recipient 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 an occupational therapist who is currently
licensed by the Texas Board of Occupational Therapy Examiners or by
an occupational therapist assistant who is licensed by the Texas Board
of Occupational Therapy Examiners to assist in the practice of occupational
therapy and is supervised by an occupational therapist;
(B) for the evaluation and function-oriented treatment
of a recipient 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 occupational
therapist's evaluation and the physician's or allowed practitioner'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 an eligible Medicaid
recipient with a physician's or an allowed practitioner'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 or an allowed practitioner'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 or an allowed practitioner.
(B) Prior authorization is required unless otherwise
specified by HHSC.
(b) Home health service limitations include the following.
(1) Recipient supervision.
(A) A recipient must be seen by the recipient's physician
or allowed practitioner, within 30 days prior to the start of home
health services. This requirement may be waived when a diagnosis has
already been established by the physician or allowed practitioner
and the recipient is currently undergoing active medical care and
treatment. Such a waiver is based on the physician's or allowed practitioner's
statement that an additional evaluation visit is not medically necessary.
(B) A recipient receiving home health care services
must remain under the care and supervision of a physician or an allowed
practitioner who reviews and revises the plan of care at least every
60 days or more frequently as the physician or allowed practitioner
determines necessary.
(2) Time limited prior authorizations.
(A) Prior authorizations for payment of home health
services may be issued by HHSC for a service period not to exceed
60 days on any given authorization. Specific authorizations may be
limited to a time period less than the established maximum. When the
need for home health services exceeds 60 days, or when there is a
change in the service plan, the provider must obtain prior approval
and retain the physician's or allowed practitioner's signed and dated
orders with the revised plan of care.
(B) The provider must be notified by HHSC in writing
of the authorization or denial of requested services.
(C) Prior authorization requests for covered Medicaid
home health services must include the following information:
(i) the Medicaid identification form with the following
information about the recipient:
(I) full name, age, and address;
(II) Medical Assistance Program Identification number;
(III) health insurance claim number (where applicable);
and
(IV) Medicare number;
(ii) the physician's or allowed practitioner's written,
signed, and dated plan of care (submitted by the provider if requested);
(iii) the clinical record data (completed and submitted
by the provider if requested);
(iv) a description of the home or living environment;
(v) a composition of the family/caregiver;
(vi) observations pertinent to the overall plan of
care in the home; and
(vii) the type of service the recipient is receiving
from other community or state agencies.
(D) If inadequate or incomplete information is provided,
the provider will be requested to furnish additional documentation
as required by HHSC to make a decision on the request.
(3) Medication administration. Nursing visits for the
purpose of administering medications are not covered if:
(A) the medication is not considered medically necessary
to the treatment of the recipient's illness;
(B) the administration of medication exceeds the therapeutic
frequency or duration by accepted standards of medical practice;
(C) there is not a medical reason prohibiting the administration
of the medication by mouth; or
(D) the recipient, a primary caregiver, a family member,
a legally authorized representative (LAR), a court appointed guardian,
or a neighbor of the recipient has been taught or can be taught to
administer intramuscular (IM) and intravenous (IV) injections.
(4) Prior approval. Services or supplies furnished
without prior approval, unless otherwise specified by HHSC, are not
covered home health services.
(5) Recipient residence. Services, equipment, or supplies
furnished to a recipient who is a resident or patient in a hospital,
skilled nursing facility, or intermediate care facility are not covered
home health services.
(6) Non-billable services. Skilled nursing services
that are considered administrative and are not billable include:
(A) nursing visits for the primary purpose of assessing
a recipient's care needs to develop a plan of care; and
(B) RN visits for general supervision of nursing care
provided by a home health aide or others over whom the RN is professionally
responsible.
(c) Home health services are subject to utilization
review, which includes the following:
(1) the physician or allowed practitioner is responsible
for retaining in the recipient's record a copy of the plan of care
or a copy of the request form documenting the medical necessity of
the home health care service, supply, or item of DME and how it meets
the recipient's health care needs;
(2) the home health services provider is responsible
for documenting the amount, duration, and scope of services in the
recipient's plan of care, the DME and supply order request form, and
the recipient's record based on the physician's or allowed practitioner's
orders; and
(3) HHSC may conduct retrospective random, and targeted
reviews to ensure the appropriate utilization of home health services
and to monitor the cost effectiveness of home health services.
|
| Source Note: The provisions of this §354.1039 adopted to be effective June 26, 1997, 22 TexReg 5826; amended to be effective July 1, 1999, 24 TexReg 4365; transferred effective September 1, 2001, as published in the Texas Register May 24, 2002, 27 TexReg 4561; amended to be effective November 14, 2002, 27 TexReg 10588; amended to be effective October 2, 2016, 41 TexReg 7475; amended to be effective September 21, 2022, 47 TexReg 5779 |
