1 Tex. Admin. Code § 354.1039

Current through Reg. 49, No. 45; November 8, 2024

Section 354.1039 - Benefits 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

(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.

1 Tex. Admin. Code § 354.1039

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 by Texas Register, Volume 41, Number 39, September 23, 2016, TexReg 7475, eff. 10/2/2016; Amended by Texas Register, Volume 47, Number 37, September 16, 2022, TexReg 5779, eff. 9/21/2022