Section 441.78.9. Home health agencies.

Payment shall be approved for medically necessary home health agency services prescribed by a physician in a plan of home health care provided by a Medicare-certified home health agency.

The number of hours of home health agency services shall be reasonable and appropriate to meet an established medical need of the member that cannot be met by a family member, significant other, friend, or neighbor. Services must be medically necessary in the individual case and be related to a diagnosed medical impairment or disability.

The member need not be homebound to be eligible for home health agency services; however, the services provided by a home health agency shall only be covered when provided in the member’s residence with the following exception. Private duty nursing and personal care services for persons aged 20 and under as described at 78.9(10)“a” may be provided in settings other than the member’s residence when medically necessary.

Medicaid members of home health agency services need not first require skilled nursing care to be entitled to home health aide services.

Further limitations related to specific components of home health agency services are noted in subrules 78.9(3) to 78.9(10).

Payment shall be made on an encounter basis. An encounter is defined as separately identifiable hours in which home health agency staff provide continuous service to a member.

Payment for supplies shall be approved when the supplies are incidental to the patient’s care, e.g., syringes for injections, and do not exceed $15 per month. Dressings, durable medical equipment, and other supplies shall be obtained from a durable medical equipment dealer or pharmacy. Payment of supplies may be made to home health agencies when a durable medical equipment dealer or pharmacy is not available in the member’s community.

Payment may be made for restorative and maintenance home health agency services.

Payment may be made for teaching, training, and counseling in the provision of health care services.

Treatment plans for these services shall additionally reflect: to whom the services are to be provided (patient, family member, etc.); prior teaching training, or counseling provided; medical necessity for the rendered service; identification of specific services and goals; date of onset of the teaching, training, or counseling; frequency of services; progress of member in response to treatment; and estimated length of time these services will be needed.

The following are not covered: services provided in the home health agency office, homemaker services, well child care and supervision, and medical equipment rental or purchase.

Services shall be authorized by a physician, evidenced by the physician’s signature and date on a plan of treatment.

         78.9(1) Treatment plan. A plan of treatment shall be completed prior to the start of care and at a minimum reviewed every 62 days thereafter. The plan of care shall support the medical necessity and intensity of services to be provided by reflecting the following information:

            a.               Place of service.

            b.               Type of service to be rendered and the treatment modalities being used.

            c.               Frequency of the services.

            d.               Assistance devices to be used.

            e.               Date home health services were initiated.

            f.                Progress of member in response to treatment.

            g.               Medical supplies to be furnished.

            h.               Member’s medical condition as reflected by the following information, if applicable:

             (1)             Dates of prior hospitalization.

             (2)             Dates of prior surgery.

             (3)             Date last seen by a physician.

             (4)             Diagnoses and dates of onset of diagnoses for which treatment is being rendered.

             (5)             Prognosis.

             (6)             Functional limitations.

             (7)             Vital signs reading.

             (8)             Date of last episode of instability.

             (9)             Date of last episode of acute recurrence of illness or symptoms.

             (10)            Medications.

            i.                Discipline of the person providing the service.

            j.                Certification period (no more than 62 days).

            k.               Estimated date of discharge from the hospital or home health agency services, if applicable.

            l.                Physician’s signature and date. The plan of care must be signed and dated by the physician before the claim for service is submitted for reimbursement.

         78.9(2) Supervisory visits. Payment shall be made for supervisory visits two times a month when a registered nurse acting in a supervisory capacity provides supervisory visits of services provided by a home health aide under a home health agency plan of treatment or when services are provided by an in-home health care provider under the department’s in-home health-related care program as set forth in 441—Chapter 177.

         78.9(3) Skilled nursing services. Skilled nursing services are services that when performed by a home health agency require a licensed registered nurse or licensed practical nurse to perform. Situations when a service can be safely performed by the member or other nonskilled person who has received the proper training or instruction or when there is no one else to perform the service are not considered a “skilled nursing service.” Skilled nursing services shall be available only on an intermittent basis. Intermittent services for skilled nursing services shall be defined as a medically predictable recurring need requiring a skilled nursing service at least once every 60 days, not to exceed five days per week (except as provided below), with an attempt to have a predictable end. Daily visits (six or seven days per week) that are reasonable and necessary and show an attempt to have a predictable end shall be covered for up to three weeks. Coverage of additional daily visits beyond the initial anticipated time frame may be appropriate for a short period of time, based on the medical necessity of service. Medical documentation shall be submitted justifying the need for continued visits, including the physician’s estimate of the length of time that additional visits will be necessary. Daily skilled nursing visits or multiple daily visits for wound care or insulin injections shall be covered when ordered by a physician and included in the plan of care. Other daily skilled nursing visits which are ordered for an indefinite period of time and designated as daily skilled nursing care do not meet the intermittent definition and shall be denied.

Skilled nursing services shall be evaluated based on the complexity of the service and the condition of the patient.

Private duty nursing for persons aged 21 and over is not a covered service. See subrule 78.9(10) for guidelines for private duty nursing for persons aged 20 or under.

         78.9(4) Physical therapy services. Payment shall be made for physical therapy services when the services relate directly to an active written treatment plan, follow a treatment plan established by the physician after any needed consultation with the qualified physical therapist, are reasonable and necessary to the treatment of the patient’s illness or injury, and meet the guidelines defined for restorative, maintenance, or trial therapy as set forth in subrule 78.19(1), paragraphs “a” and “b.”

For physical therapy services, the treatment plan shall additionally reflect goals, modalities of treatment, date of onset of conditions being treated, restorative potential, and progress notes.

         78.9(5) Occupational therapy services. Payment shall be made for occupational therapy services when the services relate directly to an active written treatment plan, follow a treatment plan established by the physician, are reasonable and necessary to the treatment of the patient’s illness or injury, and meet the guidelines defined for restorative, maintenance, or trial therapy as set forth in subrule 78.19(1), paragraphs “a” and “c.”

For occupational therapy services, the treatment plan shall additionally reflect goals, modalities of treatment, date of onset of conditions being treated, restorative potential, and progress notes.

         78.9(6) Speech therapy services. Payment shall be made for speech therapy services when the services relate directly to an active written treatment plan, follow a treatment plan established by the physician, are reasonable and necessary to the treatment of the patient’s illness or injury, and meet the guidelines defined for restorative, maintenance, or trial therapy as set forth in subrule 78.19(1), paragraphs “a” and “d.”

For speech therapy services, the treatment plan shall additionally reflect goals, modalities of treatment, date of onset of conditions being treated, restorative potential, and progress notes.

         78.9(7) Home health aide services. Payment shall be made for unskilled services provided by a home health aide if the following conditions are met:

            a.               The service as well as the frequency and duration are stated in a written plan of treatment established by a physician. The home health agency is encouraged to collaborate with the member, or in the case of a child with the child’s caregiver, in the development and implementation of the plan of treatment.

            b.               The member requires personal care services as determined by a registered nurse or other appropriate therapist. The services shall be given under the supervision of a registered nurse, physical, speech, or occupational therapist and the registered nurse or therapist shall assign the aide who will provide the care.

            c.               Services shall be provided on an intermittent basis. “Intermittent basis” for home health agency services is defined as services that are usually two to three times a week for two to three hours at a time. Services provided for four to seven days per week, not to exceed 28 hours per week, when ordered by a physician and included in a plan of care shall be allowed as intermittent services. Increased services provided when medically necessary due to unusual circumstances on a short-term basis of two to three weeks may also be allowed as intermittent services when the home health agency documents the need for the excessive time required for home health aide services.

Home health aide daily care may be provided for persons employed or attending school whose disabling conditions require the persons to be assisted with morning and evening activities of daily living in order to support their independent living.

Personal care services include the activities of daily living, e.g., helping the member to bathe, get in and out of bed, care for hair and teeth, exercise, and take medications specifically ordered by the physician, but ordinarily self-administered, and retraining the member in necessary self-help skills.

Certain household services may be performed by the aide in order to prevent or postpone the member’s institutionalization when the primary need of the member for home health aide services furnished is for personal care. If household services are incidental and do not substantially increase the time spent by the aide in the home, the entire visit is considered a covered service. Domestic or housekeeping services which are not related to patient care are not a covered service if personal care is not rendered during the visit.

For home health aide services, the treatment plan shall additionally reflect the number of hours per visit and the living arrangement of the member, e.g., lives alone or with family.

         78.9(8) Medical social services.

            a.               Payment shall be made for medical social work services when all of the following conditions are met and the problems are not responding to medical treatment and there does not appear to be a medical reason for the lack of response. The services:

             (1)             Are reasonable and necessary to the treatment of a member’s illness or injury.

             (2)             Contribute meaningfully to the treatment of the member’s condition.

             (3)             Are under the direction of a physician.

             (4)             Are provided by or under the supervision of a qualified medical or psychiatric social worker.

             (5)             Address social problems that are impeding the member’s recovery.

            b.               Medical social services directed toward minimizing the problems an illness may create for the member and family, e.g., encouraging them to air their concerns and providing them with reassurance, are not considered reasonable and necessary to the treatment of the patient’s illness or injury.

         78.9(9) Home health agency care for maternity patients and children. The intent of home health agency services for maternity patients and children shall be to provide services when the members are unable to receive the care outside of their home and require home health care due to a high-risk factor. Routine prenatal, postpartum, or child health care is a covered service in a physician’s office or clinic and, therefore, is not covered by Medicaid when provided by a home health agency.

            a.               Treatment plans for maternity patients and children shall identify:

             (1)             The potential risk factors,

             (2)             The medical factor or symptom which verifies the child is at risk,

             (3)             The reason the member is unable to obtain care outside of the home,

             (4)             The medically related task of the home health agency,

             (5)             The member’s diagnosis,

             (6)             Specific services and goals, and

             (7)             The medical necessity for the services to be rendered. A single high-risk factor does not provide sufficient documentation of the need for services.

            b.               The following list of potential high-risk factors may indicate a need for home health services to prenatal maternity patients:

             (1)             Aged 16 or under.

             (2)             First pregnancy for a woman aged 35 or over.

             (3)             Previous history of prenatal complications such as fetal death, eclampsia, C-section delivery, psychosis, or diabetes.

             (4)             Current prenatal problems such as hypertensive disorders of pregnancy, diabetes, cardiac disease, sickle cell anemia, low hemoglobin, mental illness, or drug or alcohol abuse.

             (5)             Sociocultural or ethnic problems such as language barriers, lack of family support, insufficient dietary practices, history of child abuse or neglect, or single mother.

             (6)             Preexisting disabilities such as sensory deficits, or mental or physical disabilities.

             (7)             Second pregnancy in 12 months.

             (8)             Death of a close family member or significant other within the previous year.

            c.               The following list of potential high-risk factors may indicate a need for home health services to postpartum maternity patients:

             (1)             Aged 16 or under.

             (2)             First pregnancy for a woman aged 35 or over.

             (3)             Major postpartum complications such as severe hemorrhage, eclampsia, or C-section delivery.

             (4)             Preexisting mental or physical disabilities such as deaf, blind, hemaplegic, activity-limiting disease, sickle cell anemia, uncontrolled hypertension, uncontrolled diabetes, mental illness, or mental retardation.

             (5)             Drug or alcohol abuse.

             (6)             Symptoms of postpartum psychosis.

             (7)             Special sociocultural or ethnic problems such as lack of job, family problems, single mother, lack of support system, or history of child abuse or neglect.

             (8)             Demonstrated disturbance in maternal and infant bonding.

             (9)             Discharge or release from hospital against medical advice before 36 hours postpartum.

             (10)            Insufficient antepartum care by history.

             (11)            Multiple births.

             (12)            Nonhospital delivery.

            d.               The following list of potential high-risk factors may indicate a need for home health services to infants:

             (1)             Birth weight of five pounds or under or over ten pounds.

             (2)             History of severe respiratory distress.

             (3)             Major congenital anomalies such as neonatal complications which necessitate planning for long-term follow-up such as postsurgical care, poor prognosis, home stimulation activities, or periodic development evaluation.

             (4)             Disabling birth injuries.

             (5)             Extended hospitalization and separation from other family members.

             (6)             Genetic disorders, such as Down’s syndrome, and phenylketonuria or other metabolic conditions that may lead to mental retardation.

             (7)             Noted parental rejection or indifference toward baby such as never visiting or calling the hospital about the baby’s condition during the infant’s extended stay.

             (8)             Family sociocultural or ethnic problems such as low education level or lack of knowledge of child care.

             (9)             Discharge or release against medical advice before 36 hours of age.

             (10)            Nutrition or feeding problems.

            e.               The following list of potential high-risk factors may indicate a need for home health services to preschool or school-age children:

             (1)             Child or sibling victim of child abuse or neglect.

             (2)             Mental retardation or other physical disabilities necessitating long-term follow-up or major readjustments in family lifestyle.

             (3)             Failure to complete the basic series of immunizations by 18 months, or boosters by 6 years.

             (4)             Chronic illness such as asthma, cardiac, respiratory or renal disease, diabetes, cystic fibrosis, or muscular dystrophy.

             (5)             Malignancies such as leukemia or carcinoma.

             (6)             Severe injuries necessitating treatment or rehabilitation.

             (7)             Disruption in family or peer relationships.

             (8)             Suspected developmental delay.

             (9)             Nutritional deficiencies.

         78.9(10) Private duty nursing or personal care services for persons aged 20 and under. Payment for private duty nursing or personal care services for persons aged 20 and under shall be approved if determined to be medically necessary. Payment shall be made on an hourly unit of service.

            a.               Definitions.

             (1)             Private duty nursing services are those services which are provided by a registered nurse or a licensed practical nurse under the direction of the member’s physician to a member in the member’s place of residence or outside the member’s residence, when normal life activities take the member outside the place of residence. Place of residence does not include nursing facilities, intermediate care facilities for the mentally retarded, or hospitals.

Services shall be provided according to a written plan of care authorized by a licensed physician. The home health agency is encouraged to collaborate with the member, or in the case of a child with the child’s caregiver, in the development and implementation of the plan of treatment. These services shall exceed intermittent guidelines as defined in subrule 78.9(3). Private duty nursing and personal care services shall be inclusive of all home health agency services personally provided to the member. Enhanced payment under the interim fee schedule shall be made available for services to children who are technology dependent, i.e., ventilator dependent or whose medical condition is so unstable as to otherwise require intensive care in a hospital.

Private duty nursing or personal care services do not include:

            1.      Respite care, which is a temporary intermission or period of rest for the caregiver.

            2.      Nurse supervision services including chart review, case discussion or scheduling by a registered nurse.

            3.      Services provided to other persons in the member’s household.

            4.      Services requiring prior authorization that are provided without regard to the prior authorization process.

            5.      Transportation services.

            6.      Homework assistance.

             (2)             Personal care services are those services provided by a home health aide or certified nurse’s aide and which are delegated and supervised by a registered nurse under the direction of the member’s physician to a member in the member’s place of residence or outside the member’s residence, when normal life activities take the member outside the place of residence. Place of residence does not include nursing facilities, intermediate care facilities for the mentally retarded, or hospitals. Payment for personal care services for persons aged 20 and under that exceed intermittent guidelines may be approved if determined to be medically necessary as defined in subrule 78.9(7). These services shall be in accordance with the member’s plan of care and authorized by a physician. The home health agency is encouraged to collaborate with the member, or in the case of a child with the child’s caregiver, in the development and implementation of the plan of treatment.

Medical necessity means the service is reasonably calculated to prevent, diagnose, correct, cure, alleviate or prevent the worsening of conditions that endanger life, cause pain, result in illness or infirmity, threaten to cause or aggravate a disability or chronic illness, and no other equally effective course of treatment is available or suitable for the member requesting a service.

            b.               Requirements.

             (1)             Private duty nursing or personal care services shall be ordered in writing by a physician as evidenced by the physician’s signature on the plan of care.

             (2)             Private duty nursing or personal care services shall be authorized by the department or the department’s designated review agent prior to payment.

             (3)             Prior authorization shall be requested at the time of initial submission of the plan of care or at any time the plan of care is substantially amended and shall be renewed with the department or the department’s designated review agent. Initial request for and request for renewal of prior authorization shall be submitted to the department’s designated review agent. The provider of the service is responsible for requesting prior authorization and for obtaining renewal of prior authorization.

The request for prior authorization shall include a nursing assessment, the plan of care, and supporting documentation. The request for prior authorization shall include all items previously identified as required treatment plan information and shall further include: any planned surgical interventions and projected time frame; information regarding caregiver’s desire to become involved in the member’s care, to adhere to program objectives, to work toward treatment plan goals, and to work toward maximum independence; and identify the types and service delivery levels of all other services to the member whether or not the services are reimbursable by Medicaid. Providers shall indicate the expected number of private duty nursing RN hours, private duty nursing LPN hours, or home health aide hours per day, the number of days per week, and the number of weeks or months of service per discipline. If the member is currently hospitalized, the projected date of discharge shall be included.

Prior authorization approvals shall not be granted for treatment plans that exceed 16 hours of home health agency services per day. (Cross reference 78.28(9))

         78.9(11) Vaccines. In order to be paid for the administration of a vaccine covered under the Vaccines for Children (VFC) Program, a home health agency must enroll in the VFC program. Payment for the vaccine will be approved only if the VFC program stock has been depleted.

This rule is intended to implement Iowa Code section 249A.4.

[ARC 7548B, IAB 2/11/09, effective 4/1/09; ARC 9315B, IAB 12/29/10, effective 2/2/11; ARC 0065C, IAB 4/4/12, effective 6/1/12]