GENERAL INFORMATION
This chapter applies to Home Health providers.
Home health is a covered Medicaid benefit for beneficiaries whose conditions do not require continuous medical/nursing and related care, but do require health services on an intermittent basis in the home setting for the treatment of an injury, illness, or disability. Medicaid covered services may be provided in the home only if circumstances, conditions, or situations exist which prevent the beneficiary from being served in a physician’s office or other outpatient setting. Except as detailed in this chapter, the beneficiary’s primary need must be for nursing care and/or physical therapy, rather than personal care or physician’s care.
A Home Health Agency (HHA) is an organization that provides home care services, such as skilled nursing care, physical therapy (PT), occupational therapy (OT), speech therapy (ST) and care by home health aides. The HHA must be Medicare certified to enroll as a Medicaid provider and must comply with the Medicare/Medicaid Conditions of Participation (42 CFR § 484) and the policies outlined in this manual.
Services solely to prevent an illness, injury or disability are only covered for women/newborns following delivery. For postpartum/newborn follow-up nurse visits, a nursing diagnosis can be used to establish medical necessity. Otherwise, a medical diagnosis is required to establish medical necessity. Medicaid beneficiaries are expected to be an active participant in the planning for their home health care. For beneficiaries enrolled in a Medicaid Health Plan (MHP), the HHA must contact that health plan for authorization to provide services to their members.
Medicaid home health services must be ordered, in writing, by the beneficiary’s attending physician (MD, DO) as part of a written plan of care (POC) and reviewed by this physician every 60 days. The physician’s order and POC must be only for functions that are within the scope of his current medical practice and Medicaid guidelines.
This chapter includes information about services covered for Medicaid and Children’s Special Health Care Services (CSHCS) beneficiaries unless otherwise noted.
FACE-TO-FACE ENCOUNTER
A physician certifying eligibility for home health services must provide documentation of a face-to-face encounter with the beneficiary within 90-days prior to or 30-days after the start of care. The face-to-face encounter may occur through telehealth in compliance with Section 1834(m) of the Social Security Act. NOTE: The face-to-face encounter requirement pertains only to initial certification for home health services.
Only a physician may order home health services and certify a beneficiary’s eligibility for the benefit. The face-to-face encounter ensures that the orders and certification for home health services are based on current knowledge of the beneficiary’s clinical condition, and will identify the primary reason for home health services.
In a situation where a physician orders home health services based on a new condition that was not evident during a visit within the 90-days prior to the start of care, the certifying physician or nonphysician practitioner (NPP) must see the beneficiary within 30 days of admission to home health services.
The certifying physician must document the face-to-face encounter regardless of whether the physician or a permitted NPP performed the encounter. When the face-to-face encounter is performed by a NPP, he/she must document the clinical findings of the face-to-face encounter and communicate those findings to the physician; the physician must then sign the certification.
Permitted NPPs include:
* A nurse practitioner or clinical nurse specialist (as defined in section 1861(aa)(5) of the Social Security Act) who is working in collaboration with the physician in accordance with state law;
* A certified nurse-midwife (as defined in section 1861(gg) of the Social Security Act, as authorized by State law); or
* A physician assistant (as defined in section 1861(aa)(5) of the Social Security Act) under the supervision of the physician.
The face-to-face beneficiary encounter must be a separate and distinct section of, or an addendum to, the certification and must be clearly titled, dated and signed by the certifying physician. Use of a specificform for the certification or the plan of care is not required.
Documentation of the face-to-face encounter must reflect the certifying practitioner’s assessment of the beneficiary and include:
* Date of the encounter,
* Primary reason for the encounter (medical condition),
* Clinical findings that support the need for skilled nursing or therapy services, and
* Clinical findings that support home health eligibility.
An addendum may consist of clinical documents from a hospital or post-acute facility (e.g., emergency visit record or discharge summary). It is allowable for the certifying physician to use such a document as an addendum for the face-to-face encounter if:
* The addendum contains all of the documentation requirements for face-to-face documentation;
* The addendum document, which is serving as the face-to-face documentation, is clearly titledand dated as such; and
* The certifying physician signs and dates the addendum, demonstrating that the certifying physician received that information from the allowed NPP or physician who performed the faceto- face encounter, and that the certifying physician is using that addendum document as his/her documentation of the face-to-face encounter.
While typically the same physician will certify, establish and sign the POC, it is allowable for physicians who attend to the beneficiary in the acute and post-acute settings to certify the need for home health care based on their face-to-face contact, initiate the orders (POC) for home health services, and “hand off” the beneficiary’s care to the community-based physician to review and sign off on the plan of care.
HOME SETTING
Home health services are intended for beneficiaries who are unable to access services (nursing, OT, PT, speech and language pathology therapy [ST]) in an outpatient setting. However, it is not required that beneficiaries be totally restricted to their home. A determination and documentation is required by the HHA that the home is the most appropriate setting in which to provide the service(s). Home health services are not provided solely on the basis of convenience.
All covered home health services must be rendered in a beneficiary’s home, except for those services listed below. Home may be the beneficiary’s owned/rented home, an apartment, Assisted Living Facility, Adult Foster Care (AFC) facility, or home of another family member (secondary residence of the beneficiary, i.e., joint custody situation for a minor child).
* Home Health aide services are not a covered benefit for beneficiaries who reside in a Home for the Aged (HFA) or Adult Foster Care (AFC) facility as this would be duplication of personal care services already provided by staff of these facilities.
* Michigan Department of Health and Human Services (MDHHS) does not cover any Home Health services rendered to a beneficiary in a hospital, nursing facility, Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF/IID), Intermediate Care Facility for the Mentally Ill (ICF/MI), school or adult day care.
To determine if services in the home, rather than in an outpatient setting, are most appropriate, consider the following:
* Is in-home care necessary for the adaptation, training or teaching of nursing or treatment procedures, plans, equipment, appliances or prosthetics in the home setting*
* Is in-home care necessary to prevent undue exposure to infection and/or stress for the beneficiary as identified and documented by a health care professional*
* Is leaving the home medically contraindicated, as identified and documented by a health care professional*
* Is in-home care necessary to prevent a documented problem with access to services, continuity of care or provider, or coordination of services, as documented by a health care professional*
* Is in-home care the most cost-effective method to provide care*
Services must be appropriate and necessary for the treatment of an identified illness, injury or disability. The services provided must be consistent with the nature and severity of the beneficiary’s illness, injury or disability, his particular medical needs and accepted standards of medical practice. Beneficiaries with established frail conditions may need assessments by skilled nurses to prevent further decline of the frail condition.
PLAN OF CARE
The plan of care (POC) must include the following:
* Date of most recent hospitalization.
* Medical diagnosis and impact of functional limitation.
* Specific circumstances, conditions, or situations that require services to be provided in the home and not in a physician’s office or outpatient clinic.
* Date of the HHA’s first visit for this admission.
* The date for which the HHA began providing home care. (This date remains the same on subsequent POCs until the beneficiary is discharged from home health care services.)
* Detailed description of each service to be provided, including frequency and duration of services.
* Detailed description of current goals as related to the services provided and the goal for discharge planning.
* A full description of the reason(s) that initial and/or continued home care is needed (e.g., pertinent laboratory values, medications, wounds, abnormal vital signs).
* Environment status (e.g., electricity, telephone, indoor plumbing).
* Identification of other resources used by the beneficiary (e.g., Area Agency on Aging, Protective Services, Home Help Services).
* Date of physician’s last contact.
* Role of family or support person.
* HHA’s name, address and provider NPI number, and beneficiary’s name, date of birth, and Medicaid ID number.
* The attending physician’s signature and date he signed the POC. The POC must be signed and dated by the beneficiary’s attending physician before the HHA submits a claim to MDHHS for payment.
If the attending physician signs the POC after the service(s) is rendered, there must be a pre-existing written or verbal order for the service(s) to be covered by Medicaid. If the service(s) is rendered prior to the date the physician dated the POC and there is no pre-existing written or verbal order, Medicaid does not cover the service(s) provided. The verbal order obtained from the ordering physician must contain the signature of the HHA staff person who obtained the verbal order and the date the verbal order was received. All verbal orders must be countersigned and dated by the ordering physician before the claim is submitted to MDHHS for payment.
Ordering physicians must determine that medical/health services are medically necessary and/or appropriate. Any increase in the frequency of services, addition of new services, or modifications of treatment during a certification period must be authorized by the attending physician and documented in the beneficiary’s medical record by way of a verbal order or written order prior to the provision of the increased, additional, or modified treatment.
The POC signed by the attending physician, along with any written or verbal orders as needed, and progress notes must be retained in the beneficiary’s medical record.
OUTCOME AND ASSESSMENT INFORMATION SET
The Centers for Medicare & Medicaid Services (CMS) requires Medicare certified HHAs to use a standard assessment data set, referred to as the Outcome and Assessment Information Set (OASIS). The requirement to collect and submit OASIS clinical data applies to all beneficiaries receiving Medicare and/or Medicaid home health services. This means beneficiaries under Medicaid traditional fee-for service (FFS), MHP, Children’s Waiver, Home and Community Based Services Waiver for the Elderly and
Disabled (MI Choice Waiver), Habilitation Supports Waiver, Healthy Michigan Plan, and CSHCS who receive home health services are to have OASIS information collected by the HHA. Assessments for all beneficiaries are to be conducted in compliance with Medicare certification requirements.
HHAs are also required to electronically transmit the OASIS data to the designated state agency responsible for collecting OASIS data in accordance with CMS specifications. MDHHS contracts with a vendor to provide OASIS transmission assistance. HHAs needing assistance with transmitting data to the state repository should contact the MDHHS contractor. (Refer to the Directory Appendix for contact information.)
The CMS rules for OASIS are published in the Federal Registers that are available online at the OASIS website. (Refer to the Directory Appendix for website information.)
POST-PAYMENT REVIEW
Ordering physicians must determine that medical/health services are medically necessary and/or appropriate. All home health services ordered are subject to review for conformity with accepted medical practice and Medicaid coverage and limitations. Post-payment reviews of paid claims may be conducted to assure that the services provided, as well as the type of provider and setting, were appropriate, necessary, and compliant with Medicaid policy. Post-payment review also includes verification that appropriate procedure codes were used to bill the services provided.
Post-payment review includes verification that all third-party resources were utilized to their fullest extent prior to billing MDHHS. If post-payment review reveals that MDHHS was billed prior to utilizing these resources and the HHA knew the beneficiary had other insurance coverage for the service rendered, it may be considered fraud.
The General Information for Providers Chapter of this manual contains additional information regarding post-payment review and fraud.
