R414-14-5. Service Coverage

  (1) Two levels of home health service are covered: Skilled Home Health Services and Supportive Maintenance Home Health Services.

  (2) Skilled nursing service encompasses the expert application of nursing theory, practice and techniques by a registered professional nurse to meet the needs of patients in their place of residence through professional judgments, through independently solving patient care problems, and through application of standardized procedures and medically delegated techniques.

  (3) Home health aide service encompasses assistance with, or direct provision of, routine care not requiring specialized nursing skill. The home health aide is closely supervised by a registered, professional nurse to assure competent care. The aide works under written instructions and provides necessary care for the patient.

  (4) Supportive maintenance home health care serves those patients who have a medical condition which has stabilized, but who demonstrate continuing health problems requiring minimal assistance, observation, teaching, or follow-up. This assistance can be provided by a certified home health agency through the knowledge and skill of a licensed practical nurse (LPN) or a home health aide with periodic supervision by a registered nurse. A physician continues to provide direction.

  (5) IV therapy, enteral and parenteral nutrition therapy are provided as a home health service either in conjunction with skilled or maintenance care or as the only service to be provided. Specific policy is outlined in the Medical Supplies and Durable Medical Equipment Utah Medicaid Provider Manual, and all requirements of the home health program must be met in relation to orders, plan of care, and 60-day review and recertification.

  (6) Physical therapy and speech-language pathology services are occasionally indicated and approved for the patient needing home health services. Any therapy services offered by the home health agency directly or under arrangement must be ordered by a physician and provided by a qualified licensed therapist in accordance with the plan of care. Occupational therapy and speech-language pathology services in the home are available only to clients who are pregnant women or who are eligible under the Early and Periodic Screening, Diagnosis and Treatment Program.

  (7) Medical supplies utilized for home health service must be consistent with physician orders, and approved as part of the plan of care.

  (8) Medical supplies provided by the home health agency do not require prior approval, but are limited to:

  (a) supplies used during the initial visit to establish the plan of care;

  (b) supplies that are consistent with the plan of care; and

  (c) non-durable medical equipment.

  (9) Supportive maintenance home health services is limited in time equal to one visit per day determined by care needs and care giver participation.

  (10) A registered nurse employed by an approved, certified home health agency must supervise all home health services. Nursing service and all approved therapy services must be provided by the appropriate licensed professional.

  (11) Only one home health provider (agency) may provide service to a patient during any period of time. However, a subcontractor of a home health provider may provide service if the original agency is the only provider that bills for services. A second provider or agency requesting approval of service will be denied.

  (12) Home health care provided to a patient capable of self-care is not a covered Medicaid benefit.

  (13) Personal care services, except as determined necessary in providing skilled care, is not a covered home health benefit.

  (14) Housekeeping or homemaking services are not covered home health benefits.

  (15) Occupational therapy is not a covered Medicaid benefit except for children covered under CHEC for medically necessary service.

  (16) Home health nursing service beyond the initial evaluation visit requires prior authorization.

  (17) All home health service beyond the initial visit, including supplies and therapies, shall be in the plan of care that the home health agency submits for prior authorization. After initial authorization, if level of service needs change and additional services are required, the home health agency must submit a new prior authorization request.

  (18) A home health agency may provide therapy services only in accordance with medical necessity and after receiving prior authorization.