††††† 907 KAR 1:030. Home health agency services.

 

††††† RELATES TO: KRS 205.520

††††† STATUTORY AUTHORITY: KRS 194A.030(2), 194A.050(1), 205.520(3), EO 2004-726

††††† NECESSITY, FUNCTION, AND CONFORMITY: EO 2004-726, effective July 9, 2004, reorganized the Cabinet for Health Services and placed the Department for Medicaid Services and the Medicaid Program under the Cabinet for Health and Family Services. The Cabinet for Health and Family Services, Department for Medicaid Services has responsibility to administer the Medicaid Program. KRS 205.520(3) authorizes the cabinet, by administrative regulation, to comply with any requirement that may be imposed or opportunity presented by federal law for the provision of Medical Assistance to Kentucky's indigent citizenry. This administrative regulation establishes the provisions relating to home health care services for which payment shall be made by the Medicaid Program in behalf of both the categorically needy and the medically needy.

 

††††† Section 1. Definitions. (1) "Department" means the Department for Medicaid Services or its designee.

††††† (2) "Home health agency" or "HHA" means a Medicare and Medicaid-certified agency licensed in accordance with 902 KAR 20:081.

††††† (3) "Home health aide" means a person who meets the home health aide requirements established in 902 KAR 20:081.

††††† (4) "Licensed practical nurse" or "LPN" means a person who is:

††††† (a) Licensed in accordance with KRS 314.051; and

††††† (b) Under the supervision of a registered nurse.

††††† (5) "Medical social worker" means a person who meets the medical social worker requirements as established in 902 KAR 20:081.

††††† (6) "Medically necessary" or "medical necessity" means that a covered benefit is determined to be needed in accordance with 907 KAR 3:130.

††††† (7) "Nursing service" means the delivery of medication, or treatment by a registered nurse or a licensed practical nurse supervised by a registered nurse, consistent with KRS Chapter 314 scope of practice provisions and the Kentucky Board of Nursing scope of practice determination guidelines.

††††† (8) "Occupational therapist" means a person who meets the occupational therapist requirements established in 902 KAR 20:081.

††††† (9) "Physical therapist" means a person who meets the physical therapist requirements established in 902 KAR 20:081.

††††† (10) "Place of residence" means, excluding a hospital or nursing facility, the location at which a recipient resides.

††††† (11) "Plan of care" means a written plan which shall:

††††† (a) Stipulate the type, nature, frequency and duration of a service; and

††††† (b) Be reviewed and signed by a physician and HHA staff person at least every sixty (60) days.

††††† (12) "Qualified medical social worker" means a person who meets the qualified medical social worker requirements as established in 902 KAR 20:081.

††††† (13) "Qualified social work assistant" means a social work assistant as defined in 42 C.F.R. 484.4.

††††† (14) "Registered nurse" or "RN" means a person licensed in accordance with KRS 314.041.

††††† (15) "Speech pathologist" means a person who meets the speech pathologist requirements established in 902 KAR 20:081.

 

††††† Section 2. Conditions of Participation. (1) In order to provide home health services, a provider shall:

††††† (a) Be an HHA; and

††††† (b) Comply with 907 KAR 1:671, 907 KAR 1:672, and 907 KAR 1:673; and

††††† (c) Comply with the Home Health Services Manual.

††††† (2) A home health provider shall maintain a medical record for each recipient for whom services are provided. The medical record shall:

††††† (a) Substantiate the services billed to the department and be signed and dated by HHA staff;

††††† (b) Contain a copy of the plan of care;

††††† (c) Document verbal orders from the physician, if applicable;

††††† (d) Be retained for a minimum of five (5) years from the date a covered service is provided, except in the case of a minor, whose records shall be retained for three (3) years after the recipient reaches the age of majority under state law, whichever is longest;

††††† (e) Be kept in an organized central file within the HHA; and

††††† (f) Be made available to the department upon request.

 

††††† Section 3. Covered Services. (1) A home health service shall:

††††† (a) Effective November 15, 2001, be prior authorized by the department to ensure that the service or modification of the service is medically necessary and adequate for the needs of the recipient;

††††† (b) Be provided pursuant to a plan of care; and

††††† (c) Be provided in a recipientís place of residence.

††††† (2) The following services provided to a recipient by a home health provider, who meets the requirements in Section 2 of this administrative regulation, shall be covered by the department:

††††† (a) A nursing service which shall:

††††† 1. Include part-time or intermittent nursing services;

††††† 2. If provided daily, be limited to thirty (30) days unless additional days are prior authorized by the department;

††††† (b) A therapy service which shall:

††††† 1. Include physical therapy provided by a physical therapist or a qualified physical therapist assistant as defined in 42 C.F.R. 484.4 who is under the supervision of a qualified physical therapist;

††††† 2. Include occupational therapy provided by an occupational therapist or a qualified occupational therapy assistant as defined in 42 C.F.R. 484.4 who is under the supervision of a qualified occupational therapist;

††††† 3. Include speech therapy provided by or under the supervision of a speech pathologist;

††††† 4. Be provided pursuant to a plan of treatment which shall be developed by the appropriate qualified therapist and physician; and

††††† 5. Be provided in accordance with 907 KAR 1:023 and comply with the physical therapy, occupational therapy and speech therapy requirements established in "Technical Criteria for Reviewing Ancillary Services for Adults, February 2000 Edition" or "Technical Criteria for Reviewing Ancillary Services for Pediatrics, April 2000 Edition";

††††† (c) A home health aide service which shall:

††††† 1. Include the performance of simple procedures as an extension of therapy services, personal care, range of motion exercises and ambulation, assistance with medications that are ordinarily self-administered, reporting a change in the recipientís condition and needs, incidental household services which are essential to the recipientís health care at home when provided in the course of a regular visit, and completing appropriate records;

††††† 2. Be provided by a home health aide who is supervised at least every two (2) weeks by:

††††† a. An RN;

††††† b. A physical therapist, for any physical therapy services that are provided by the home health aide;

††††† c. An occupational therapist, for any occupational therapy services that are provided by the home health aide; or

††††† d. A speech therapist, for any speech therapy services that are provided by the home health aide; and

††††† 3. Be a service that the recipient is either physically or mentally unable to perform;

††††† (d) A medical social service which shall:

††††† 1. Be provided by a qualified medical social worker or qualified social work assistant; and

††††† 2. Be provided in conjunction with at least one (1) other service listed in this section;

††††† (e) A disposable medical supply which shall:

††††† 1. Include the following:

††††† a. An adapter;

††††† b. An applicator;

††††† c. Drainage supplies;

††††† d. Dressing supplies;

††††† e. Catheter, ileostomy or ureostomy supplies;

††††† f. Colostomy supplies;

††††† g. A detection reagent for other than sugar or ketone;

††††† h. Except for the limitations contained in Section 4(5) of this administrative regulation, diapers, underpads or incontinent pants;

††††† i. An egg crate mattress;

††††† j. An enema or elimination supplies including a fleet enema or dulcolax suppository;

††††† k. Gastrostomy supplies;

††††† l. Gloves;

††††† m. Inhalation therapy supplies;

††††† n. Irrigation solutions;

††††† o. IV therapy supplies;

††††† p. Lambs wool or a synthetic pad;

††††† q. A lotion, powder or cream for an invalid or bedfast recipient;

††††† r. A nipple if designed for cleft palate;

††††† s. Inexpensive occupational therapy supplies which may include a plastic utensil holder or a long arm reacher;

††††† t. Suction supplies;

††††† u. Support supplies which may include antiembolism stockings, support vest, support gauntlet, or support glove;

††††† v. A syringe or needle (excluding an insulin syringe for a diabetic);

††††† w. Tracheostomy supplies; or

††††† x. Tubing; and

††††† 2. If provided to a recipient who is not in need of a home health visit, be required to maintain him in his place of residence. A physician shall certify the medical necessity of a disposable medical supply by completing and signing a MAP 248 form; and

††††† (f) An enteral nutritional product which shall:

††††† 1. Be ingested orally or delivered by tube into the gastrointestinal tract; and

††††† 2. Provide for the total or supplemental nutrition of a recipient.

 

††††† Section 4. Limitations and Exclusions from Coverage. (1) A domestic or housekeeping service which is unrelated to the health care of a recipient shall not be covered.

††††† (2) A medical social service shall not be covered unless provided in conjunction with another service pursuant to Section 3 of this administrative regulation.

††††† (3) Supplies for personal hygiene shall not be covered.;

††††† (4) Drugs shall not be covered.

††††† (5) Disposable diapers shall not be covered for a recipient age three (3) years and under regardless of the recipientís medical condition.

††††† (6) Except for the first week following a home delivery, a newborn or postpartum service without the presence of a medical complication shall not be covered.

††††† (7) A recipient who has elected to receive hospice care shall not be eligible to receive coverage under the home health program.

 

††††† Section 5. Appeal Rights. (1) An appeal of a negative action taken by the department regarding a Medicaid beneficiary shall be in accordance with 907 KAR 1:563.

††††† (2) An appeal of a negative action taken by the department regarding Medicaid eligibility of an individual shall be in accordance with 907 KAR 1:560.

††††† (3) An appeal of a negative action taken by the department regarding a Medicaid provider shall be in accordance with 907 KAR 1:671.

 

††††† Section 6. Incorporation by Reference. (1) The following material is incorporated by reference:

††††† (a) MAP-248, Commonwealth of Kentucky, Cabinet for Health Services, Department for Medicaid Services, December 2001 revision;

††††† (b) Home Health Services Manual, November 1993 edition;

††††† (c) Technical Criteria for Reviewing Ancillary Services for Adults, February 2000 Edition; and

††††† (d) Technical Criteria for Reviewing Ancillary Services for Pediatrics, April 2000 Edition.

††††† (2) This material may be inspected, copied, or obtained, subject to applicable copyright law, at the Department for Medicaid Services, 275 East Main Street, Frankfort, Kentucky 40621, Monday through Friday 8 a.m. to 4:30 p.m. (Recodified from 904 KAR 1:030, 5-2-86; Am. 15 Ky.R. 2458; eff. 8-5-89; 21 Ky.R. 141; eff. 8-17-94; 29 Ky.R. 1409; 1819; 2108; eff. 1-15-2003.)