Family and Children's Medicaid MA-3540 Medicaid Covered Services

Xviii. HOME HEALTH SERVICES

Home health services are medically necessary intermittent skilled services (skilled nursing, physical therapy, speech and language pathology and occupational therapy) and non-skilled services (home health aide services and medical supplies) provided to recipients who reside in private residences. Home health skilled services and medical supplies can be provided to recipients in an adult care home. Home health aide services cannot be provided in this setting because the personal care and incidental tasks are performed by the staff of the adult care home.

Refer to DMA’s website at http://www.dhhs.state.nc.us/dma/mp/mpindex.htm for specific coverage criteria, prior approval requirements, and service limitations.

A. Covered Services

Home health services include skilled nursing, home health aide services, physical therapy, speech and language pathology, occupational therapy, and medical supplies. Home health skilled services and aide services are provided on a per visit basis. Medical supplies may be provided to a recipient even when no home health services are needed.

B. Restrictions

1. Home health services do not count towards a recipient’s professional services visit limit.

2. The home health agency must be able to provide the services safely and effectively in the recipient’s home in accordance with all applicable state and federal rules, regulations, and agency policy and procedures

Home health services are deemed appropriate when the recipient’s medical record accurately documents one or more of the reasons specified below relative to why the services should be provided in the recipient’s home instead of the physician’s office, clinic, or other outpatient setting.

a. The recipient would require ambulance transportation.

b. The recipient requires assistance in leaving the home, such as with opening doors and other routine activities.

c. The recipient is wheelchair bound with a medical condition that precludes leaving home on a regular basis.

d. The recipient is medically fragile or unstable.

e. Leaving the home would interfere with the effectiveness of the services.

REVISED 08/01/11 – CHANGE NO. 14-11

(XVIII. B. 2)

3. All services must be ordered by a physician and rendered according to an authorized plan of care.

4. Recipients residing in an adult care home are only eligible to receive skilled nursing, skilled therapy services, and medical supplies.

5. Skilled nursing and/or in-home health aide services may be provided up to 7 days per week but cannot exceed eight hours per day and 34 hours per week.

NOTE: Relative to number 5 above and for recipients under the age of 21 in regard to EPSDT requirements, see I. and XXXVIII. of this manual section.

C. Copayments

There are no copayments for home health services.

D. Prior Approval

1. It is the provider's responsibility to obtain prior approval if needed. (Refer to II.G. for additional information.)

2. Required for recipients receiving MPW coverage.