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Coverage criteria policies

Home Health Service – Minnesota Health Care Programs

These services may or may not be covered by your HealthPartners plan. Please see your plan documents for your specific coverage information. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage.

Administrative Process

Prior authorization is required:

  • After the 15th home care visit, inclusive of nursing and all therapies, received in a calendar year.
  • At the onset of extended hours of nursing in the home.

Prior authorization is not required for IV therapy services received in the home.

Coverage

Home health services are covered per the indications listed below, and per your plan documents.

Services must be received from a contracted, Medicare Certified Home Care agency.

Indications that are covered

The following criteria must be met for coverage of all home health care services:

  1. All services must be ordered by a medical provider, i.e., physician, physician’s assistant, or Nurse Practitioner.
  2. The care must be:
    1. Provided to an eligible member, and
    2. Medically necessary, and
    3. Provided in the member’s residence, and
    4. Included in a written home care plan.
  3. The services require skilled care and could not be performed by non-medical personnel.
  4. Services eligible for coverage include Skilled Nursing (SNV), Home Health Aide (HHA), and Rehabilitative therapies including Licensed Physical Therapist (PT) or Physical Therapy Assistant (PTA), Registered Occupational Therapist (OT) or Certified Occupational Therapy Assistant (COTA), Speech Therapy (ST) or Respiratory Therapy (RT).

Indications for Skilled Nursing Visit Coverage

  1. Intermittent home visits to initiate and complete professional nursing tasks based on a member’s need for service as assessed to maintain or restore optimal health. Visits are made by a registered nurse (RN) or licensed practical nurse (LPN), under the supervision of an RN. If the necessary medical services are more complex and require more time than can be performed in a single or twice daily skilled nurse visit, private duty nursing services are an appropriate option.
  2. Observation, assessment, and evaluation of a person’s physical or mental health status. This may be covered when the likelihood of a change in condition requires skilled nursing personnel to identify and evaluate the need for possible modification of treatment or initiation of additional medical procedures until the member’s treatment regimen is stabilized.
  3. A procedure that requires substantial and specialized nursing skill such as administration of intravenous therapy, intra-muscular injections, sterile catheter insertion or sterile wound cares.
  4. Teaching and training that requires the skills of a nurse. Examples could include, teaching self-administration of injectable medications or a complex range of medications; teaching a newly diagnosed diabetic person or caregiver on all aspects of diabetic management; teaching self-catheterization or bowel and/or bladder training.
  5. Postpartum visits to new mothers and their newborn infants. Post-delivery care includes a minimum of one home visit by a licensed RN. The RN must provide parent education, assistance and training in breast and bottle-feeding and conduct any necessary and appropriate clinical tests. The RN should make the home visit as soon as possible, generally within four days following hospital discharge. A separate plan of care is needed for the mother and newborn.
  6. Community health nursing visits provided by a public health agency or home health agency for the sole purpose of maternal, child, and adult health promotion ONLY when an authorized skilled nursing service is provided at the same visit.
  7. Two visits per day can be authorized when necessary.
  8. Venipuncture from a peripheral site when there is not an available lab service that can visit the member’s home to obtain the venipuncture.

Indications for Skilled Nursing Visits that are Not Covered

  1. Usual and customary equipment and supplies used to complete a skilled nursing visit (SNV) (i.e., stethoscope, nail clippers, sphygmomanometer, alcohol wipes, etc.)
  2. SNV for the sole purpose of supervising a home health aide or PCA. However, supervision may be done during a SNV that qualified for coverage.
  3. SNV for the sole purpose of monitoring medication compliance, with an established medication program for a member.
  4. SNV for the sole purpose of monitoring a member’s overall physical status, when the member’s physical status has not changed and the person is considered stable.
  5. SNV to set up or administer oral medications; pre-fill injections, such as insulin syringes for an adult member when the need can be met by an available pharmacy; or the member is physically and mentally able to self-administer or pre-fill a medication; or if the activity can be delegated to a family member.
  6. When the sole purpose of the visit is to train other home health agency workers;
  7. When the visit is performed in a place other than the member’s residence.
  8. For Medicare evaluation or administrative nursing visits required by Medicare but not qualifying as a SNV. (These visits are an administrative expense for the Medicare certified agency and cannot be billed to MA)
  9. SNV provided by an RN that is employed by a Personal Care Provider Organization (PCPO) or non-Medicare certified private duty nursing agency.
  10. A communication between the home care nurse and member that consists solely of a telephone conversation, facsimile, electronic mail or a consultation between two health care practitioners is not considered a tele-home-care visit.

Indications for Home Health Aide Visit Coverage:

  1. Assisting with personal cares such as bathing, dressing, grooming, feeding, toileting, routine catheter and colostomy care, ambulating, transfers or positioning.
  2. Simple dressing changes that do not require the skills of a licensed nurse.
  3. Assisting with medications that are ordinarily self-administered and do not require the skill of a licensed nurse for safe and effective provision.
  4. Assisting with activities that are directly supportive of skilled therapy services but do not require the skill of a therapist to be safely and effectively performed, such as routine maintenance exercises.
  5. Routine care of prosthetic and orthotic devices.
  6. Incidental household services necessary to the provision of one of the above health related services.

Indications for Home Health Aide Visits that are Not Covered:

  1. Home health aide visits for the sole purpose of providing household tasks, transportation, companionship, or socialization.
  2. Services that are not medically necessary.
  3. Services provided in a hospital, nursing facility (NF), or intermediate care facility (ICF).
  4. More than one home health aide visit per day.

Indications for Rehabilitation Therapy Coverage

  1. Rehabilitation therapy services may be provided once per day, with the exception of Respiratory Therapy which may be provided more than once per day, for services provided in the member’s home.
  2. Services must be provided to a member who is confined to the home or it takes “considerable effort” to depart.
  3. The functional status is expected to progress toward or achieve the goals specified in the recipient’s plan of care within a 60-day period.

Indications for Rehabilitation Services that are not covered

  1. Rehabilitation services in the home when the member can reasonably access these services outside his/her residence, or to a member who can leave at will.
  2. Rehabilitation provided to a child who could easily be transported, by a parent/guardian to a rehab center.

Definitions

Home health service includes one or more of the following disciplines: skilled nursing, physical therapy, occupational therapy, speech therapy, respiratory therapy, home health aide (requires a skilled discipline in the home), and intravenous therapy (IV).

Home Health Aide (HHA): Services that are medically oriented tasks required to maintain the member’s health or to facilitate treatment of an illness or injury.

Skilled Nurse Visits (SNV): Intermittent nursing services ordered by a physician for a member whose illness, injury, physical, or mental condition creates a need for the service. Services under the direction of an RN are provided in the recipient’s residence by an RN, or LPN; and provided under a plan of care that specifies a level of care which the nurse is qualified to provide

Rehabilitation Therapies: Services and interventions specifically designed to improve cognitive functions and designed to restore the recipient’s functional status to a level consistent with the recipient’s physical or mental limitations. Home Care Rehabilitative Therapies include: Occupational Therapy, Physical Therapy, Speech Therapy and Respiratory Therapy.

Products

This information is for most, but not all, HealthPartners plans. Please read your plan documents to see if your plan has limits or will not cover some items. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage. These coverage criteria may not apply to Medicare Products if Medicare requires different coverage. For more information regarding Medicare coverage criteria or for a copy of a Medicare coverage policy, contact Member Services at 952-883-7979 or 1-800-233-9645.

Reference

Home Care Services. (01-23-2015). MHCP Provider Manual. Retrieved from http://www.dhs.state.mn.us/main/idcplg?IdcService=GET_DYNAMIC_
CONVERSION&RevisionSelectionMethod=LatestReleased&dDocName=id_008994#P53_2251

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Policy activity

  • 07/26/2012 - Date of origin
  • 12/01/2016 - Effective date
Review date
  • 12/2017

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