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FLORIDA MEDICAID

FLORIDA MEDICAID . OVERVIEW OF CHANGES TO THE HOME HEALTH SERVICES COVERAGE AND LIMITATIONS HANDBOOK, DECEMBER 2011. PRESENTERS: CLAIRE DAVIS SHEVAUN HARRIS SEPTEMBER 2012. GOALS OF TRAINING. To provide policy clarification.

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FLORIDA MEDICAID

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  1. FLORIDA MEDICAID OVERVIEW OF CHANGES TO THE HOME HEALTH SERVICES COVERAGE AND LIMITATIONS HANDBOOK, DECEMBER 2011 PRESENTERS: CLAIRE DAVIS SHEVAUN HARRIS SEPTEMBER 2012

  2. GOALS OF TRAINING To provide policy clarification. To help decrease the number of incomplete case submissions. To introduce the handbook changes.

  3. TARGET AUDIENCE Florida Medicaid providers of: • Home health visits • Private duty nursing • Personal care services

  4. DEFINITIONS • Babysitting: The act of providing custodial care, daycare, supervision, or similar childcare unrelated to the services that are documented to be medically necessary for the recipient.

  5. DEFINITIONS Instrumental Activities of Daily Living: Instrumental activities of daily living (IADLs) are tasks which enable a recipient to function independently in the community.

  6. DEFINITIONS • Caregiver: An individual such as a parent, foster parent, head of household or family member who attends to the needs of a child or dependent adult. This individual generally provides care without compensation.

  7. DEFINITIONS • Provider: An individual, such as nurse, aide, or health professional who assists in the identification, prevention, or treatment of an illness or disability. This individual is usually an employee of an agency and provides care for compensation.

  8. INDEPENDENT PERSONAL CARE PROVIDER QUALIFICATIONS Independent personal care group providers must meet the home health licensure exemption requirements defined in 400.464, Florida Statutes in order to be reimbursed for personal care services provided to Medicaid recipients.

  9. SKILL LEVEL OF STAFF The skill level that reimbursement is requested for must be reflective of the standards outlined in the Nurse Practice Act. See Florida Statutes Chapter 464. Requests for a skill level higher than the less costly alternative must justify the need.

  10. DUPLICATION OF SERVICES Medicaid does not reimburse for home health services when the service duplicates another provider’s service under the Medicaid program or other state or local program or if a comparable home and community-based service is provided to the recipient at the same time on the same day.

  11. REQUIRED DOCUMENTATION Physician assessment (within 30 days of initial requests and every 180 days thereafter) Physician’s written order for services. Nursing assessment (home health agencies) Plan of care (must be signed and dated before initiation of services) For no longer valid: private duty nursing and personal care services (in addition to the above): Parent work and/or school schedule Parental limitations

  12. REQUIRED DOCUMENTATION The questions in eQSuite must be completed without omitting any answers. The actual documents must be submitted at the time of the request.

  13. GETTING STARTED If the physician initiates home health services after a hospital stay or assessment in the physician’s office the provider must complete the review request within 5 business days of the start of care to receive authorization from the start of care date. The physician assessment cannot be more than 30 days old.

  14. GETTING STARTED The home health provider must ensure that: Due to a medical condition, illness or injury, the services must be delivered at the place of residence (or other authorized location) rather than an office, clinic or other outpatient facility because:

  15. GETTING STARTED Leaving home is medically contraindicated and would increase the risk for exacerbation or deterioration of the condition; or The recipient is unable to leave home without the assistance of another person

  16. Medicaid physician’s written prescription for home health services AHCA-Med Serv Form 5000-3525, September 2011

  17. AHCA-Med Serv Form 5000-3525, December 2011

  18. PHYSICIAN ASSESSMENT The physician assessment can be a: Hospital discharge summary (when services are initiated after a hospitalization); OR Current history and physical; OR AHCA Physician Visit form.

  19. PHYSICIAN VISIT DOCUMENTATION FORM AHCA-Med Serv Form 5000-3502, October 2010

  20. AHCA-Med Serv Form 5000-3502, October 2010

  21. IN-HOME ASSESSMENT Licensed home health agencies perform an in-home RN assessment Independent personal care providers perform an in-home assessment

  22. PLAN OF CARE The plan of care cannot exceed 60 days for licensed home health agencies. Personal care services may be approved for up to 180 days if provided by an independent personal care services provider.

  23. PLAN OF CARE All plans of care must contain current information concerning the recipient – NO photocopies allowed. A new physician’s order must be obtained before the creation of each plan of care. The plan of care must be reviewed and signed by the attending physician before submitting the prior authorization request.

  24. EXCLUSIONS Refer to page 2-13 in the Home Health Services Coverage and Limitations Handbook for examples of services that are not reimbursable under the Medicaid state plan home health services program.

  25. PRESCRIBED PEDIATRIC EXTENDED CARE (PPEC) Update is in the handbook: A recipient who is medically able to attend a PPEC center and whose needs can be met by the PPEC shall be provided with PPEC services instead of private duty nursing services.

  26. PRIVATE DUTY NURSING BY PARENT OR LEGAL GUARDIAN Medicaid will only reimburse a home health agency up to 40 hours per week of private duty nursing services provided by a parent or legal guardian. Parents and legal guardians must participated in providing care to the fullest extent possible and are expected to continue to provide non-reimbursed care as the primary caregiver.

  27. PRIVATE DUTY NURSING BY PARENT OR LEGAL GUARDIAN Medicaid will not approve additional private duty nursing hours for the child so that the child’s parent or legal guardian who is providing private duty nursing for the child can also work outside the home or for respite. The parent or legal guardian is not eligible to participate in the program if he is unable to provide the required care because of a medical condition or disability.

  28. PRIVATE DUTY NURSING Medicaid only reimburses private duty nursing services outside the place of residence if: • The services are unavailable through other public or private resources, including schools (documentation will be required); and Private duty nursing may be considered for the medically-complex child at school if: • Theschool system is not currently providing the intensity of nursing care required by the child, and private duty nursing services would enable the child to attend school (documentation will be required).

  29. PERSONAL CARE SERVICES Medicaid reimburses personal care services for recipients under the age of 21 who: • Have a medical condition or disability that substantially limits their ability to perform their ADLs or IADLs; and • Require more individual and continuous care than can be provided through a home health aide visit.

  30. PERSONAL CARE SERVICES ADLS include: • Eating (oral feedings and fluid intake); • Bathing; • Dressing; • Toileting; • Transferring; and • Maintaining continence (examples include taking care of a catheter or colostomy bag or changing a disposable incontinence product when the recipient is unable to control his bowel or bladder functions).  

  31. PERSONAL CARE SERVICES IADLs (when necessary for the recipient to function independently) include: • Personal hygiene; • Light housework; • Laundry; • Meal preparation; • Transportation; • Grocery shopping; • Using the telephone to take care of essential tasks (examples include paying bills and setting up medical appointments); • Medication management; and • Money management.

  32. PERSONAL CARE SERVICES Medically necessary personal care services may be authorized when a recipient has a documented cognitive impairment which prevents him from knowing when or how to carry out the personal care task.

  33. PARENTAL RESPONSIBILITY This language applies to personal care services only now: Parents and caregivers must participate in providing care to the fullest extent possible. • Services ARE authorized to supplement the care provided by the parents or caregivers. • Services ARE NOT authorized primarily for the convenience of the child, parents, or the caregiver. • Services ARE NOT reimbursed for respite care.

  34. MEDICAL RECORD REQUIREMENTS Each clinical record of a home health agency must contain: Nursing notes of the initial assessment and subsequent visits; Most current plan of care; Most current physician’s orders (signed and dated); Progress notes; Tasks and duties assigned to LPNs and home health aides; Dates and signatures of individuals who render care; Legal documents; Consent forms; and Recipient and caregiver verification of services received.

  35. MEDICAL RECORD REQUIREMENTS Each clinical record of an independent provider must contain: • Most current plan of care; • Most current physician’s orders (signature and date are required); • Recipient name; • Recipient’s Medicaid ID number; • Date the service was rendered; • Start and end times; • Identification of the setting in which the service was rendered, including the specific activities or tasks performed; • Identification of the supplies or equipment used; • Updates regarding the recipient’s progress, toward meeting the goals of the plan of care; • Provider’s name and provider Medicaid ID number; • Name of the person rendering the service along with his signature; and • Recipient and caregiver verification of services received.

  36. PRIOR AUTHORIZATION Medicaid will not reimburse for services without prior authorization when it is required. Prior to providing certain services to recipients, prior authorization must be obtained. A provider may be suspended from obtaining access to new prior authorizations for Medicaid services until deficiencies are addressed.

  37. PRIOR AUTHORIZATION For initial service requests, it is recommended that the home health provider submit the request at least 10 (ten) business days prior to the start of care. For subsequent authorization requests (continued stay requests), the home health provider must submit the request at least 10 (ten) business days prior to the start of the new certification period. The earliest effective date of the authorization is the date the request is received by the Medicaid QIO. All required documentation to support the request must be submitted to the Medicaid QIO at the time of the request.

  38. PRIOR AUTHORIZATION • All requests for prior authorization must be submitted to the Medicaid QIO via its web-based Internet system. • See page 2-35 for the requirements of an authorization request.

  39. PRIOR AUTHORIZATION Prior authorization requests for home health services that appear to deviate from the treatment norms, established standards of care, or utilization norms may be subject to a more intensified review by the QIO prior to rendering a determination. This may include a telephonic or face-to-face contact with the Medicaid recipient in his place of residence, interviews with the ordering physician, and a review of the recipient’s medical record.

  40. MODIFICATION REQUESTS When requesting additional visits or hours within a certification period, the provider should indicate that the request: Is for additional visits or hours or change to an already requested certification period. Includes the attending physician approved POC, new orders, and a reason for the adjustment.

  41. RECONSIDERATION REQUESTS If a denial determination is rendered, the provider, recipient, or physician may request reconsideration. If reconsideration is requested, additional information must be submitted to the QIOwithin five business days of the date of the denial or modified approval determination.

  42. TERMINATION OF SERVICES A discharge request must be submitted to the Medicaid QIO when a home health services provider terminates services. It must include, at a minimum, the last date that services were provided to the recipient and the number of units used on the prior authorization number up until the point of discharge. This language removed: The provider that terminates services does not bill for the date of discharge.

  43. HOME HEALTH VISITS FOR MULTIPLE RECIPIENTS AT ONE LOCATION Home health visit services provided to two or more recipients at a single location are reimbursed as follows; For the first recipient, Medicaid reimburses the services at the established Medicaid visit rate. For the second recipient and any additional recipients, Medicaid reimburses the service at 50 percent of the established Medicaid visit rate.

  44. PDN AND PC SERVICES FOR MULTIPLE RECIPIENTS AT ONE LOCATION PDN and PC furnished by one nurse, home health aide or independent personal care provider to two or more recipients is reimbursed as follows: For the first recipient, Medicaid reimburses the services at the established Medicaid rate; For the second recipient, Medicaid reimburses the services at 50 percent of the established Medicaid rate; and For additional recipients, Medicaid reimburses services at 25 percent of the established Medicaid rate.

  45. BILLING FOR MULTIPLE RECIPIENTS AT ONE LOCATION The provider should bill using the TT modifier on all cases, but should reduce their billing for each as indicated in policy for subsequent cases within the same residence.

  46. MULTIPLE HOME HEALTH SERVICE PROVIDERS In situations that require services from more than one home health provider in order to provide all the care required by a recipient, each provider is responsible for: Coordinating its plan of care with the other involved providers; Informing the QIO of the other providers; If the provider is second to begin services: Adding the UF modifier to the procedure code to identify that services are being coordinated with another provider

  47. DUALLY-ELIGIBLE RECIPIENTS A home health aide visit associated with skilled nursing services may be reimbursable by Medicare; and if so, the service must be billed to Medicare first for a dually-eligible recipient.

  48. QUESTIONS/COMMENTS?

  49. If you have additional questions or comments about this session, email: CLAIRE DAVIS davisc@ahca.myflorida.com

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