Long Term Care Division

1. Long Term Care Division Alabama Medicaid Agency Long Term Care Division Outreach and Education Unit February 2004

2. P R E S E N T S An Overview Of Home Health Care AND Durable Medical Equipment

3. Home Health Care

4. What is Home Health Care? • Skilled Nursing and Home Health Aide Services prescribed by a physician are provided to eligible recipients on a part-time or intermittent basis. • These services cover preventive, restorative, and supportive care to persons who meet Medicaid Home Health Care criteria.

5. What is Home Health Care? • Nursing and personal care provided under the Home Health Program must be certified by licensed physicians and provided by Home Health Agencies under contract with Medicaid.

6. Target Populationfor Home Health Care • Alabama Medicaid Home Health Care Services are available for all Medicaid eligible persons of any age, who meet the admission criteria on the basis of a reasonable expectation that a patient’s medical, nursing, and social needs can adequately be met in the patient’s place of residence.

7. Purpose of providing Home Health Care Home Health care is provided for the following reasons: • To promote, maintain, or restore health to individuals and families in their place of residence; and • To maximize the level of independence while minimizing the effects of disability and illness.

8. In–Home Therapies • Physical, Speech, and Occupational Therapy in the home are limited to individuals under 21 years of age that are referred from an EPSDT screening.

9. Eligibility Requirements To be eligible for Home Health Care, a recipient must meet the following criteria: • The recipient’s illness, injury, or disability prevents the recipient from going to a physician’s office, clinic, or other outpatient setting for required treatment; as a result, he or she would, in all probability, have to be admitted to a hospital or nursing home because of complications arising from lack of treatment;

10. Eligibility Requirements..continued • The recipient is unable to leave home under normal circumstances. Leaving home requires considerable taxing efforts by the recipient, and absences from the home are infrequent, of relative short duration, and for medical reasons; and • The recipient is unable to function without the aid of supportive devices, such as crutches, a cane, wheelchair or walker and requires the use of special transportation or the assistance of another person.

11. What is a Certificate of Need? • The Certificate of Need Process is intended to control expansion of facilities and services by preventing excessive or duplicative development of facilities and services.

12. Certificate of Need Process • Health Care entities interested in becoming a Home Health Agency must have a certificate of need in order to participate in the Medicaid Program.

13. Home Health Coverage • Medicaid in Alabama may cover up to 104 home health visits per year per beneficiary. Medicaid may authorize additional home health visits for beneficiaries under age 21 who have exhausted the home health benefit of 104 nursing visits per calendar year.

14. Financial Criteria • For an individual to receive Home Health Benefits under the Medicaid program, they must have full Medicaid eligibility.

15. State Certified Home Health Agencies • In FY 2003, 128 participating Home Health Agencies served Medicaid recipients.

16. $ Payment Rates • The payment rates for Home Health visits are $27.00 per visit for private agencies. • Home Health visits provided by the Alabama Department of Public Health are paid at cost.

17. Average Number Served • During FY 2003, over 6,000 recipients received visits costing a total of approximately $9.2 million.

18. Covered Services • If ordered by the patient’s physician, and authorized by Medicaid, a professional registered nurse employed by a certified home health agency can provide part-time or intermittent nursing services to a patient.

19. Covered Services…continued • The registered nurse is responsible for a nursing care plan, which is made in accordance with the physician’s written plan of care. • Restorative, preventive, maintenance, and supportive services are covered.

20. Covered Services…continued Licensed Practical Nurse Services • If ordered by a patient’s physician, a licensed practical nurse, supervised by a professional registered nurse, employed by a participating Home Health Agency, can provide intermittent or part-time nursing services to the patient when assignment is made by the professional registered nurse. • LPN services are assigned and provided in accordance with existing State Law.

21. Covered Services…continued Home Health Aide/Orderly Services • A Home Health Aide/Orderly can provide personal care and services as specified in the physician’s plan of treatment. • These services can be provided on a part-time basis only when they are supervised by the nurse who is responsible for the care of the patient and services are authorized by Medicaid.

22. Durable Medical Equipment

23. Durable Medical Equipment • Supplies, Appliances, and Durable Medical Equipment (DME) are mandatory benefits under the Home Health Program. • Medicaid recipients do not have to receive Home Health Services to qualify for DME, but all items must be medically necessary and suitable for use in the home.

24. Durable Medical Equipment • During FY 2003, over 752 Medicaid DME providers throughout the state furnished services at a cost of approximately $21 million.

25. Non-Covered Services • There is no coverage under the Medicaid Home Health Care plan for visits by paramedical personnel, physical therapists, speech therapist, occupational therapist, and inhalation therapist. • Sitter service, private duty nursing service, medical social workers and dietitians are not covered by Medicaid.

26. Non-Covered Services…continued • Supervisory visits made by a professional registered nurse to evaluate appropriateness of services being rendered to a patient by an LPN, aide, or orderly and considered as administrative cost to the agency and may not be billed as skilled nursing services.

27. Additional Information If you have further questions regarding Alabama Medicaid Agency Long Term Care Programs, please contact: LTC Provider/Recipient Services Unit, 334-293-5504