Section 17b-262-728 - Services covered and limitations(a) Subject to the limitations and exclusions identified in sections 17b-262-724 to 17b-262-735, inclusive, of the Regulations of Connecticut State Agencies, the department shall pay for medically necessary and medically appropriate home health care services provided by home health care agencies that are directly related to the client's diagnosis, symptoms or medical history. These services include: (1) nursing care services limited to the following:(A) physical nursing care or the teaching of nursing care, including, but not limited to, direct services such as enemas, irrigations, dressing changes, treatments and administration and supervision of medication;(B) admission of clients to agency services; development of the initial care plan; and subsequent reviews of the care plan, no more than one every 60 days;(C) diabetic teaching for thirty consecutive days per diabetic client;(D) pregnancy-related preventive prenatal and postpartum nursing care services to women at high risk of negative pregnancy outcome that are performed during the prenatal or postpartum period of pregnancy for the purpose of, but not limited to: (i) evaluation of medical health status, obstetrical history, present and past pregnancy related problems and psychosocial factors such as emotional status, inadequate resources, supportive helping networks and parenting skills; and(ii) the provision of general health education and counseling, referral, instruction, suggestions, support or observation to monitor for any untoward changes in the condition of a prenatal or postpartum woman at high risk so that other medical or social services, if necessary, can be instituted during the prenatal or postpartum stage of childbearing;(2) hands on care provided by a home health aide;(3) home health aide assistance with an IADL provided in conjunction with hands on care;(4) physical therapy services;(5) speech therapy or speech pathology services;(6) occupational therapy services; and(b) Limitations on covered services shall be as follows:(1) The department shall pay for home health care services only when these services are provided in the client's home. However, the department shall pay for medically necessary and medically appropriate nursing care services for clients who leave their place of residence to engage in normal life activities. The total number of hours of nursing care services shall be limited to those hours to which the client would be entitled if services were provided exclusively at the client's place of residence. Such services shall not be provided in hospitals, nursing facilities, chronic disease hospitals, intermediate care facilities for the mentally retarded or other facilities that are paid an all-inclusive rate directly by Medicaid for the care of the client.(2) The department shall pay for only those services that are listed in the department's fee schedule for home health care services.(3) The department shall pay for pregnancy-related preventive postpartum nursing care services only for high risk women as described in section 17b-262-731 of the Regulations of Connecticut State Agencies. Such payment shall be limited to services provided during the sixty-day time period immediately following childbirth.(4) Home health aide services in excess of fourteen hours per week must be cost effective, as described in section 17b-262-730 of the Regulations of Connecticut State Agencies, for Medicaid payment to be available.(5) Extended nursing services shall be cost effective as described in section 17b-262-730 of the Regulations of Connecticut State Agencies.(6) The fee for medication administration shall include the administration of medication(s) while the nurse is present as well as the pre-pouring of additional doses, less than a one week supply, that the client will self administer at a later time and the teaching of self administration of the medication that has been pre-poured.(7) When the purpose of the visit is to pre-pour medication for a week or more, the skilled nursing visit codes for either a registered nurse or a licensed practical nurse shall be used. The skilled nursing visit is provided for a client who has a documented need for this service because of his or her inability to correctly count out or draw up the medication for self-administration. Documentation shall include a full assessment of the client's medical and behavioral status as well as notes addressing the client's understanding of the drug therapy and his or her continued ability to self-administer the medications.(8) If during the course of a scheduled medication administration visit, there is a change in the client's condition and the client's prescribing practitioner is notified, the medication administration visit may become a skilled nursing visit. This may occur even if a revision to the client's plan of care is not required. The client's medical record shall be fully updated to reflect the change in medical and behavioral health observed during the visit, the additional skilled services provided to the client and the revisions, if any, made to the plan of care. If this situation occurs and the services have been prior authorized, the provider shall contact the department to request modification of the prior authorization.Conn. Agencies Regs. § 17b-262-728
Adopted effective March 7, 2007