471 Neb. Admin. Code, ch. 9, § 004

Current through June 17, 2024

Section 471-9-004 - SERVICES REQUIREMENTS

004.01GENERAL SERVICE REQUIREMENTS.

004.01(A)MEDICAL NECESSITY. The Department incorporates the medical necessity requirements outlined in 471 NAC 1 as if fully rewritten herein. Services and supplies that do not meet the requirements in 471 NAC 1 are not covered. Durable medical equipment, prosthetics, orthotics, and medical supplies (DMEPOS) must meet the guidelines outlined in 471 NAC 7. In addition to the medical necessity criteria outlined in 471 NAC 1, all home health services and skilled nursing services must be:

(i) Necessary to a continuing medical treatment plan;

(ii) Prescribed by a licensed physician, nurse practitioner, physician assistant, or clinical nurse specialist; and

(iii) Recertified by the licensed physician, nurse practitioner, physician assistant, or clinical nurse specialist at least every 60 days.

004.01(B)PRIOR AUTHORIZATION FOR HOME HEALTH SERVICES AND SKILLED NURSING SERVICES. Durable medical equipment, prosthetics, orthotics, and medical supplies (DMEPOS) must meet the requirements and procedures for prior authorization outlined in 471 NAC 7. All home health agency services must be authorized and the eligibility of the client must be verified by the home health agency. The Department or its designee may grant authorization of home health agency services. To request authorization, the home health agency must submit Form MS-72, Nebraska Home Health Prior Authorization, and submit a copy of the physician, nurse practitioner, physician assistant, or clinical nurse specialist order and the home health agency's plan of care. Skilled nursing services and home health agencies must be authorized under the same criteria however, providers must send requests for authorization electronically using the standard Health Care Services Review - Request for Review and Response transaction (ASC X 12N 278) or by submitting Form MS-81: Certification and Plan of Care For Private-Duty Nursing to the Medicaid designee. The plan of care must include:

(i) The client's name, address, Medicaid identification number, and date of birth;

(ii) The dates of the period covered, not exceeding 60 days;

(iii) The diagnosis;

(iv) The type and frequency of services;

(v) The equipment and supplies needed;

(vi) A brief, specific description of the client's needs and services provided;

(vii) Any other pertinent documentation that justifies the medical necessity of the services; and

(viii) The plan of care must include a signature or verbal authorization from the physician, nurse practitioner, physician assistant, or clinical nurse specialist at prior authorization submittal. Verbal authorizations must be signed within 30 days.

004.01(C)ELIGIBILITY AND ADVANCE PRACTICE REGISTURED NURSE OR PHYSICIAN CERTIFICATION. To be eligible for home health services and skilled nursing services, the attending physician, nurse practitioner, physician assistant, or clinical nurse specialist must certify that based on the client's medical condition, home health services and skilled nursing services are medically necessary and appropriate services to be provided in the home.

004.01(D)FACE-TO-FACE VISIT. The physician, nurse practitioner, physician assistant, or clinical nurse specialist must document a face-to-face encounter that is related to the primary reason the beneficiary requires home health services and occurred no more than 90 days before or 30 days after the start of services.

004.01(E)SECOND VISIT ON SAME DAY. The medical necessity of a second visit on the same date of service must be documented. Substantiating documentation for skilled nursing services must be submitted with MC-82N, or the request for prior authorization with the standard Health Care Claim: Professional Transaction (ASC X12N 837).

004.01(F)SERVICES PROVIDED FOR CLIENTS ENROLLED IN NEBRASKA MEDICAID MANAGED CARE. See 471 NAC 1.

004.01(G)HEALTH CHECK SERVICES. See 471 NAC 33.

004.01(H)ADVANCE DIRECTIVES. Medicaid-participating home health agencies must comply with applicable state and federal requirements.

004.02COVERED SERVICES. Medicaid covers the following home health agency services and private duty nursing services:

(i) Skilled nursing services by:

(1) A registered nurse (RN);

(2) A licensed practical nurse (LPN);

(3) A certified nurse midwife;

(4) A nurse practitioner;

(5) A physician assistant; or

(6) A clinical nurse specialist;

(ii) Home health aide services by:

(1) A nurse aide; or

(iii) Physical therapy provided by a licensed physical therapist;

(iv) Speech therapy provided by a licensed speech pathologist;

(v) Occupational therapy provided by a licensed occupational therapist; and

(vi) Durable medical equipment and medical supplies.

004.02(A)USE OF AUTHORIZED HOURS. A client who requires and is authorized to receive home health nursing services in the home setting may use their approved hours outside of the home during those hours when their normal life activities take them out of the home. The Department will not authorize any additional hours of nursing service beyond what would normally be authorized. If a client requests to receive nursing services to attend school or other activities outside the home, but does not need nursing services in the home, nursing services cannot be authorized.

004.02(B)HOME HEALTH AIDES. A home health aide may provide services to a client in the client's home to meet personal care needs resulting from the client's illness or disability. Skilled nursing visits are not a prerequisite for the provision of home health aide services. The services must be:

(1) Necessary because the care is not available to the client without payment by Medicaid;

(2) Necessary to continuing a plan of care;

(3) Prescribed by a licensed physician, nurse practitioner, physician assistant, or clinical nurse specialist;

(4) Recertified by the licensed physician, nurse practitioner, physician assistant, or clinical nurse specialist at least every 60 days; and

(5) Supervised by a registered nurse.

004.02(B)(i)LIMITATION. For extended-hour aide services in home health and nursing services, the Department limits aide services to 56 hours a week with a maximum of 12 hours in a 24 hour period. Department approval must be obtained for services in excess of 56 hours a week.

004.02(C)MEDICATIONS. Medicaid covers intravenous or intramuscular injections and intravenous feeding. Oral medications are covered only where the complexity of the medical condition (physical or psychological) and the number of drugs require a licensed nurse to monitor, detect, and evaluate side effects. The complexity of the medical condition must be documented and submitted with the plan of care.

004.02(C)(i)PREFILLING INSULIN SYRINGES. The Department reimburses home health agencies and private duty nurses for prefilling insulin syringes for blind or disabled diabetic clients who are unable to perform this task themselves and where there is no one else available to fill the insulin syringe on the client's behalf. The Department considers this a professional nursing service that must be provided only through a professional nurse visit.

004.02(C)(ii)VITAMIN B-12 INJECTIONS. Vitamin B-12 injections are covered initially once a week for a maximum of six weeks, and then once a month when maintenance is established for the treatment of pernicious anemia and other macrocytic anemias, and neuropathies associated with pernicious anemia.

004.02(D)ADDITIONAL SERVICES FOR DIABETIC CLIENTS. Medicaid covers blood sugar testing and foot care for blind or disabled diabetic clients who are unable to perform this task themselves and where there is no one else available to perform the tasks on the client's behalf.

004.02(E)DECUBITUS AND SKIN DISORDERS. Covered when specific physician, nurse practitioner, physician assistant, or clinical nurse specialist orders indicate that skilled care is necessary, or that skilled nursing care is necessary, requiring prescribed medications and treatment.

004.02(F)DRESSINGS. Medicaid covers application of dressings when aseptic technique and prescription medications are used.

004.02(G)COLOSTOMY, ILEOSTOMY, AND GASTROSTOMY. These services are covered during immediate postoperative time when maintenance care and control by the patient or family is being established. This includes the initial teaching. General maintenance care is not covered.

004.02(H)ENTEROSTOMAL THERAPY. Medicaid recognizes enterostomal therapy visits as a skilled nursing service.

004.02(I)ENEMAS AND REMOVAL OF IMPACTIONS. Medicaid covers enemas and removal of impactions when the complexity of the patient's condition establishes that the skills of a nurse are required.

004.02(J)BOWEL AND BLADDER TRAINING. The Department covers teaching skills and facts necessary to adhere to a specific formal regimen. General routine maintenance program or treating is not covered.

004.02(K)URETHRAL CATHETERS AND STERILE IRRIGATIONS. The Department covers insertions and changes when active urological problems are present or when client is unable to do physician-ordered irrigations. Routine catheter maintenance care is not covered.

004.02(L)CASTS. Casts are covered if the physician's order evidences more complexity than routine or general supportive care.

004.02(M)DRAW OR COLLECTION OF LABORATORY SPECIMENS. Medicaid covers the collection of specimens only if based on the client's medical condition home health services are medically necessary and appropriate services to be provided in the home.

004.02(N)OBSERVATION AND EVALUATION. Medicaid covers observation and evaluation requiring the furnishing of a skilled service for an unstable condition. An unstable condition is evidenced by the presence of one of the following conditions:

(i) An episode in the previous 60 days;

(ii) A recent acute episode;

(iii) A well-documented history of noncompliance without nursing intervention; or

(iv) A significant probability that complications would arise without the skilled supervision of the treatment program on an intermittent basis.

004.02(O)TEACHING AND TRAINING ACTIVITIES. Medicaid limits postpartum visits for teaching and training to two visits. The Department covers up to two visits of skilled nursing services for teaching or training purposes. The necessity of further visits must be justified by additional documentation evidencing extenuating circumstances that create the need beyond two visits. Medicaid covers skilled nursing visits for teaching or training that require the skills or knowledge of a nurse. The client must have a medical condition that has been diagnosed and treated by a physician, nurse practitioner, or clinical nurse specialist, and there must be a physician, nurse practitioner, physician assistant, or clinical nurse specialist order for the specific teaching and training. Visits are covered on an individual basis. The provider must maintain specific documentation of both the need for the teaching or training, and the teaching or training provided. Documentation must be submitted along with the plan of care. Teaching or training can occur in the following areas:

(i) Injections;

(ii) Irrigating of a catheter;

(iii) Care of ostomy;

(iv) Administration of medical gases;

(v) Respiratory treatment;

(vi) Preparation and following a therapeutic diet;

(vii) Application of dressing to wounds involving prescription medications and aseptic techniques;

(viii) Bladder training;

(ix) Bowel training;

(x) Use of adaptive devices and special techniques when loss of function has occurred;

(xi) Postpartum visits;

(xii) Care of a bed-bound patient; and

(xiii) Performance of body transfer activities.

004.02(P)OCCUPATIONAL THERAPY, PHYSICAL THERAPY, AND SPEECH, HEARING, AND LANGUAGE THERAPY. Medicaid covers occupational therapy, physical therapy, and speech, hearing, and language therapy as a home health agency service only when the services meet the requirements in accordance with 471 NAC 14 and 23.

004.02(Q)DURABLE MEDICAL EQUIPMENT, PROSTHETICS, ORTHOTICS, AND MEDICAL SUPPLIES (DMEPOS). Durable medical equipment, prosthetics, orthotics, and medical supplies provided by a home health agency or any skilled nursing services must meet all requirements outlined in 471 NAC 7. The Department covers medically necessary durable medical equipment, prosthetics, orthotics, and medical supplies (DMEPOS) which meets program guidelines when ordered by a physician, nurse practitioner, physician assistant, or clinical nurse specialist.

004.02(R)EXTENDED-HOUR NURSING SERVICES. Provision of extended-hour nursing services must be authorized by the Department or its designee. Extended-hour nursing services are authorized only when the client's care needs must be provided by skilled nursing personnel in the absence of the caregiver or parents. Clients are authorized 56 hours a week for a maximum of 12 hours a day in a 24 hour period.

004.02(R)(i)EXTENDED-HOUR NURSING SERVICES FOR ADULTS. Clients are authorized 56 hours a week for a maximum of 12 hours a day in a 24 hours period. Clients are only authorized 56 hours a week. Changes in the client's condition or schedule of the caregiver may require a reevaluation of the approved nursing hours. The Department will authorize the following service:

(1) Patients that are chronically ventilator dependent, 24 hours per day in which interruption from life sustaining ventilation cannot be tolerated may qualify for additional hours based on medical necessity as deemed appropriate by the Department.

004.02(R)(ii)EXTENDED-HOUR NURSING SERVICES FOR CHILDREN. Children must have documented medical needs, which cannot be met by a traditional child care provider system. When providing extended-hour nursing care, the Department will authorize coverage for a maximum of 56 hours a week, depending upon the complexity of a client's care or as approved by The Department. Children who seek Early and Periodic Screening, Diagnosis & Treatment (EPSDT) services and are deemed to have a medical necessity are not limited to certain hours as outlined in 471 NAC 33. A maximum of 12 hours may be approved in a 24-hour period. Changes in the client's condition or schedule of the caregiver or parents may require a reevaluation of the approved nursing hours. If a parent works from home they can request home health services for a child with disabilities during their working hours.

004.02(R)(iii)NURSING COVERAGE AT NIGHT. Caregivers or families may be eligible for night hours if the client requires procedures on an ongoing basis throughout the night hours. As used in this chapter, night hours refers to the period after the client has gone to bed for the day. Day and evening hours refers to the period of time before the client goes to bed for the day. Night hours will be authorized only if the monitoring and treatments cannot be accomplished during day and evening hours. The medical necessity for monitoring and treatments during the night hours must be reflected in the physician, nurse practitioner, physician assistant, or clinical nurse specialist orders and nursing notes. If a scheduled night shift is cancelled by the agency, the caregiver or family may reschedule those hours with the home health agency within the next 24 hours. When that is not possible, they may reschedule the hours within the 48 hours following the missed shift.

004.03NON-COVERED SERVICES.

004.03(A)MEDICATIONS. Medicaid does not cover injections that can be self-administered, drugs not considered an effective treatment for a condition given; and when a medical reason does not exist for providing the drug by injection rather than by mouth.

004.03(B)DECUBITUS AND SKIN DISORDERS. Medicaid does not cover preventative and palliative measures for minor decubiti, usually Stage I or Stage II.

004.03(C)TEACHING AND TRAINING ACTIVITIES. Medicaid does not cover visits made solely to remind or emphasize the need to follow instructions or when services are duplicated.

004.03(D)DRESSINGS. Medicaid does not cover visits made to dress non-infected closed postoperative wounds or chronic controlled conditions.

004.03(E)STUDENT NURSES. Medicaid does not cover skilled nursing visits by student nurses who are enrolled in a school of nursing and not employed by the home health agency, unless accompanied by a registered nurse who is an employee of the home health agency.

004.03(F)SUPERVISORY VISITS. Skilled nursing visits required for the supervision of licensed practical nurse (LPN) or aide services may not be billed as a skilled nursing visit. The cost of supervision is included in the payment for the licensed practical nurse (LPN) or aide service.

471 Neb. Admin. Code, ch. 9, § 004

Amended effective 3/17/2020

Amended effective 5/5/2024