N.J. Admin. Code § 10:60-2.1

Current through Register Vol. 56, No. 9, May 6, 2024

Section 10:60-2.1 - Covered home health agency services

(a) Home health care services covered by the New Jersey Medicaid/NJ FamilyCare fee-for-service programs are limited to those services provided directly by a home health agency approved to participate in the New Jersey Medicaid/NJ FamilyCare program or through arrangement by that agency for other services.

1. Medicaid/NJ FamilyCare reimbursement is available for these services when provided to Medicaid/NJ FamilyCare fee-for-service beneficiaries in their place of residence, such as a private home, residential hotel, residential health care facility, rooming house, and boarding home.

i. In residential health care facilities, homemaker-home health aide or personal care assistant services are excluded from Medicaid/NJ FamilyCare fee-for-service coverage.

ii. Home health services shall not be available to Medicaid/NJ FamilyCare fee-for-service beneficiaries in a hospital or nursing facility.

(b) Covered home health care services are those services provided according to medical, nursing and other health care related needs, as documented in the individual plan of care, on the basis of medical necessity and on the goals to be achieved and/or maintained.

(c) Home health care services shall be directed toward rehabilitation and/or restoration of the beneficiary to the optimal level of physical and/or mental functioning, self-care and independence, or directed toward maintaining the present level of functioning and preventing further deterioration, or directed toward providing supportive care in declining health situations.

(d) The types of home health agency services covered include professional nursing by a public health nurse, registered professional nurse, or licensed practical nurse; homemaker home health aide services; physical therapy; speech-language pathology services; occupational therapy; medical social services; nutritional services; certain medical supplies; and personal care assistant services, as defined in this section.

1. The home health agency shall provide comprehensive nursing services under the direction of a public health nurse supervisor/director as defined by the New Jersey State Department of Health. These services shall include, but not be limited to, the following:

i. Participating in the development of the plan of care with other health care team members, which includes discharge planning;

ii. Identifying the nursing needs of the beneficiary through an initial assessment and periodic reassessment;

iii. Planning for management of the plan of care particularly as related to the coordination of other needed health care services;

iv. Skilled observing and monitoring of the beneficiary's responses to care and treatment;

v. Teaching, supervising and consulting with the beneficiary and family and/or interested persons involved with his or her care in methods of meeting the nursing care needs in the home and community setting;

vi. Providing direct nursing care services and procedures including, but not limited to:

(1) Wound care/decubitus care and management;

(2) Enterostomal care and management;

(3) Parenteral medication administration; and

(4) Indwelling catheter care.

vii. Implementing restorative nursing care measures involving all body systems including, but not limited to:

(1) Maintaining good body alignment with proper positioning of bedfast/chairfast beneficiaries;

(2) Supervising and/or assisting with range of motion exercises;

(3) Developing the beneficiary's independence in all activities of daily living by teaching self-care, including ambulation within the limits of the treatment plan; and

(4) Evaluating nutritional needs including hydration and skin integrity; observing for obesity and malnutrition;

viii. Teaching and assisting the beneficiary with practice in the use of prosthetic and orthotic devices and durable medical equipment as ordered;

ix. Providing the beneficiary and the family or interested persons support in dealing with the mental, emotional, behavioral, and social aspects of illness in the home;

x. Preparing nursing documentation including nursing assessment, nursing history, clinical nursing records and nursing progress notes; and

xi. Supervising and teaching other nursing service personnel.

2. Skilled nursing supervision of a home health aide, licensed practical nurse or personal care assistant shall be covered as an overhead administrative cost and shall not be billed as a separate unit of service.

3. If two health care workers are required to provide care and the second worker is not in a supervisory capacity, two or more units of service may be covered for the simultaneous care. If two health care workers are present, but only one is needed to provide the care, only the unit(s) of service for the one worker providing the care shall be covered.

4. Homemaker-home health aide services shall be performed by a New Jersey certified homemaker-home health aide, under the direction and supervision of a registered professional nurse. Services include personal care, health related tasks, and household duties. In all areas of service, the homemaker-home health aide shall encourage the well members of the family, if any, to carry their share of responsibility for the care of the beneficiary in accordance with the written established professional plan of care.

i. Household duties shall be considered covered services only when combined with personal care and other health services provided by the home health agency. Household duties may include such services as the care of the beneficiary's room, personal laundry, shopping, meal planning and preparation. In contrast, personal care services may include assisting the beneficiary with grooming, bathing, toileting, eating, dressing, and ambulation. The determining factor for the provision of household duties shall be based upon the degree of functional disability of the beneficiary, as well as the need for physician/practitioner prescribed personal care and other health services, and not solely the beneficiary's medical diagnosis.

ii. The registered professional nurse, in accordance with the physician's/practitioner's plan of care, shall prepare written instructions for the homemaker-home health aide to include the amount and kind of supervision needed of the homemaker-home health aide, the specific needs of the beneficiary and the resources of the beneficiary, the family, and other interested persons. Supervision of the homemaker-home health aide in the home shall be provided by the registered professional nurse or appropriate professional staff member at a minimum of one visit every two weeks when in conjunction with skilled nursing, physical or occupational therapy, or speech-language pathology services. In all other situations, supervision shall be provided at the frequency of one visit every 30 days. Supervision may be provided up to one visit every two months, if written justification is provided in the agency's records.

iii. The registered professional nurse, and other professional staff members, shall make visits to the beneficiary's residence to observe, supervise and assist, when the homemaker-home health aide is present or when the aide is absent, to assess relationships between the home health aide and the family and beneficiary and determine whether goals are being met.

5. Special therapies include physical therapy, speech-language pathology services, and occupational therapy. Special therapists/pathologists shall review the initial plan of care and any change in the plan of care with the attending physician/practitioner and the professional nursing staff of the home health agency. The attending physician/practitioner shall be given an evaluation of the progress of therapies provided, as well as the beneficiary's reaction to treatment and any change in the beneficiary's condition. The attending physician/practitioner shall approve of any changes in the plan of care and delivery of therapy services.

i. The attending physician/practitioner shall prescribe, in writing, the specific methods to be used by the therapist and the frequency of therapy services. "Physical therapy as needed" or a similarly worded blanket order by the attending physician/practitioner is not acceptable.

ii. Special therapists shall provide instruction to the home health agency staff, the beneficiary, the family and/or interested persons in follow-up supportive procedures to be carried out between the intermittent services of the therapists to produce the optimal and desired results.

(1) When the agency provides or arranges for physical therapy services, they shall be provided by a licensed physical therapist. The duties of the physical therapist shall include, but not be limited to, the following:

(A) Evaluating and identifying the beneficiary's physical therapy needs;

(B) Developing long and short-term goals to meet the individualized needs of the beneficiary and a treatment plan to meet these goals. Physical therapy orders shall be related to the active treatment program designed by the attending physician/practitioner to assist the beneficiary to his or her maximum level of function which has been lost or reduced by reason of illness or injury;

(C) Observing and reporting to the attending physician/practitioner the beneficiary's reaction to treatment, as well as any changes in the beneficiary's condition;

(D) Documenting clinical progress notes reflecting restorative procedures needed by the beneficiary, care provided, and the beneficiary's response to therapy along with the notification and approval received from the physician/practitioner; and

(E) Physical therapy services which may include, but not be limited to, active and passive range of motion exercises, ambulation training, and training for the use of prosthetic and orthotic devices. Physical therapy does not include physical medicine procedures, administered directly by a physician/practitioner or by a physical therapist which are purely palliative; for example, applications of heat in any form, massage, routine and/or group exercises, assistance in any activity or in the use of simple mechanical devices not requiring the special skill of a qualified physical therapist.

(2) When the agency provides or arranges for speech-language pathology services, the services shall be provided by a certified speech-language pathologist. The duties of a speech-language pathologist shall include, but not be limited to, the following:

(A) Evaluating, identifying, and correcting the individualized problems of the communication impaired beneficiary;

(B) Developing long and short-term goals and applying speech-language pathology service procedures to achieve identified goals;

(C) Coordinating activities with and providing assistance to a certified audiologist, when indicated;

(D) Observing and reporting to the attending physician/practitioner the beneficiary's reaction to treatment, as well as, any changes in the beneficiary's condition; and

(E) Documenting clinical progress notes reflecting restorative procedures needed by the beneficiary, the care provided, and the beneficiary's response to therapy, along with the notification and approval received from the physician/practitioner.

(3) The need for occupational therapy is not a qualifying criterion for initial entitlement to home health services benefits. However, if an individual has otherwise qualified for home health benefits, his or her eligibility for home health services may be continued solely because of his or her need for occupational therapy. Occupational therapy services shall include, but not be limited to, activities of daily living, use of adaptive equipment, and home-making task-oriented therapeutic activities. When the agency provides or arranges for occupational therapy services, the services shall be provided by a registered occupational therapist. The duties of an occupational therapist shall include, but not be limited to, the following:

(A) Evaluating and identifying the beneficiary's occupational therapy needs;

(B) Developing long and short-term goals to meet the individualized needs of the beneficiary and a treatment plan to achieve these needs;

(C) Observing and reporting to the attending physician/practitioner the beneficiary's reaction to treatment as well as any changes in the beneficiary's condition;

(D) Documenting clinical progress notes reflecting restorative procedures needed by the beneficiary, the care provided, and the beneficiary's response to therapy along with the notification and approval received from the physician/practitioner; and

(E) Occupational therapy services shall include but not be limited to activities of daily living, use of adaptive equipment, and homemaking task oriented therapeutic activities.

6. When the agency provides or arranges for medical social services, the services shall be provided by a social worker, or by a social work assistant under the supervision of a social worker. These shall include, but not be limited to, the following:

i. Identifying the significant social and psychological factors related to the health problems of the beneficiary and reporting any changes to the home health agency;

ii. Participating in the development of the plan of care, including discharge planning, with other members of the home health agency;

iii. Counseling the beneficiary and family/interested persons in understanding and accepting the beneficiary's health care needs, especially the emotional implications of the illness;

iv. Coordinating the utilization of appropriate supportive community resources, including the provision of information and referral services; and

v. Preparing psychosocial histories and clinical notes.

7. When the agency provides or arranges for nutritional services, the services shall be provided by a registered dietitian or nutritionist. These services shall include, but are not limited to, the following:

i. Determining the priority of nutritional care needs and developing long and short-term goals to meet those needs;

ii. Evaluating the beneficiary's home situation, particularly the physical areas available for food storage and preparation;

iii. Evaluating the role of the family/interested persons in relation to the beneficiary's diet control requirements;

iv. Evaluating the beneficiary's nutritional needs as related to medical and socioeconomic status of the home and family resources;

v. Developing a dietary plan to meet the goals and implementing the plan of care;

vi. Instructing beneficiary, other home health agency personnel and family/interested persons in dietary and nutritional therapy; and

vii. Preparing clinical and dietary progress notes.

8. Medical supplies, other than drugs and biologicals, including, but not limited to, gauze, cotton bandages, surgical dressing, surgical gloves, ostomy supplies, and rubbing alcohol shall be normally supplied by the home health agency, as needed, to enable the agency to carry out the plan of care established by the attending physician/practitioner and agency staff.

i. When a beneficiary requires more than one month of medical supplies, prior authorization for the supplies shall be requested and received from the Division. Requests for prior authorization of an unusual or an excessive amount of medical supplies provided by an approved medical supplier shall be accompanied by a personally signed, legible prescription from the attending physician/practitioner. If a beneficiary is an enrollee of a private HMO, prior authorization shall be obtained from the private HMO.

ii. When a beneficiary requires home parenteral therapy, the home health agency shall arrange the therapy prescribed with a medical supplier specialized to provide such services.

(1) Administration kits, supply kits, and parenteral therapy pumps, not owned by the home health agency, shall be provided to the beneficiary and billed to the Medicaid/NJ FamilyCare program by the medical supplier.

(2) Provision of disposable parenteral therapy supplies which are required to properly administer prescribed therapy shall be the responsibility of the agency.

9. Personal care assistant services shall be as described in N.J.A.C. 10:60-3.

(e) Medical equipment is an item, article, or apparatus which is used to serve a medical purpose, is not useful to a person in the absence of disease, illness, or injury, and is capable of withstanding repeated use (durable). When durable medical equipment is essential in enabling the home health agency to carry out the plan of care for a beneficiary, a request for authorization for the equipment shall be made by an approved medical supplier. The request for authorization shall be submitted to DDS or DMAHS and shall include a personally signed, legible prescription from the attending physician/practitioner, as well as a personally signed legible prescription from the MCO, if applicable. Durable medical equipment, either rented or owned by the home health agency, shall not be billed to the New Jersey Medicaid/NJ FamilyCare program, as applicable (see Medical Supplier Services chapter, N.J.A.C. 10:59).

N.J. Admin. Code § 10:60-2.1

New Rule, R.1994 d.41, effective 1/18/1994.
See: 25 N.J.R. 2803(a), 26 N.J.R. 364(c).
Administrative Correction.
See: 26 N.J.R. 2285(a).
Amended by R.1996 d.43, effective 1/16/1996.
See: 27 N.J.R. 279(a), 28 N.J.R. 289(a).
Amended by R.1998 d.586, effective 12/21/1998 (operative January 1, 1999).
See: 30 N.J.R. 3198(a), 30 N.J.R. 4377(a).
In (d), inserted new 2 and 3, and recodified former 2 through 7 as 4 through 9.
Recodified from N.J.A.C. 10:60-1.4 and amended by R.2001 d.14, effective 1/2/2001.
See: 32 N.J.R. 3940(a), 33 N.J.R. 66(a).
In (a), inserted references to NJ KidCare fee-for-service throughout, and inserted a reference to NJ KidCare in the introductory paragraph; substituted references to beneficiaries for references to recipients throughout the section. Former N.J.A.C. 10:60-2.1, Community Care Program for the Elderly and Disabled (CCPED), recodified to N.J.A.C. 10:60-10.1(a) and (b).
Amended by R.2006 d.238, effective 7/3/2006.
See: 38 N.J.R. 1136(a), 38 N.J.R. 2810(a).
Substituted "FamilyCare" for "KidCare" throughout; and in (e), substituted "DDS or DMAHS" for "the Division", and deleted "-1.5 through 1.7".

Amended by 54 N.J.R. 1721(a), effective 9/6/2022