PROPOSED RULEMAKING
DEPARTMENT OF
PUBLIC WELFARE
[55 PA. CODE CH. 1249]
Home Health Agency Services
[34 Pa.B. 6544] The Department of Public Welfare (Department), under the authority of sections 403, 443.2(2) and 509 of the Public Welfare Code (62 P. S. §§ 403, 443.2(2) and 509), proposes to amend Chapter 1249 (relating to home health agency services) to read as set forth in Annex A.
Purpose of the Proposed Rulemaking
The proposed amendments to Chapter 1249 remove the requirement that a recipient be homebound to qualify for Home Health Agency (HHA) services and remove service limits for home health services from the regulation by relocating them to the Medical Assistance (MA) Outpatient Fee Schedule.
Need for the Proposed Rulemaking
In accordance with the Department's move to provide for increased emphasis on home and community based services, rather than providing more restrictive and expensive alternatives such as nursing home care, as well as a Federal directive clarifying Federal regulations regarding the Medicaid home health benefit, the Department is removing the requirement that individuals must be homebound to receive home health services.1
Requirements
In accordance with this determination, the Department proposes to amend Chapter 1249 to remove the requirement that an MA recipient must be homebound to qualify for HHA services. The Department proposes to eliminate the definition and references to ''homebound'' in §§ 1249.2, 1249.42(1)(ii), 1249.52 and 1249.57(b).
With the removal of the homebound requirement throughout the regulations, and the specific exemption to this requirement in § 1249.57(b) it is no longer appropriate to list prenatal care in this section. Since the remainder of § 1249.57(b) only deals with postpartum and child services, the Department proposes to remove the term ''prenatal'' from this section. The amount and scope of the MA Fee Schedule prenatal services are not changed by this revision.
The Department also proposes to amend § 1249.59(2) (relating to limitations on payment), which currently provides that, after the first 28 days of unlimited home health care, payment is limited to 15 home visits per month, per treatment plan. The Department proposes to remove this limit on service from regulation and, instead, place it in the MA Fee Schedule, consistent with limits on other MA services. The existing limits will not be altered, however, by removing this requirement from the regulation. A program exception may be granted to exceed this limit if ordered by the attending physician's plan of care and deemed medically necessary. The purpose of this amendment is to allow the flexibility to meet the documented medical needs of recipients in the least restrictive and most cost-effective setting possible.
Affected Organizations and Individuals
The proposed amendments to Chapter 1249 will have a positive affect on MA participating physicians, HHAs and recipients of MA HHA services. The proposed rulemaking will permit the attending physician to prescribe medically necessary home health services to recipients who are not homebound. In addition, the proposed removal of HHA visit limitations from the regulation will improve access to medically necessary care. This formalizes a process whereby individuals with medically necessary and appropriate need for continued care in excess of the MA Fee Schedule limitations, will be able to apply for a program exception to the fee schedule limitations rather than seeking a waiver from the Secretary of the Department.
Accomplishments/Benefits
The proposed rulemaking benefits MA recipients who meet medically necessary criteria and prior authorization requirements for home health services. There are times when MA eligible individuals are in need of medical care that can be provided cost-effectively in their own homes, rather than in a hospital, long-term care facility or other institutional setting. The proposed rulemaking allows for medically necessary treatment to be provided in the home for clients who normally remain in the home, but who from time to time may, with assistance, be able to go to a doctor's appointment or to visit family for a holiday.
In addition, recipients of MA HHA services and their physicians will benefit from the proposed rulemaking. The proposed amendment to § 1249.59 would permit the attending physician to prescribe, and the MA recipient to receive, medically necessary home health services beyond the existing service limits, if approved through a program exception.
Fiscal Impact
Public Sector
Commonwealth
It is anticipated that there will be minimal cost to the Department based on the proposed rulemaking. The Department has covered and continues to cover medically necessary services. This proposed rulemaking will allow those services to be provided in a home setting, as opposed to a hospital or institutional setting, offsetting any increase in the number of MA recipients qualifying for home health care.
Political Subdivisions
There will be no fiscal impact on political subdivisions as a result of this proposed rulemaking.
Private Sector
There will be no fiscal impact on the private sector as a result of this proposed rulemaking.
General Public
There will be no fiscal impact on the general public as a result of this proposed rulemaking.
Paperwork Requirements
No additional reporting, paperwork or record keeping is required to comply with the proposed rulemaking.
Effective Date
This proposed rulemaking will be effective upon final-form publication in the Pennsylvania Bulletin.
Sunset Date
There is no sunset date.
Public Comments
Interested persons are invited to submit written comments, suggestions or objections regarding the proposed rulemaking to the Department of Public Welfare, Office of Medical Assistance Programs, Attention: Regulations Coordinator, c/o Deputy Secretary's Office, Room 515, Health and Welfare Building, Harrisburg, PA 17120 within 30 days after the date of publication of this proposed rulemaking in the Pennsylvania Bulletin. Persons with a disability may use the AT&T Relay Service at (800) 654-5984 (TDD users) or (800) 654-5988 (voice users).
Regulatory Review
Under section 5(a) of the Regulatory Review Act (71 P. S. § 745.5(a)), on November 30, 2004, the Department submitted a copy of this proposed rulemaking and a copy of a Regulatory Analysis Form to the Independent Regulatory Review Commission (IRRC) and to the Chairpersons of the House Committee on Health and Human Services and the Senate Committee on Public Health and Welfare. A copy of this material is available to the public upon request.
Under section 5(g) of the Regulatory Review Act, IRRC may convey any comments, recommendations or objections to the proposed rulemaking within 30 days of the close of the public comment period. The comments, recommendations or objections must specify the regulatory review criteria which have not been met. The Regulatory Review Act specifies detailed procedures for review, prior to final publication of the rulemaking, by the Department, the General Assembly and the Governor of comments, recommendations or objections raised.
ESTELLE B. RICHMAN,
SecretaryFiscal Note: 14-491. No fiscal impact; (8) recommends adoption
Annex A
TITLE 55. PUBLIC WELFARE
PART III. MEDICAL ASSISTANCE MANUAL
CHAPTER 1249. HOME HEALTH AGENCY SERVICES
GENERAL PROVISIONS § 1249.2. Definitions.
The following words and terms, when used in this chapter, have the following meanings, unless the context clearly indicates otherwise:
* * * * * [Homebound--A condition due to illness or injury that restricts the individual's ability to leave his residence without assistance or makes leaving medically contraindicated. The term does not relate to maternal/child services.]
* * * * *
PROVIDER PARTICIPATION § 1249.42. Ongoing responsibilities of providers.
Ongoing responsibilities of providers are established in Chapter 1101 (relating to general provisions). The home health agency shall:
(1) Have written policies concerning the acceptance of recipients and the feasibility of meeting the recipient's needs in the home care setting, which include, but are not limited to:
* * * * * (ii) [The homebound status of the recipient.] Assessment and documentation of the need for continued home health agency services.
* * * * *
PAYMENT FOR HOME HEALTH SERVICES § 1249.52. Payment conditions for various services.
(a) Home health agencies are reimbursed for services furnished to MA recipients within the MA Program Fee Schedule limits if the following conditions are met:
* * * * * (2) [The attending physician certifies that the recipient is homebound and as part of the treatment plan review certifies that the recipient continues to remain homebound. To be considered homebound, the recipient shall have a condition due to illness or injury that restricts the individual's ability to leave his residence without assistance or makes leaving medically contraindicated.] The attending physician certifies that the recipient requires care in the home and either of the following conditions exist:
(i) The only alternative to home health agency services is hospitalization.
(ii) The recipient has an illness, injury or mental health condition, documented in the recipient's medical records, which justifies that the service must be provided at the recipient's residence instead of a physician's office, clinic or other outpatient setting.
(3) The attending physician certifies that the recipient requires the skilled services of a nurse, physical therapist, occupational therapist [or], speech therapist or home health aide. If the recipient requires only home health aide services, the physician shall certify the need for these services.
* * * * * (6) A new treatment plan may be started with the onset of a new primary diagnosis or the exacerbation of an existing diagnosis which causes a significant change in the recipient's condition and requires a change in the treatment. If home health services are provided following the onset of an illness which does not involve a hospitalization, the initial evaluation home health visit begins a new treatment plan.
(7) The Department has determined that prior authorization requirements have been met.
* * * * * § 1249.57. Payment conditions for maternal/child services.
* * * * * (b) [Prenatal, postpartum] Postpartum and child services. [A recipient is not required to be homebound to receive these services.] When the mother no longer requires postpartum visits for medical reasons, but the child continues to need medical services, payment will be made for the additional visits for care of the child only if the services are ordered by the attending physician and are part of a written plan of care written specifically for the child.
§ 1249.59. Limitations on payment.
The following limits apply to payment for covered services:
* * * * * (2) [After the first 28-days of unlimited home health care, payment is limited to 15 home visits per month per treatment plan. A new period of unlimited care begins following hospitalization, the onset of a new primary diagnosis or the exacerbation of an existing diagnosis which causes a change in the recipient's conditions and requires a change in the plan of treatment, subject to § 1249.52(a)(4) (relating to payment conditions for various services).] Home visits which exceed the MA Program Fee Schedule maximums are not compensable. If a new treatment plan is instituted, the payment limitations begin with the first service provided in the new treatment plan.
(3) [If home health services are provided following the onset of an illness which does not involve a hospitalization, payment is made for the initial evaluation home health visit which will begin the 28-day period of unlimited service.
(4)] For prenatal and postpartum care, the following limits apply:
(i) [Payment for prenatal care is limited to one visit per month.] Complications [attributable to] of pregnancy are not counted as [part of the one visit per month limit] prenatal care but are classified for invoicing purposes as acute illness.
* * * * * [(5)] (4) * * *
[Pa.B. Doc. No. 04-2178. Filed for public inspection December 10, 2004, 9:00 a.m.] _______
1 On July 25, 2000, the Health Care Financing Administration, now the Centers for Medicare and Medicaid Services (CMS), issued ''Olmstead Update No. 3.'' See Attachment 3-g: Prohibition of Homebound Requirements in Home Health (www.cms.hhs.gov/states/letters/smd725a0.asp). Based upon Olmstead v. L.C., 527 U.S. 581 (1999), this document clarified the CMS's position that the use of a ''homebound'' requirement to qualify for Medicaid HHA services is a violation of Federal regulatory requirements in 42 CFR 440.230(c) and 440.240(b).
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