§ 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 and documented in the recipient’s medical record:
(Editor’s Note: Under section 2(5)(i) of the act of October 28, 2022 (P.L. 1632, No. 98) and to the extent permitted under Federal law, § 1249.52(a)(1) is abrogated to the extent that home health services are only covered and reimbursable under the medical assistance program if a physician orders the services and establishes the plan of treatment.)
(1) The services are ordered by and included in the plan of treatment established by the recipient’s attending physician.
(2) The attending physician certifies that the recipient requires care in the home and one of the following conditions exist:
(i) The specific home health services would avoid or delay the need for treatment in a hospital or other institutional setting for the condition being treated.
(ii) The recipient has an illness, injury or mental health condition that justifies providing the services 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 the services of a home health aide.
(4) A change in the treatment plan is made in writing and signed by the physician, or if given orally, is put in writing and signed by the health care professional receiving the oral order on behalf of the agency. The order shall be countersigned by the physician within 30 days of the physician’s order. The following health care professionals may receive oral orders from the physician:
(i) Registered nurses.
(ii) Licensed practical nurses.
(iii) Physical therapists, occupational therapists and speech therapists. These health care professionals may only receive oral orders that pertain to these specialties.
(5) The plan is reviewed by the attending physician, in consultation with agency professional personnel at least every 60 days. The review of the recipient’s plan must contain the signature of the attending physician and the date the review was performed.
(6) The Department has prior authorized the services.
(b) Home health agencies are reimbursed for the following services furnished to MA recipients:
(1) Skilled nursing care.
(2) Home health aide services.
(3) Physical and occupational therapy.
(4) Speech pathology and audiology services.
(5) Medical/surgical supplies listed in the MA Program Fee Schedule.
Authority The provisions of this § 1249.52 amended under sections 403(a) and (b), 443.2(2) and 509 of the Public Welfare Code (62 P. S. § § 403(a) and (b), 443.2(2) and 509).
Source The provisions of this § 1249.52 adopted December 6, 1980, effective December 1, 1980, 10 Pa.B. 4618; amended August 12, 1988, effective September 1, 1988, 18 Pa.B. 3571; amended August 9, 1991, effective immediately and applies retroactively to May 12, 1990, 21 Pa.B. 3512; amended May 11, 2007, effective May 12, 2007, 37 Pa.B. 2185. Immediately preceding text appears at serial pages (251263) to (251264).
Cross References This section cited in 55 Pa. Code § 1249.51 (relating to general payment policy); and 55 Pa. Code § 1249.59 (relating to limitations on payment).
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