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Department of Human Services Department of Human Services  
 
Home Care Services

Revised: 08-16-2010


Home care services offer a range of medical care and support services provided in the recipient’s home and community. Services range from simple assistance in activities of daily living (ADL), to a level of care similar to cares provided in a hospital.


Specialty Specific Sections


Eligible Providers
Eligible providers must be enrolled with MHCP and categorized as one or more of the following:


Providers are required to:

• Verify eligibility for each MHCP recipient each month
• Maintain signed doctor’s orders in each recipient’s file at the provider’s office
• Follow additional provider requirements outlined under each covered service
• Review additional Providers Requirements

Multiple Providers of Services
Service authorization can be issued to more than one provider agency at the same time. Each provider agency must receive their own service authorization. Each provider agency may be able to bill for the same type of service on the same day. Each agency must have an approved line item on the service agreement:

• Services must only be billed in consecutive date spans, to avoid duplicate billing
• 15-minute codes may be billed by more than one provider, per date of service

Provider Type Home Page Links
Review related Web pages for the latest news and additions, forms, and quick links.

Eligible Recipients
Recipients are eligible under one of the following programs:

Medical Assistance
MinnesotaCare (Benefit Sets differ depending on the service)
Waivered Service Programs

Covered Services
Click on the appropriate covered service to learn more about how to provide that service.

Home Health Aide
Private Duty Nursing (PDN)
Rehabilitation Therapies (physical, occupational, speech and respiratory therapy)
Skilled Nurse Visits

Services must be:

• Provided to an eligible recipient
• Medically necessary
• Physician ordered
• Provided in the recipient’s own residence
• Documented in a written care plan

Home Care & Hospice Election
The hospice benefit is:

• A comprehensive package of services offering palliative care support to terminally ill individuals and their families.
• Designed to supplement the care provided by primary care givers such as family (as the patient defines family), friends and neighbors.
• NOT intended to replace the supportive services provided by primary caregivers.
• NOT intended to duplicate health services or supports that relate to a pre-existing condition.
Example: A home care service or supply is required for a condition unrelated to the terminal condition (e.g., quadriplegia, schizophrenia, cerebral palsy) and does not supplant or duplicate the covered hospice benefit.

• NOT intended to cover medical needs that arise during the period of the hospice benefit that are unrelated to the terminal illness.

Generally, the determination about whether a service duplicates a hospice benefit service will be made as part of the hospice provider’s general responsibility to provide care coordination. The hospice care coordinator assumes the lead responsibility for collaborating with the county case manager, home care agency, physician, or other providers providing the services that are outside of the hospice benefit.

For further information and details about the hospice benefit, refer to the Hospice section of the provider manual.

Home Care & Individualized Education Plans (IEP)
Covered IEP services include nursing services, personal care assistants (PCA), physical therapy, occupational therapy, speech language pathology, mental health services, special transportation, and assistive technology devices.

The child may also be receiving these services through MA and/or a home and community-based services waiver. When services are provided through the school, they are considered IEP services and billed as such. IEP services are not considered or billed as home care, therapy or waiver services.

Coordination of IEP services and home care services are assessed on a 24-hour non-school day. A parent/guardian may choose to use authorized home care or waiver services in the school rather than have the school bill for the education plan service:

• Services must be listed in the child’s IEP/IFSP/IIIP
• Permission must be given by the parent/guardian in the care plan and retained by the provider in their records
• The IEP services do not count against the prior authorization cap for home care services, will not be counted against the waiver cap or affect the amount of services available under the waiver and are not counted against DHS service limitations or thresholds for therapies.
• The IEP team and the home care provider, or waiver case manager, are responsible to coordinate and not duplicate services

For further information and details about IEP, refer to the IEP section.


Non-Covered Services
• Services that are not ordered by the recipient’s physician
• Services that are not specified in the recipient’s service plan or care plan
• Services provided without authorization from DHS when required
• Services that have already been paid by Medicare, health plans, health insurance policies, or any other liable third party at more than the MHCP allowable amount
• PDN or PCA services provided to Minnesota Care non-pregnant recipients
• Services to other members of the recipient’s household
• Home care services included in the daily rate of a community-based residential facility where the recipient is residing
• Services that are the responsibility of the foster care provider under the terms of the foster care placement agreement and administrative rules
• Services provided when the number of foster care residents is greater than four (unless the county responsible for the recipient’s foster placement made prior to April 1,1992, requests that home care service be provided, and county or state case management is provided)
• Services provided to GAMC recipients

There may be additional non-covered services outlined under each provider-type specific covered service page.


Authorization Requirements
Prior authorization for home care services is required for:

• All home health aide services
• All private duty nursing services
• Skilled nurse visits above nine visits per recipient, per calendar year for MA
• All tele-home-care visits

Submit prior authorization requests for SNV, HHA, and PDN directly to DHS. Refer to the Service Agreement Quick Reference Guide for the complete process.

Before requesting an authorization:

• Verify MHCP eligibility online via MN–ITS
• Obtain all health insurance coverage information
• Use all insurance and Medicare benefits

Service Agreements (SA) may be either temporary (45 days), or long-term (up to 365 days or 366 days in a leap year). A start date will not be granted prior to the date of submission for prior authorization. DHS must receive all the required information before authorization can be approved.

Exceptions to Prior Authorization
Authorization may be requested after a home care service is provided to a recipient only under the following conditions:

Exceptional Condition Explanation for requesting authorization after performing service Procedure for SNV, HHA and PDN
Emergency Service Provision The home care services were required to treat an emergency medical condition that, if not immediately treated, could cause a recipient serious physical or mental disability, continuation of severe pain, or death. You must be able to substantiate the emergency by documentation such as reports, notes, and admission or discharge history. Request retroactive authorization via fax from DHS no later than five working days after giving the initial service by submitting the Home Care Fax Form to (651) 431-7432.
Retroactive Eligibility Home care services were provided on or after the date on which the recipient’s eligibility began, but before the date the recipient was notified that their case opened. Submit the request to DHS within 20 working days of the date the recipient was notified that the case was opened; and the required documentation for a long-term authorization as listed under each home care service in this chapter is provided; along with a copy of the notice of eligibility.
Third Party Payer A third party payer for home care services denied or adjusted a payment. Submit authorization requests to DHS within 20 working days of the notice of denial or adjustment. Submit required documentation for a long-term authorization as listed under each home care service in this chapter and include a copy of the third party payer’s notice with the request.
Administrative Error The local county agency or DHS made an error. Submit required documentation for a long-term authorization as listed under each service in this chapter and include a statement that specifies which agency made the error, what the error was, and when it occurred. If a county agency made an error, supporting documentation from that agency must be included.
Medical Need The professional nurse determines an immediate medical need for up to 40 skilled nursing or home health aide visits per calendar year. Exceptions to prior authorization requests are evaluated according to the same criteria applied to prior authorization requests. MHCP cannot authorize Waiver or Alternative Care (AC) services requested by a home care provider. Refer to Elderly Waiver (EW) and Alternative Care (AC) Program chapter for more information about Waiver and AC programs.

Changes in Medical Status or Primary Caregiver Availability
Changes in medical status are either temporary for 45 days or less or long term for up to 365 days (366 days in leap years). These include, but are not limited to, a change in health or level of care, service addition, a change in physician orders, recent facility placement, or a change in primary caregiver’s availability. Documentation must support the requested change in service. Temporary authorizations can only be approved for 45 days or less. DHS cannot approve back-to-back temporary requests.

Upon Receiving Service Authorization
Review the Service Authorization immediately for content and comments. Line item dates may differ from header dates. If you have questions about this process, contact the Provider Call Center at (651) 431-2700 or 1-800-366-5411.

Plan of Care
The Private Duty Nurse (PDN) Care Plan is a written description of professional nursing services needed by the recipient as assessed to maintain and/or restore optimal health.

The orders or plan of care must:

• Specify the disciplines providing care
• Specify the frequency and duration of all services
• Demonstrate the need for the services and be supported by all pertinent diagnoses
• Include recipient’s functional level, medications, treatments, and clinical summary
• Be individualized based on recipient needs
• Have realistic goals
• Subsequent plans of care must show recipient response to services and progress since the previous plan was developed; and
• Changes to the plan of care are expected if the recipient is not achieving expected care outcomes.

Billing
MHCP pays for services after the recipient has used all other sources of payment. MHCP is the payer of last resort. The order of payers for an MHCP recipient is:

• First, third party payers or primary payers to Medicare (e.g., large and small group health plans, private health plans, group health plans covering the beneficiary with End Stage Renal Disease for the first 18 months, workers compensation law or plan, no-fault or liability insurance policy or plan)
• Second, Medicare
• Third, MHCP Medical Assistance or MinnesotaCare
• Last, MHCP Waivered Services programs or Alternative Care (AC) program

Providers must bill all third party payers, including Medicare, and receive payment to the fullest extent possible before billing DHS. MHCP becomes the payer only after all other pay options (other than an MA waiver program) have been exhausted. Services that could have been paid by Medicare, an HMO, or insurance plan if applicable rules were followed are not covered by MHCP.

Providers must be familiar with Medicare coverage for home care recipients. Bill Medicare when Medicare is liable for the service or, if not Medicare certified, refer the recipient to a Medicare certified provider of the recipient’s choice, and notify recipients when Medicare is no longer the liable payer for home care services.

Medicare Home Health Prospective Payment System (PPS)
If the service is covered by Medicare, then Medicare guidelines must be followed. This affects all dually eligible recipients (those covered under a Medicare home health plan of care and on Medical Assistance);

• Medicare requires consolidated billing of all home health services while a Medicare recipient is under a home health plan of care. All supplies and services listed under PPS are the responsibility of the Home Health Agency that has the recipient under an episode, and are not billable by other providers
• During each 60 day episode, the home health agency is responsible to bill Medicare all home health services, including:
• A home health agency affiliated or under common control with that hospital
• Care for homebound patients involving equipment too cumbersome to take to the home
• Home health aide services
• Medical services provided by an intern or resident-in-training at a hospital, under an approved teaching program of the hospital
• Medical social services
• Skilled nursing care
• Speech-language pathology
• Occupational therapy
• Physical therapy
• Routine and non-routine medical supplies

Home health services are paid on a cost basis. Therefore, the PPS rate assigned to the beneficiary includes all the above services. Home health agencies that do not have these services available need to hire staff and keep supplies on hand or contract services with other agencies.


MA/MinnesotaCare Home Care Service Procedure Code Modifier Shared Indicator Authorization Required Service Unit
County PHN Service Update for Personal Care Assistant Services T1001 TS   No* Per Update
County PHN Temporary Service Increase for Personal Care Assistant Services T1001 U6   Yes Per Update
Home Health Aide Visit T1021     Yes Visit
LPN - Regular Private Duty T1003     Yes 15 Minutes
LPN - Shared Private Duty 1:2 T1003 TT Y Yes 15 Minutes
LPN - Complex Private Duty T1003 TG   Yes 15 Minutes
Occupational Therapy Visit S9129     No Visit
Physical Therapy Visit S9131     No Visit
Respiratory Therapy Visit S5181     No Visit
RN - Regular Private Duty T1002     Yes 15 Minutes
RN - Shared Private Duty 1:2 T1002 TT Y Yes 15 Minutes
RN - Complex Private Duty T1002 TG   Yes 15 Minutes
Skilled Nurse Visit T1030     No** Visit
Speech Therapy Visit S9128     No Visit
* Authorization is required for more than one service update, per recipient, per calendar year.

**Authorization is required after 9 skilled nurse visits per recipient, per calendar year, except for AC and waivered service program recipients who always require authorization.

Information about the Waivered Services and the Alternative Care (AC) program can be found in HCBS Waivered Services and Elderly Waiver and Alternative Care.

Recovery of Excessive Payments
DHS will seek monetary recovery from home care providers who exceed coverage and payment limits. This does not apply to services provided to a recipient at the previously authorized level pending an appeal.

Any provider found to be providing services that are not medically necessary is prohibited from participating in MHCP. The DHS Disabilities Services Division (DSD) or Surveillance and Integrity Review Section (SIRS) will determine whether excessive services have been provided according to Minnesota Rules 9505.2160 to 9505.2245. The termination of the provider will be consistent with the Provider Agreement, (DHS 4138) between the provider and DHS.

Additional billing information and resources are available at the MHCP Provider Website.


Definitions
Activities of Daily Living (ADLs): Eating, toileting, grooming, dressing, bathing, transferring, mobility and positioning

Assessment: A review and evaluation of a recipient’s need for home care services

Care Plan – PDN: A written description of professional nursing services needed by the recipient as assessed to maintain and/or restore optimal health

Health-Related Functions: Functions that can be delegated or assigned by a licensed health care professional under state law to be performed by a personal care assistant

Home Care Agency (or Class A Agency): An agency holding a Class “A” license from the Minnesota Department of Health (MDH), authorized to provide Private Duty Nursing only. To enroll as a home health agency, the provider must be a Medicare certified home health agency

Home Care Rating: Cost limits that establish a rating system based on the common assessed needs of individuals

Home Care Services: Home health agency, private duty nursing, and personal care services delivered to a recipient whose illness, injury, physical, or mental condition creates a medical need for the service

Home Health Agency (HHA): A public or private agency or organization, or part of an agency or organization, that is Medicare certified and holds a Class A home care license from the Minnesota Department of Health (MDH)

Home Health Agency Services: Services provided by a Medicare Certified agency including skilled nursing visits, home health aide, physical, occupational, speech, and respiratory therapy

Home Health Aide (HHA): An employee of a home health agency who is certified and is supervised by a nurse

Home Health Aide Services: Medically oriented tasks required to maintain the recipient’s health or to facilitate treatment of an illness or injury. Services must be ordered by a physician and have professional supervision provided by a Medicare Certified agency

Instrumental Activities of Daily Living (IADL): Meal planning and preparation, managing finances, shopping for food, communication by telephone and other media, getting around and participating in the community

Licensed Practical Nurse: Must hold current licensure from the MN State Board of Nursing; Class A Licensure from MDH; and be enrolled with the Minnesota Department of Human Services as an independent nurse

Medically Necessary or Medical Necessity: A health service that is consistent with the recipient’s diagnosis or condition, is recognized as the prevailing standard or current practice by the provider’s peer group, and meets one of the following:

• Is rendered in response to a life-threatening condition or pain
• To treat an injury, illness, or infection
• To treat a condition that could result in physical or mental disability
• To care for the mother and child through the maternity period or
• To achieve a level of physical or mental function consistent with prevailing community standards for the diagnosis or condition

Private-Duty Nursing Agency: An agency holding a Class A Home Care license and is enrolled with the Minnesota Department of Human Services to provide private duty nursing services

Private Duty Nursing (PDN) Services: Nursing services ordered by a physician, for a recipient whose illness, injury, physical or mental condition requires more individual and continuous care by a Registered (RN) or Licensed Practical Nurse (LPN) than can be provided in a single or twice daily skilled nurse visit and requires greater skill than a Home Health Aide or Personal Care Assistant can provide

Registered Nurse: Must hold a current licensure from the MN State Board of Nursing and be enrolled with the Department of Human Services as an independent nurse

Residence: The place a recipient lives. A residence does not include a hospital, nursing facility, or intermediate care facility

Service Agreement (SA): The document used to identify services, providers and payment information for a person receiving home care or waivered services. The service agreement allows providers to bill for approved services and allows the Minnesota Department of Human Services (DHS) to audit usage and payment data

Shared Care Option – PDN: An option for two recipients to share the same nurse in the same setting at the same time

Skilled Nurse Visits: Intermittent nursing services ordered by a physician for a recipient whose illness, injury, physical, or mental condition creates a need for the service. Services under the direction of an RN are provided in the recipient’s residence by an RN, or LPN; and provided under a plan of care or service plan that specifies a level of care which the nurse is qualified to provide

Tele-Home-Care: The use of telecommunications technology by a home health care professional to deliver home health care services within the professional’s scope of practice to a recipient located at a site other than the site where the practitioner is located. Currently approved for skilled nurse visits only

Ventilator-Dependent Recipients: A recipient who receives mechanical ventilation for life support at least six hours per day and is expected to be or has been dependent for at least 30 consecutive days


Legal References
MN Statute 256B.0625
MN Stat
ute 256B.0651

MN Statute 256B.0653

MN Statute 256B.0654


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