Home Care Services

Revised: January 31, 2024

· Overview

· Eligible Providers

· Eligible Members

· Covered Services

· Noncovered Services

· Authorization Requirements

· Billing

· Legal References

Overview

Minnesota Health Care Programs (MHCP) covers the following home care services:

· Home care nursing (HCN) services

· Home health aide (HHA) services

· Home health therapies

· Skilled nurse visits (SNV)

Eligible Providers

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

· Medicare-certified home health agencies with a comprehensive home care license

· Comprehensive homecare licensed home care nursing agency

· Independent registered nurse (RN) or independent licensed practical nurse (LPN) who can attest to all statements on the Home Care Nurse - Individual LPN or RN Provider Assurance Statement (DHS-7099) (PDF)

· Independent licensed practical nurse (LPN) with a comprehensive home care license

Providers are required to:

· Verify eligibility for each MHCP member each month

· Maintain signed orders from physicians, advanced practice registered nurses (APRN), or physician assistants (PA) in each member’s file at the provider’s office

· Follow additional provider requirements outlined under each covered service

· Review additional Provider Requirements

Multiple providers of services
Service authorization can be issued to more than one provider agency at the same time. Each provider agency receives a separate 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. Other billing guidance includes the following:

· Services must only be billed in consecutive date spans to avoid duplicate billing

· More than one provider may bill 15-minute codes per date of service

Eligible Members

Members are eligible under one of the following programs:

· Medical Assistance (MA)

· MinnesotaCare (benefit sets differ depending on the service)

· Alternative Care Program

Covered Services

Select the following service for the policy information about the service:

· Home care nursing (HCN) services

· Home health aide (HHA) services

· Home health therapies (physical, occupational, speech and respiratory therapy)

· Skilled nurse visits (SNV)

Services must be:

· Provided to an eligible member

· Medically necessary

· Ordered by a physician, APRN or PA

· Provided in the member’s own residence or in the community where routine life activities take the person

· Documented in a written care plan

Coordination with other MA services

Coordinate Hospice with waiver and home care services.

Face-to-Face Visits

Face-to-face visit requirement
Effective July 1, 2017, all home health services require a start of service face-to-face visit, regardless of the need for prior authorization. This applies to fee-for-service, MA waivers, AC and the nine skilled nurse visits per year that do not require prior authorization.

Services requiring the start of service face-to-face visit include skilled nurse visits, home health aide visits and home care therapies. Home care therapies are occupational, physical, respiratory and speech languages therapies.

Effective Jan. 1, 2018, this applies to all managed care members.

Exception: Skilled nurse visits provided for a one-time perinatal visit do not require the face-to-face visit.

A face-to-face visit can occur through telehealth.

At the start of home health services, a face-to-face visit must:

· Be for the primary reason the person requires home health services

· Occur within 90 days before, or 30 days after the start of services

· Be completed by a qualified provider

If a qualified provider, other than the ordering practitioner, completes the start of service face-to-face visit, they must send or transmit their documentation to the ordering practitioner including clinical findings.

Documentation of face-to-face visits
The ordering provider must document the following:

· All clinical findings of the face-to-face visit are included in the person’s medical record

· The correlation between the face-to-face visit and the associated home health services

· The face-to-face visit occurred within the required timelines

· The provider who completed the face-to-face visit and the date of the visit

Home health agencies must do the following:

· Retain the required documentation as part of the person’s medical record

· Bill only when the required documentation is part of the person’s medical record

· Submit the required documentation to the Minnesota Department of Human Services (DHS) or designee when requested

Home Care and Individualized Education Plans (IEP)

Covered IEP services include nursing services, personal care assistance (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. 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 or therapy.

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

· Services must be listed in the child’s IEP, Individualized Family Service Plan (IFSP), or Individual Interagency Intervention Plan (IIIP).

· The parent or guardian must give written authorization in the care plan and the provider must retain the written authorization in their records.

· Total hours of service allowed for home care nursing and personal care assistance services provided in a school setting as IEP services cannot exceed that which is otherwise allowed in the community or in-home setting.

Refer to the IEP Services section in the MHCP Provider Manual for more information and details about IEP.

Noncovered Services

MHCP does not cover the following:

· Services that are not ordered by the member’s physician, APRN or PA

· Services that are not specified in the member’s service plan or care plan

· Services provided without authorization when authorization is 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 amount allowed

· HCN or PCA services provided to MinnesotaCare non-pregnant members or MinnesotaCare members over age 18

· Services to other members of the member’s household

· Home care services included in the daily rate of a community-based residential facility where the member is residing

· Services that are the responsibility of the foster care provider under the terms of the foster care placement agreement and administrative rules

· HCN and PCA services provided when the number of foster care residents is greater than six, unless conditions are met for granting a variance for a sibling group

· Home health agency services without the required documentation of a face-to-face visit

There may be additional noncovered 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 home care nursing services

· Skilled nurse visits above nine visits per member, per calendar year for MA

· All telehomecare skilled nurse visits

Authorization is required after nine skilled nurse visits per member, per calendar year, except for AC and waiver service program members who always require authorization.

Submit authorization requests
For home care services through MA state plan, submit authorization requests for SNV, HHA, and HCN by following the instructions in Home Care Authorization Requests in the Authorization section under Provider Basics in the MHCP Provider Manual.

Before requesting an authorization, complete the following:

· Verify MHCP eligibility online through 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). The home care authorization requests for skilled nurse visits and home health aide visits must be received within 20 business days of the start of service. Other approved home care authorization requests can begin the date the request is received. The request can be approved outside of those timelines if the request meets an exception. MHCP must receive all the required information before authorization can be approved.

Exceptions to prior authorization
You may request authorization after providing a home care service only under the conditions listed in the table.

Reasons for an exception to prior authorization

Exception Condition	Explanation for requesting authorization after performing service	Procedure for SNV, HHA and HCN
Emergency service provision	The home care services were required to treat an emergency medical condition that, if not immediately treated, could cause a person serious physical or mental disability, continuation of severe pain, or death. You must be able to substantiate the emergency with documentation including reports, notes, and admission or discharge history.	Request retroactive authorization within five business days from starting the initial service.
Retroactive eligibility	Home care services were provided on, or after, the date on which the member’s eligibility began, but before the date the member was notified their case opened.	Request authorization within 20 business days of the date the member was notified the case was opened.
Third-party payer	A third-party payer for home care services denied or adjusted a payment.	Submit authorization requests to DHS within 20 business days of the notice of denial or adjustment. 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 the request within 20 business days and include a statement that specifies: · which agency made the error · what the error was · when the error occurred If a county agency made an error, include supporting documentation from that agency.
Medical need	The professional nurse determines an immediate medical need for up to 40 skilled nurse 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 Waiver and Alternative Care programs overview 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, change in physician, APRN, or PA orders, recent facility placement, or 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.

Receiving Service Authorization

Review the service authorization immediately for content and comments. Line item dates may differ from header dates. Call the MHCP Provider Resource Center at 651-431-2700 or 800-366-5411 with questions about this process.

Plan of Care

The Home Health or Home Care Nurse (HCN) Care Plan is a written description of the home care services the member needs as assessed to maintain or restore optimal health.

The orders or plan of care must document the following:

· 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 member’s functional level, medications, treatments, and clinical summary

· Be individualized based on the person’s needs

· Have realistic goals

Subsequent plans of care must show the member’s response to services and progress since the previous plan was developed.

The home care provider should change the plan of care if the member is not achieving expected care outcomes.

Billing

Submit claims for reimbursement of Home Care (Non-PCA) Services using the (837I) Institutional transaction.

Refer to the following Home Care Services Billing Codes chart for revenue codes needed on a claim.

Home Care Services Billing Codes

Home Care Service	HCPCS (date of service)	Revenue	Modifier	Modifier	Shared Indicator	Authorization Required	Unit
Home Health Aide Visit	T1021	0571				Yes	Visit
Home Health Aide Visit Extended (waivers) Home Health Aide Visit (AC Program)	T1004	0572				Yes	15 min.
Private Duty Nursing LPN Regular	T1003	0552				Yes	15 min.
Private Duty Nursing LPN Regular, Extended	T1003	0552	UC			Yes	15 min.
Private Duty Nursing LPN Shared 1:2	T1003	0552	TT		Y	Yes	15 min.
Private Duty Nursing LPN Shared 1:2 Ratio, Extended	T1003	0552	TT	UC	Y	Yes	15 min.
Private Duty Nursing LPN Complex	T1003	0552	TG			Yes	15 min.
Private Duty Nursing LPN Complex, Extended	T1003	0552	TG	UC		Yes	15 min.
Occupational Therapy Visit	S9129	0431				No	Visit
Occupational Therapy Assistant Visit	S9129	0431	TF			No	Visit
Occupational Therapy Extended	S9129	0431	UC			Yes	Visit
Occupational Therapy Assistant Extended	S9129	0431	TF	UC		Yes	Visit
Physical Therapy Visit	S9131	0421				No	Visit
Physical Therapy Assistant Visit	S9131	0421	TF			No	Visit
Physical Therapy Extended	S9131	0421	UC			Yes	Visit
Physical Therapy Assistant Extended	S9131	0421	TF	UC		Yes	Visit
Respiratory Therapy Visit	S5181	0411				No	Visit
Respiratory Therapy Visit Extended	S5181	0411	UC			Yes	Visit
Private Duty Nursing RN Regular Private Duty	T1002	0552				Yes	15 min.
Regular Private Duty RN Extended	T1002	0552	UC			Yes	15 min.
Private Duty Nursing RN Shared 1:2	T1002	0552	TT		Y	Yes	15 min.
Private Duty Nursing RN Shared 1:2, Extended	T1002	0552	TT	UC	Y	Yes	15 min.
Private Duty Nursing RN Complex	T1002	0552	TG			Yes	15 min.
Private Duty Nursing RN Complex, Extended	T1002	0552	TG	UC		Yes	15 min.
Skilled Nurse Visit	T1030	0551				Yes	Visit
Skilled Nurse Visit (RN) (AC Program only)	G0299	0552				Yes	15 min.
Skilled Nurse Visit (LPN) (AC Program only)	G0300					Yes	15 min.
Skilled Nurse Visit Telehomecare	T1030	0551	GT			Yes	Visit
Speech Therapy Visit	S9128	0441				No	Visit
Speech Therapy Visit Extended	S9128	0441	UC			Yes	Visit

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

· First, third-party payers or primary payers to Medicare (for example, 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 MA or MinnesotaCare

· Last, MHCP waiver services programs or Alternative Care (AC) program

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 members. Bill Medicare when Medicare is liable for the service or, if not Medicare certified, refer the member to a Medicare-certified provider of the member’s choice. Notify members 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, you must follow Medicare guidelines. This affects all dually eligible members (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 eligible member 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 member under an episode, and are not billable by other providers

· During each 30-day episode, the home health agency is responsible to bill Medicare for 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.

Multiple Providers of Services

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

Find more about the waiver services and the Alternative Care (AC) program in HCBS Waiver Services and Elderly Waiver and Alternative Care Program sections of the MHCP Provider Manual.

More billing information and resources are available on the Policies and procedures webpage.

Legal References

Minnesota Statutes, 256B.0625 (Covered Services)
Minnesota Statutes, 256B.0651 (Home Care Services)
Minnesota Statutes, 256B.0652 (Authorization and Review of Home Care Services)
Minnesota Statutes, 256B.0653 (Home Health Agency Services)
Minnesota Statutes, 256B.0654 (Home Care Nursing)
Minnesota Statutes, 245A.04, subdivision 9a (Variances)