TMPPM 2008 > Texas Medicaid Services > Texas Medicaid (Title XIX) Home Health Services > Benefits

24.5 Benefits

Home health services include SN services, HHA visits, PT visits, OT visits, DME, and expendable medical supplies that are provided to eligible Medicaid clients at their place of residence.

Medicaid beneficiaries under 21 years of age are entitled to all medically necessary DME. DME is medically necessary when it is required to correct or ameliorate disabilities or physical or mental illnesses or conditions. Any numerical limit on the amount of a particular item of DME can be exceeded for Medicaid beneficiaries under 21 years of age if medically necessary. Likewise, time periods for replacement of DME will not apply to Medicaid beneficiaries under 21 years of age if the replacement is medically necessary. When prior authorization is required, the information submitted with the request must be sufficient to document the reasons why the requested DME item or quantity is medically necessary.

Medicaid beneficiaries under 21 years of age are entitled to all medically necessary PDN services and/or home health SN services. Nursing services are medically necessary when the requested services are nursing services as defined by the Texas Nursing Practice Act and its implementing regulations; the requested services correct or ameliorate the beneficiary's disability or physical or mental illness or condition; and there is no third party resource financially responsible for the services. Requests for nursing services must be submitted on the required Medicaid forms and include supporting documentation. The supporting documentation must: clearly and consistently describe the beneficiary's current diagnosis, functional status and condition; consistently describe the treatment throughout the documentation; and provide a sufficient explanation as to how the requested nursing services correct or ameliorate the beneficiary's disability or physical or mental illness or condition. Medically necessary nursing services will be authorized either as PDN services or as Home Health SN services, depending on whether the beneficiary's nursing needs can be met on a per visit basis.

Prior authorization must be obtained for all professional services, some supplies, and most DME from TMHP within three business days of SOC. Although providers may supply some DME and medical supplies to a client without prior authorization, they must still retain a copy of the Home Health Services (Title XIX) Durable Medical Equipment (DME)/Medical Supplies Physician Order Form that has been completed and signed by the client's attending physician.

For reimbursement, providers should note the following:

•The client's attending physician must request professional and/or HHA services through a home health agency, and sign and date the POC.

•Claims are approved or denied according to the eligibility, prior authorization status, and medical appropriateness.

•Claims must represent a quantity of 1 month for supplies billed.

•Nursing, nurse aide, PT, and OT services must be provided through a Medicaid-enrolled home health agency. These services must be billed using the home health agency's provider identifier. File these services on a UB-04 CMS-1450 claim form.

•PT, OT, and/or speech therapy (ST) are always billed as POS 2 and may be authorized to be provided in the following locations: home of the client, home of the caregiver/guardian, client's day care facility, or the client's school. Services provided to a client on school premises are only permitted when delivered before or after school hours. The only THSteps-CCP therapy that can be delivered in the client's school during regular school hours are those delivered by school districts as School Health and Related Services (SHARS) in POS 9.

•DME/supplies must be provided by either a Medicaid enrolled home health agency's Medicaid/DME supply provider or an independently-enrolled Medicaid/DME supply provider. Both must enroll and bill using the provider identifier enrolled as a DME supplier. File these services on a CMS-1500 claim form.

Note: Medical social services and speech-language pathology services are available to clients 20 years of age and younger and are not a benefit of Home Health Services. These services may be considered a benefit for clients who qualify for THSteps-CCP.

Use the following type of service (TOS) codes when providing home health services: