statement of basis and purpose - cohealthinfo.com · initial review final adoption 07/14/17...

Title of Rule: Revision to the Medical Assistance Benefits Rule Concerning Home Health Services, Section 8.520 Rule Number: MSB 17-04-21-A Division / Contact / Phone: Health Programs Benefits & Operations Division / Amanda Forsythe / 303-866-6459

Initial Review Final Adoption 07/14/17

Proposed Effective Date 08/30/17 Emergency Adoption DOCUMENT #02

STATEMENT OF BASIS AND PURPOSE

1. Summary of the basis and purpose for the rule or rule change. (State what the rule says or does and explain why the rule or rule change is necessary).

The rule defines the amount, duration, and scope of covered home health services. This revision updates the home health services rule by adding provisions concerning face-to-face visits and place of service limitations, as required under recently issued federal regulations, both of which must be effective by July 1, 2017. Specifically, this revision aligns the Colorado Medicaid home health services rule with federal regulations by adding: (1) a requirement that the physician must document a face-to-face encounter with the Medicaid client for the authorization of home health services within particular timelines; and (2) language clarifying that Medicaid home health services are not limited solely to home settings.

2. An emergency rule-making is imperatively necessary

to comply with state or federal law or federal regulation and/or for the preservation of public health, safety and welfare.

Explain:

The recently issued federal home health regulations, concerning documentation of face-to-face encounters and place of service limitations, explicitly require that the Department be in compliance with the new provisions by July 1, 2017.

3. Federal authority for the Rule, if any:

42 CFR 440.70

4. State Authority for the Rule:

25.5-1-301 through 25.5-1-303, C.R.S. (2015);


REGULATORY ANALYSIS

1. Describe the classes of persons who will be affected by the proposed rule, including classes that will bear the costs of the proposed rule and classes that will benefit from the proposed rule.

The proposed rule will affect ordering providers by requiring that they must document the occurrence of a face-to-face encounter with any Colorado Medicaid client for whom they order home health services. The proposed rule will also affect home health services clients: First, it will require that the client participates in a face-to-face visit with the ordering provider to receive home health services. Second, by clarifying that home health services may be received in any setting in which normal life activities take place, it will allow many clients to receive home health services out in the community.

2. To the extent practicable, describe the probable quantitative and qualitative impact of the proposed rule, economic or otherwise, upon affected classes of persons.

The proposed rule will have a positive impact on those clients who will be able to receive necessary home health services while engaged in normal life activities in the community and not just while in the home.

The proposed rule's face-to-face documentation requirement will likely have a moderate economic impact on the ordering providers, an analysis of which is detailed in the February 2016 Centers for Medicare & Medicaid Services Final Rule concerning Medicaid home health services.

3. Discuss the probable costs to the Department and to any other agency of the implementation and enforcement of the proposed rule and any anticipated effect on state revenues.

There is no anticipated cost or effect on state revenues of implementation and enforcement of the proposed rule.

4. Compare the probable costs and benefits of the proposed rule to the probable costs and benefits of inaction.

The cost of inaction is the Department being out of compliance with federal regulations, which could result a corrective action plan, financial penalties, or other federal enforcement actions.


5. Determine whether there are less costly methods or less intrusive methods for achieving the purpose of the proposed rule.

There are no less costly methods or less intrusive methods for achieving the purpose of the proposed rule, which is the Department's compliance with new federal regulatory requirements.

6. Describe any alternative methods for achieving the purpose for the proposed rule that were seriously considered by the Department and the reasons why they were rejected in favor of the proposed rule.

There are no alternative methods for achieving the purpose of the proposed rule, which is the Department's compliance with new federal regulatory requirements.

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8.520 HOME HEALTH SERVICES 1

8.520.1. Definitions 2

8.520.1.A. Activities of Daily Living (ADL) means daily tasks that are required to maintain a 3 clientmemberclient’s health, and include eating, bathing, dressing, toileting, grooming, 4 transferring, walking, and continence. When a clientmemberclient is unable to perform 5 these activities independently, skilled or unskilled providers may be required for the 6 clientmemberclient’s needs. 7

8.520.1.B. Acute Medical Condition means a medical condition which has a rapid onset and short 8 duration. A condition is considered acute only until it is resolved or until 60 calendar days 9 after onset, whichever comes first. 10

8.520.1.C. Alternative Care Facility means an assisted living residence licensed by the Colorado 11 Department of Public Health and Environment (CDPHE), and certified by the Department 12 of Health Ccare Policy and Financing (Department) to provide Assisted Living Care 13 Services and protective oversight to clientmemberclients. 14

8.520.1.D. Behavioral Intervention means techniques, therapies, and methods used to modify or 15 minimize aggressive (verbal/physical), combative, destructive, disruptive, repetitious, 16 resistive, self-injurious, or other inappropriate behaviors outlined on the CMS-485 Plan of 17 Care (defined below). Behavioral interventions exclude frequent verbal redirection or 18 additional time to transition or complete a task, which are part of the general assessment 19 of the clientmemberclient’s needs. 20

8.520.1.E. Care Coordination means the deliberate organization of clientmemberclient care activities 21 between two or more participants (including the clientmemberclient) for the appropriate 22 delivery of health care and health support services, and organization of personnel and 23 resources needed for required clientmemberclient care activities. 24

8.520.1.F. Certified Nurse Aide Assignment Form means the form used by the Home Health Agency 25 to list the duties to be performed by the Certified Nurse Aide (CNA) at each visit. 26

8.520.1.G. Department means the Colorado Department of Health Care Policy and Financing which 27 is designated as the single State Medicaid agency for Colorado, or any divisions or sub-28 units within that agency. 29

8.520.1.H. Designee means the entity that has been contracted by the Department to review for the 30 Medical Necessity and appropriateness of the requested services, including Home Health 31 prior authorization requests (PARs). Designees may include case management entities 32 such as Single Entry Points or Community Centered Boards who manage waiver 33 eligibility and review. 34

8.520.1.I. Home Care Agency means an entity which provides Home Health or Personal Care 35 Services. When referred to in this rule without a ‘Class A’ or ‘Class B’ designation, the 36 term encompasses both types of agenciesy. 37

8.520.1.J. Home Health Agency means an agency that is licensed as a Class A Home Care Agency 38 in Colorado, and is certified to provide skilled care services to Medicare and Medicaid 39

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eligible clientmemberclients. Agencies shall hold active and current Medicare and 1 Medicaid provider IDs to provide services to Medicaid clientmemberclients. 2

8.520.1.K. Home Health Services means those services listed at Section 8.520.5, Service Types. 3

8.520.1.L. Home Health Telehealth means the remote monitoring of clinical data transmitted through 4 electronic information processing technologies, from the clientmemberclient to the home 5 health provider which meet HIPAA compliance standards. 6

8.520.1.M. Intermittent means visits that have a distinct start time and stop time, and are task 7 oriented with the goal of meeting a clientmemberclient’s specific needs for that visit. 8

8.520.1.N. Ordering Physician means the clientmemberclient’s primary care physician, or other 9 physician specialist. For clientmemberclients in a hospital or nursing facility, the Ordering 10 Physician is the physician responsible for writing discharge orders until such time as the 11 clientmemberclient is discharged. This definition may include an alternate physician 12 authorized by the Ordering Physician to care for the clientmemberclient in the Ordering 13 Physician’s absence. 14

8.520.1.O. Personal Care Worker means an employee of a licensed Home Care Agency who has 15 completed the required training to provide Personal Care Services, or who has verified 16 experience providing Personal Care Services for clientmemberclients. A Personal Care 17 Worker shall not perform tasks that are considered skilled CNA services. 18

8.520.1.P. Place of Residence means where the clientmemberclient lives. Includes temporary 19 accommodations, homeless shelters or other locations for clientmemberclients who are 20 homeless or have no permanent residence. 21

8.520.1.Q. Plan of Care means a coordinated plan developed by the Home Health Agency, as 22 ordered by the Ordering Physician for provision of services to a clientmemberclient at his 23 or her residence, and periodically reviewed and signed by the physician in accordance 24 with Medicare requirements. This shall be written on the CMS-485 (“485”) or a document 25 that is identical in content, specific to the discipline completing the plan of care. 26

8.520.1.R. Pro Re Nata (PRN) means as needed. 27

8.520.1.S. Protective Oversight means maintaining an awareness of the general whereabouts of a 28 clientmemberclient. Also includes monitoring the clientmemberclient’s activity so that a 29 caregiver has the ability to intervene and supervise the safety, nutrition, medication, and 30 other care needs of the clientmemberclient. 31

8.520.2. ClientMemberClient Eligibility 32

8.520.2.A. Home Health Services are available to all Medicaid clientmemberclients and to all Old 33 Age Pension Program clientmemberclients, as defined at Section 8.940, when all 34 program and service requirements in this rule are met. 35

8.520.2.B. Medicaid clientmemberclients aged 18 and over shall meet the Level of Care Screening 36 Guidelines for Long-Term Care Services at Section 8.401, to be eligible for Long-Term 37 Home Health Services, as set forth at Section 8.520.4.C.2. 38

8.520.3. Provider Eligibility 39

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8.520.3.A. Services must be provided by a Medicare and Medicaid-certified Home Health Agency. 1

8.520.3.B. All Home Health Services providers shall comply with the rules and regulations set forth 2 by the Colorado Department of Public Health and Environment, the Colorado Department 3 of Health Care Policy and Financing, the Colorado Department of Regulatory Agencies, 4 the Centers for Medicare and Medicaid Services, and the Colorado Department of Labor 5 and Employment. 6

8.520.3.C. Provider Agency Requirements 7

1. A Home Health Agency must: 8

a. Be certified for participation as a Medicare Home Health provider under Title 9 XVIII of the Social Security Act; 10

b. Be a Colorado Medicaid enrolled provider; 11

c. Maintain liability insurance for the minimum amount set annually by the 12 Department; and 13

d. Be licensed by the State of Colorado as a Class A Home Care Agency in good 14 standing. 15

2. Home Health Agencies which perform procedures in the clientmemberclient's home that 16 are considered waivered clinical laboratory procedures under the Clinical Laboratory 17 Improvement Act of 1988 shall possess a certificate of waiver from the Centers for 18 Medicare and Medicaid Services (CMS) or its Designee. 19

3. Home Health Agencies shall regularly review the Medicaid rules, 10 CCR 2505-10. The 20 Home Health Agency shall make access to these rules available to all staff. 21

4. A Home Health Agency cannot discontinue or refuse services to a clientmemberclient 22 unless documented efforts have been made to resolve the situation that triggers such 23 discontinuation or refusal. The Home Health Agency must provide notice of at least thirty 24 days to the clientmemberclient, or the clientmemberclient’s legal guardian. 25

5. In the event a Home Health Agency is ceasing operations, or ceasing services to 26 Medicaid clientmemberclients, the agency will provide notice to the Department’s Home 27 Health Policy Specialist of at least thirty days prior to the end of operations. 28

8.520.4. Covered Services 29

8.520.4.A. Home Health Services are covered under Medicaid only when all of the following are met: 30

1. Services are Medically Necessary as defined in Section 8.076.1.8; 31

2. Services are provided under a Plan of Care as defined at Section 8.520.1., Definitions; 32

3. Services are provided on an Intermittent basis, as defined at Section 8.520.1., 33 Definitions; 34

4. The ClientMemberclient meets one of the following: 35

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a. The only alternative to Home Health Services is hospitalization or emergency 1 room care; or 2

b. ClientMemberClient medical records indicate that medically necessary services 3 should be provided in the clientmemberclient's place of residence, instead of an 4 outpatient setting, according to one or more of the following guidelines: 5

i) The clientmemberclient, due to illness, injury or disability, is unable to 6 travel to an outpatient setting for the needed service; 7

ii) Based on the clientmemberclient's illness, injury, or disability, travel to an 8 outpatient setting for the needed service would create a medical 9 hardship for the clientmemberclient; 10

iii) Travel to an outpatient setting for the needed service is contraindicated 11 by a documented medical diagnosis; 12

iv) Travel to an outpatient setting for the needed service would interfere with 13 the effectiveness of the service; or 14

v) The clientmemberclient's medical diagnosis requires teaching which is 15 most effectively accomplished in the clientmemberclient's place of 16 residence on a short-term basis. 17

5. The clientmemberclient is unable to perform the health care tasks for him or herself, and 18 no unpaid family/caregiver is able and willing to perform the tasks; and 19

6. Covered service types are those listed in Service Types, Section 8.520.5. 20

8.520.4.B. Place of Service 21

1. Services shall be provided in the clientmemberclient’s place of residence or one of the 22 following places of service: 23

a. Assisted Living Facilities (ALFs); 24

b. Alternative Care Facilities (ACFs); 25

c. Group Residential Services and Supports (GRSS) including host homes, 26 apartments or homes where three or fewer clientmemberclients reside. Services 27 shall not duplicate those that are the contracted responsibility of the GRSS; 28

d. Individual Residential Services and Supports (IRSS) including host homes, 29 apartments or homes where three or fewer clientmemberclients reside Services 30 shall not duplicate those that are the contracted responsibility of the IRSS; or 31

e. Hotels, or similar temporary accommodations while traveling, will be considered 32 the temporary place of residence for purposes of this rule. 33

f. Nothing in this section should be read to prohibit a client from receiving Home 34 Health Services in any setting in which normal life activities take place, other than 35 a hospital, nursing facility; intermediate care facility for individuals with intellectual 36

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disabilities; or any setting in which payment is or could be made under Medicaid 1 for inpatient services that include room and board. 2

2. A ClientMember’s place of residence shall not include a nursing facility or hospital. 3

8.520.4.C. Service Categories 4

1. Acute Home Health Services 5

a. Acute Home Health Services are covered for clientmemberclients who 6 experience an acute health care need that requires Home Health Services. 7

b. Acute Home Health Services are provided for 60 or fewer calendar days or until 8 the acute medical condition is resolved, whichever comes first. 9

c. Acute Home Health Services are provided for the treatment of the following acute 10 medical conditions/episodes: 11

i) Infectious disease; 12

ii) Pneumonia; 13

iii) New diagnosis of a life-altering disease; 14

iv) Post-heart attack or stroke; 15

v) Care related to post-surgical recovery; 16

vi) Post-hospital care provided as follow-up care for medical conditions that 17 required hospitalization, including neonatal disorders; 18

vii) Post-nursing home care, when the nursing home care was provided 19 primarily for rehabilitation following hospitalization and the medical 20 condition is likely to resolve or stabilize to the point where the 21 clientmemberclient will no longer need Home Health Services within 60 22 days following initiation of Home Health Services; 23

viii) Complications of pregnancy or postpartum recovery; or 24

iv) Individuals who experience an acute incident related to a chronic disease 25 may be treated under the acute home health benefit. Specific information 26 on the acute incident shall be documented in the record. 27

d. A clientmemberclient may receive additional periods of acute Home Health 28 Services when at least 10 days have elapsed since the clientmemberclient’s 29 discharge from an acute home health episode and one of the following 30 circumstances occurs: 31

i) The clientmemberclient has a change in medical condition that 32 necessitates acute Home Health Services; 33

ii) New onset of a chronic medical condition; or 34

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iii) Treatment needed for a new acute medical condition or episode. 1

e. Nursing visits provided solely for the purpose of assessment or teaching are 2 covered only during the acute period under the following guidelines: 3

i) An initial assessment visit ordered by a physician is covered for 4 determination of whether ongoing nursing or CNA care is needed. 5 Nursing visits for the sole purpose of assessing a clientmemberclient for 6 recertification of Home Health Services shall not be reimbursed if the 7 clientmemberclient receives only CNA services; 8

ii) The visit instructs the clientmemberclient or family 9 memberclient/caregiver in providing safe and effective care that would 10 normally be provided by a skilled home health provider; or 11

iii) The visit supervises the clientmemberclient or family 12 memberclient/caregiver to verify and document that they are competent 13 in providing the needed task. 14

f. Acute Home Health Services may be provided to clientmemberclients who 15 receive Health Maintenance tasks through In-Home Supports and Services 16 (IHSS) or Consumer Directed Attendant Supports and Services (CDASS). 17

g. GRSS group home residents may receive acute Home Health Services. 18

h. If the acute home health clientmemberclient is hospitalized for planned or 19 unplanned services for 10 or more calendar days, the Home Health Agency may 20 close the clientmemberclient’s acute home health episode and start a new acute 21 home health episode when the clientmemberclient is discharged. 22

i. Acute Care Home Health Limitations: 23

i) A new period of acute Home Health Services shall not be used for 24 continuation of treatment from a prior Acute Home Health episode. New 25 Acute Episodes must be utilized for a new or worsening condition. 26

ii) A clientmemberclient who is receiving either Long-Term Home Health 27 Services or HCBS waiver services may receive acute Home Health 28 Services only if the clientmemberclient experiences an event listed in 29 subpart c. as an acute incident, which is separate from the standard 30 needs of the clientmemberclient and makes acute Home Health Services 31 necessary. 32

iii) If a clientmemberclient’s acute medical condition resolves prior to 60 33 calendar days from onset, the clientmemberclient shall be discharged 34 from acute home health or transitioned to the clientmemberclient’s 35 normal Long-Term Home Health services. 36

2. Long-Term Home Health Services 37

a. Long-term Home Health Services are covered for clientmemberclients who have 38 long-term chronic needs requiring ongoing Home Health Services. 39

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b. Long-term Home Health Services may be provided to clientmemberclients who 1 receive health maintenance tasks through IHSS. 2

c. Long-term Home Health Services may not be provided to clientmemberclients 3 who receive health maintenance tasks through CDASS. 4

d. Long-term Home Health Services are provided: 5

i) Following the 60th calendar day for acute home health 6 clientmemberclients who require additional services to meet treatment 7 goals or to be safely discharged from Home Health Services; 8

ii) On the first day of Home Health Services for clientmemberclients with 9 well documented chronic needs when the clientmemberclient does not 10 require an acute home health care transition period; or 11

iii) Continuation of ongoing long-term home health Plan of Care. 12

e. Long-Term Home Health Limitations: 13

i) ClientMemberClients aged 20 and younger may obtain long-term home 14 health physical therapy, occupational therapy, and speech therapy 15 services when Medically Necessary and when: 16

1) Therapy services will be more effective if provided in the home 17 setting; or 18

2) Outpatient therapy would create a hardship for the 19 clientmemberclient. 20

ii) ClientMemberClients aged 21 and older who continue to require physical 21 therapy, occupational therapy, and speech therapy services after the 22 initial acute home health period may only obtain such long-term services 23 in an outpatient setting. 24

iii) ClientMemberClients admitted to long-term Home Health Services 25 through the HCBS waiver program shall meet level of care criteria to 26 qualify for long-term Home Health Services. 27

iv) Long-term Home Health Services may be provided in GRSS group home 28 settings, when the GRSS provider agency reimburses the Home Health 29 Agency directly for these Home Health Services. Long-term Home 30 Health Service provision in GRSS group homes is not reimbursable 31 through the State Plan. 32

3. Long-Term with Acute Episode Home Health: 33

a. An episode is considered acute only until it is resolved or until 60 calendar days 34 after onset, whichever comes first. 35

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b. Long-term with acute episode home health is covered if the clientmemberclient is 1 receiving long-term home health services and requires treatment for an acute 2 episode as defined in section 8.520.4.C.1. 3

8.520.5. Service Types 4

8.520.5.A. Nursing Services 5

1. Standard Nursing Visit 6

a. Those skilled nursing services that are provided by a registered nurse under 7 applicable state and federal laws, and professional standards; 8

b. Those skilled nursing services provided by a licensed practical nurse under the 9 direction of a registered nurse, to the extent allowed under applicable state and 10 federal laws; 11

c. Standard Nursing Visits include but are not limited to: 12

i. 1st medication box fill (medication pre-pouring) of the week; 13

ii. 1st visit of the day; the remaining visits shall utilize brief nursing units as 14 appropriate; 15

iii. Insertion or replacement of indwelling urinary catheters; 16

iv. Colostomy and illeostomyileostomy stoma care; excluding care 17 performed by clientmemberclients; 18

v. Treatment of decubitus ulcers (stage 2 or greater); 19

vi. Treatment of widespread, infected or draining skin disorders; 20

vii. Wounds that require sterile dressing changes; 21

viii. Visits for foot care; 22

ix. Nasopharyngeal, tracheostomy aspiration or suctioning, ventilator care; 23

x. Bolus or continuous Levin tube and gastrostomy (G-tube) feedings, when 24 formula/feeding needs to be prepared or more than 1 can of prepared 25 formula is needed per bolus feeding per visit, ONLY when there is not an 26 able or willing caregiver; and 27

xi. Complex Wound care requiring packing, irrigation, and application of an 28 agent prescribed by the physician. 29

2. Brief Nursing Visits 30

a. Brief nursing visits for established long-term home health clientmemberclients 31 who require multiple visits per day for uncomplicated skilled tasks that can be 32 completed in a shorter or brief visit (excluding the first regular nursing visit of the day) 33

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b. Brief Nursing Visits include, but are not limited to: 1

i) Consecutive visits for two or more clientmemberclients who reside in the 2 same location and are seen by the same Home Health Agency nurse, 3 excluding the first visit of the day; 4

ii) Intramuscular, intradermal and subcutaneous injections (including 5 insulin) when required multiple times daily, excluding the first visit of the 6 day; 7

iii) Insulin administration: if the sole reason for a daily visit or multiple visits 8 per day, the first visit of the week is to be treated as a standard nursing 9 visit and all other visits of the week are to be treated as brief nursing 10 visits. 11

iv) Additional visits beyond the first visit of the day where simple wound care 12 dressings are the sole reason for the visit; 13

v) Additional visits beyond the first visit of the day where catheter irrigation 14 is the sole reason for the visit; 15

vi) Additional visits beyond the first visit of the day where external 16 catheterization, or catheter care is the sole purpose for the visit; 17

vii) Bolus Levin or G-tube feedings of one can of prepared formula excluding 18 the first visit of the day, ONLY when there is no willing or able caregiver 19 and it is the sole purpose of the visit; 20

viii) Medication box refills or changes following the first medication pre-21 pouring of the week; 22

ix) Other non-complex nursing tasks as deemed appropriate by the 23 Department or its Designee when documented clinical findings support a 24 brief visit as being appropriate; or 25

x) A combination of uncomplicated tasks when deemed appropriate by the 26 Department or its Designee when documented clinical findings support a 27 brief visit as being appropriate. 28

c. Ongoing assessment shall be billed as brief nursing visits unless the 29 clientmemberclient experiences a change in status requiring a standard visit. If a 30 standard nursing visit is required for the assessment, the agency shall provide 31 documentation supporting the need on the PAR form and on the Plan of Care for the 32 Department or its Designee. 33

3. PRN Nursing Visits 34

a. May be standard nursing visits or brief nursing visits; and 35

b. Shall include specific criteria and circumstances that warrant a PRN visit along 36 with the specific number of PRN visits requested for the certification period. 37

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4. Nursing Service Limitations 1

a. Nursing assessment visits are not covered if provided solely to open or recertify 2 the case for CNA services, physical, occupational, or speech therapy. 3

b. Nursing visits solely for recertifying a clientmemberclient are not covered. 4

c. Nursing visits that are scheduled solely for CNA supervision are not covered. 5

d. Family memberclients/caregivers, who meet the requirements to provide nursing 6 services and are nurses credentialed by, and in active status with the Department of 7 Regulatory Agencies, may be employed by the Home Health Agency to provide 8 nursing services to a clientmemberclient, but may only be reimbursed for services 9 that exceed the usual responsibilities of the Family MemberClient/Caregiver. 10

e. PRN nursing visits may be requested as standard nursing visits or brief nursing 11 visits and shall include a physician’s order with specific criteria and circumstances 12 that warrant a PRN visit along with the specific number of PRN visits requested for 13 the certification period. 14

f. Nursing visits are not reimbursed by Medicaid if solely for the purpose of 15 psychiatric counseling, because that is the responsibility of the Behavioral Health 16 Organization. Nursing visits for mentally ill clientmemberclients are reimbursed under 17 Home Health Services for pre-pouring of medications, venipuncture, or other nursing 18 tasks, provided that all other requirements in this section are met. 19

g. Medicaid does not reimburse for two nurses during one visit except when two 20 nurses are required to perform a procedure. For this exception, the provider may bill 21 for two visits, or for all units for both nurses. Reimbursement for all visits or units will 22 be counted toward the maximum reimbursement limit. 23

h. Nursing visits provided solely for the purpose of assessing or teaching are 24 reimbursed by the Department only in the following circumstances: 25

i) Nursing visits solely for the purpose of assessing the clientmemberclient 26 or teaching the clientmemberclient or the clientmemberclient's unpaid 27 family memberclient/caregiver are not reimbursed unless the care is 28 acute home health or long-term home health with acute episode, per 29 Section 8.520.3, or the care is for extreme instability of a chronic medical 30 condition under long-term home health, per Section 8.520.3. Long-term 31 home health nursing visits for the sole purpose of assessing or teaching 32 are not covered. 33

ii) When an initial assessment visit is ordered by a physician and there is a 34 reasonable expectation that ongoing nursing or CNA care may be 35 needed. Initial nursing assessment visits cannot be reimbursed if 36 provided solely to open the case for physical, occupational, or speech 37 therapy. 38

iii) When a nursing visit involves the nurse performing a nursing task for the 39 purpose of demonstrating to the clientmemberclient or the 40 clientmemberclient's unpaid family memberclient/caregiver how to 41

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perform the task, the visit is not considered as being solely for the 1 purpose of assessing and teaching. A nursing visit during which the 2 nurse does not perform the task, but observes the clientmemberclient or 3 unpaid family/caregiver performing the task to verify that the task is being 4 performed correctly is considered a visit that is solely for the purpose of 5 assessing and teaching and is not covered. 6

iv) Nursing visits provided solely for the purpose of assessment or teaching 7 cannot exceed the frequency that is justified by the clientmemberclient's 8 documented medical condition and symptoms. Assessment visits may 9 continue only as long as there is documented clinical need for 10 assessment, management, and reporting to physician of specific medical 11 conditions or symptoms which are not stable or not resolved. Teaching 12 visits may be as frequent as necessary, up to the maximum 13 reimbursement limits, to teach the clientmemberclient or the 14 clientmemberclient's unpaid family memberclient/caregiver, and may 15 continue only as long as needed to demonstrate understanding or to 16 perform care, or until it is determined that the clientmemberclient or 17 unpaid family memberclient/caregiver is unable to learn or to perform the 18 skill being taught. The visit in which the nurse determines that there is no 19 longer a need for assessment or teaching shall be reimbursed if it is the 20 last visit provided solely for assessment or teaching. 21

v) Nursing visits provided solely for the purpose of assessment or teaching 22 are not reimbursed if the clientmemberclient is capable of self-23 assessment and of contacting the physician as needed, and if the 24 clientmemberclient's medical records do not justify a need for 25 clientmemberclient teaching beyond that already provided by the hospital 26 or attending physician, as determined and documented on the initial 27 Home Health assessment. 28

vi) Nursing visits provided solely for the purpose of assessment or teaching 29 cannot be reimbursed if there is an available and willing unpaid family 30 memberclient/caregiver who is capable of assessing the 31 clientmemberclient's medical condition and needs and contacting the 32 physician as needed; and if the clientmemberclient's medical records do 33 not justify a need for teaching of the clientmemberclient's unpaid family 34 memberclient/caregiver beyond the teaching already provided by the 35 hospital or attending physician, as determined and documented on the 36 initial Home Health assessment. 37

i.) Nursing visits provided solely for the purpose of providing foot care are 38 reimbursed by Medicaid only if the clientmemberclient has a documented and 39 supported diagnosis that supports the need for foot care to be provided by a nurse, 40 and the clientmemberclient or unpaid family memberclient/caregiver is not able or 41 willing to provide the foot care. 42

j.) Documentation in the medical record shall specifically, accurately, and clearly 43 show the signs and symptoms of the disease process at each visit. The clinical 44 record shall indicate and describe an assessment of the foot or feet, physical and 45 clinical findings consistent with the diagnosis and the need for foot care to be 46

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provided by a nurse. Severe peripheral involvement shall be supported by 1 documentation of more than one of the following: 2

i) Absent (not palpable) posterior tibial pulse; 3

ii) Absent (not palpable) dorsalis pedis pulse; 4

iii) Three of the advanced trophic changes: 5

1) Hair growth (decrease or absence), 6

2) Nail changes (thickening), 7

3) Pigmentary changes (discoloration), 8

4) Skin texture (thin, shiny), or 9

5) Skin color (rubor or redness); 10

iv) Claudication (limping, lameness); 11

v) Temperature changes (cold feet); 12

vi) Edema; 13

vii) Parasthesia; or 14

viii) Burning. 15

kl.) Nursing visits provided solely for the purpose of pre-pouring medications into 16 medication containers such as med-minders or electronic medication dispensers are 17 reimbursed only if: 18

i) The clientmemberclient is not living in a licensed Adult Foster Home or 19 Alternative Care Facility, where the facility staff is trained and qualified to 20 pre-pour medications under the medication administration law at C.R.S. 21 25-1.5-301; 22

ii) The clientmemberclient is not physically or mentally capable of pre-23 pouring medications or has a medical history of non-compliance with 24 taking medications if they are not pre-poured; 25

iii) The clientmemberclient has no unpaid family memberclient/caregiver 26 who is willing or able to pre-pour the medications for the 27 clientmemberclient; and 28

iv) There is documentation in the clientmemberclient's chart that the 29 clientmemberclient's pharmacy was contacted upon admission to the 30 Home Health Agency, and that the pharmacy will not provide this 31 service; or that having the pharmacy provide this service would not be 32 effective for this particular clientmemberclient. 33

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a. l. The unit of reimbursement for nursing services is one visit, which is 1 defined as the length of time required to provide the needed care, up to a 2 maximum of two and one-half hours spent in clientmemberclient care or 3 treatment. 4

8.520.5.B. Certified Nurse Aide Services 5

1. CNA services may be provided when a nurse or therapist determines that an eligible 6 clientmemberclient requires the skilled services of a qualified CNA, as such services are 7 defined in this section 8.520.5.B.13 8

2. CNA tasks shall not duplicate waiver services or the clientmemberclient’s residential 9 agreement (such as an ALF, IRSS, GRSS, or other Medicaid reimbursed Residence, or 10 adult day care setting). 11

3. Skilled care shall only be provided by a CNA when a clientmemberclient is unable to 12 independently complete one or more ADLs. Skilled CNA services shall not be reimbursed 13 for tasks or services that are the contracted responsibilities of an ALF, IRSS, GRSS or 14 other Medicaid reimbursed Residence. 15

4. Before providing any services, all CNAs shall be trained and certified according to 16 Federal Medicare regulations, and all CNA services shall be supervised according to 17 Medicare Conditions of Participation for Home Health Agencies found at 42 CFR 484.36. 18 Title 42 of the Code of Federal Regulations, Part 484.36 (2013) is hereby incorporated by 19 reference into this rule. Such incorporation, however, excludes later amendments to or 20 editions of the referenced material. These regulations are available for public inspection 21 at the Department of Health Care Policy and Financing, 1570 Grant Street, Denver, CO 22 80203. The agency shall provide certified copies of the material incorporated at cost upon 23 request or shall provide the requestor with information on how to obtain a certified copy of 24 the material incorporated by reference from the agency of the United States, this state, 25 another state, or the organization or association originally issuing the code, standard, 26 guideline or rule) is hereby incorporated by reference into this rule. Such incorporation, 27 however, excludes later amendments to or editions of the referenced material. These 28 regulations are available for public inspection at the Department of Health Care Policy 29 and Financing, 1570 Grant Street, Denver, CO 80203. The agency shall provide certified 30 copies of the material incorporated at cost upon request or shall provide the requestor 31 with information on how to obtain a certified copy of the material incorporated by 32 reference from the agency of the United States, this state, another state, or the 33 organization or association originally issuing the code, standard, guideline or rule. 34

5. If the clientmemberclient receiving CNA services also requires and receives skilled 35 nursing care or physical, occupational or speech therapy, the supervising registered 36 nurse or therapist shall make on-site supervisory visits to the clientmemberclient's home 37 no less frequently than every two weeks. 38

6. If the clientmemberclient receiving CNA services does not require skilled nursing care or 39 physical, occupational or speech therapy, the supervising registered nurse shall make 40 on-site supervisory visits to the clientmemberclient's home no less frequently than every 41 60 days. Each supervisory visit shall occur while the CNA is providing care. Visits by the 42 registered nurse to supervise and to reassess the care plan are considered costs of 43 providing the CNA services, and cannot be billed to Medicaid as nursing visits. 44

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7. Registered nurses and physical, occupational and speech therapists supervising CNAs 1 shall comply with applicable state laws governing their respective professions. 2

8. CNA services can include personal care and homemaking tasks if such tasks are 3 completed during the skilled care visit and are defined below: 4

a. Personal care or homemaking services which are directly related to and 5 secondary to skilled care are considered part of the skilled care task, and are not 6 further reimbursed. For clientmemberclients who are also eligible for HCBS personal 7 care and homemaker services, the units spent on personal care and homemaker 8 services may not be billed as CNA services. 9

b. Nurse aide tasks performed by a CNA pursuant to the nurse aide scope of 10 practice defined by the State Board of Nursing, but does not include those tasks that 11 are allowed as personal care, at Section 8.535, PEDIATRIC PERSONAL CARE. 12

c. Personal care means those tasks which are allowed as personal care at Section 13 8.535, PEDIATRIC PERSONAL CARE, and Section 8.489, HOME AND 14 COMMUNITY BASED SERVICES-EBD, PERSONAL CARE. 15

d. Homemaking means those tasks allowed as homemaking tasks at Section 8.490, 16 HOME AND COMMUNITY BASED SERVICES. - EBD, HOMEMAKER SERVICES. 17

190. CNA services solely for the purpose of behavior management are not a benefit under 18 Medicaid Home Health, because behavior management is outside the nurse aide scope 19 of practice. 20

101. The usual frequency of all tasks is as ordered by the Ordering Physician on the Plan of 21 Care unless otherwise noted. 22

112. The Home Health Agency shall document the decline in medical condition or the need for 23 all medically necessary skilled tasks. 24

123. Skilled Certified Nurse Aide Tasks 25

a. Ambulation 26

i) Task includes: Walking or moving from place to place with or without 27 assistive device. 28

ii) Ambulation is a skilled task when: 29

1) ClientMemberClient is unable to assist or direct care; 30

2) Hands on assistance is required for safe ambulation and 31 clientmemberclient is unable to maintain balance or to bear weight 32 reliably; or 33

3) ClientMemberClient has not been deemed independent with 34 assistive devices ordered by a qualified physician. 35

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iii) Special Considerations: Ambulation shall not be a sole reason for a CNA 1 visit. 2

b. Bathing/Showering 3

i) Task includes either: 4

1) Preparation for bath or shower, checking water temperature; 5 assisting clientmemberclient into bath or shower; applying soap and 6 shampoo; rinsing off, towel drying; and all transfers and ambulation 7 related to bathing; all hair care, pericare and skin care provided in 8 conjunction with bathing; or 9

2) Bed bath or sponge bath. 10

ii) The usual frequency of this task shall be up to one time daily. 11

iii) Bathing/Showering is a skilled task when either: 12

1) Open wound(s), stoma(s), broken skin or active chronic skin 13 disorder(s) are present; or 14

2) ClientMemberClient is unable to maintain balance or to bear 15 weight due to illness, injury, disability, a history of falls, temporary 16 lack of mobility due to surgery or other exacerbation of illness, injury 17 or disability. 18

iv) Special Considerations: 19

1) Additional baths may be warranted for treatment and shall be 20 documented by physician order and Plan of Care. 21

2) A second person may be staffed when required to safely bathe 22 the clientmemberclient. 23

3) Hand over hand assistance may be utilized for short term (up to 24 90 days) training of the clientmemberclient in Activities of Daily Living 25 when there has been a change in the clientmemberclient’s medical 26 condition that has increased the clientmemberclient’s ability to 27 perform this task. 28

c. Bladder Care 29

i) Task includes: 30

1) Assistance with toilet, commode, bedpan, urinal, or diaper; 31

2) Transfers, skin care, ambulation and positioning related to 32 bladder care; and 33

3) Emptying and rinsing commode or bedpan after each use. 34

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ii) Bladder Care concludes when the clientmemberclient is returned to a 1 pre-urination state. 2

iii) Bladder Care is a skilled task when either: 3

1) ClientMemberClient is unable to assist or direct care, broken skin 4 or recently healed skin breakdown (less than 60 days); or 5

2) ClientMemberClient requires skilled skin care associated with 6 bladder care or clientmemberclient has been assessed as having a 7 high and ongoing risk for skin breakdown. 8

d. Bowel Care 9


1) Changing and cleaning incontinent clientmemberclient, or 11

hands on assistance with toileting; and 12

2) Returning clientmemberclient to pre‐bowel movement status, 13

which includes transfers, skin care, ambulation and positioning related 14

to bowel care. 15

ii) Bowel care is a skilled task when either :either: 16

1) ClientMemberClient is unable to assist or direct care, broken 17

skin or recently healed skin breakdown (less than 60 days) is present; or 18

2) ClientMemberClient requires skilled skin care associated with 19

bowel care or clientmemberclient has been assessed as having a high 20

and ongoing risk for skin breakdown. 21

e. Bowel Program 22

i) Skilled Task includes: 23

1) Administering bowel program as ordered by the 24

clientmemberclient’s qualified physician, including digital stimulation, 25

administering enemas, suppositories, and returning clientmemberclient 26

to pre‐bowel program status; or 27

2) Care of a colostomy or illeostomyileostomy, which includes 28

emptying the ostomy bag, changing the ostomy bag and skin care at the 29

site of the ostomy and returning the clientmemberclient to pre‐30

procedure status. 31

ii) Special Considerations 32

1) To perform the task, the clientmemberclient must have a 33

relatively stable or predictable bowel program/condition and a qualified 34

physician deems that the CNA is competent to provide the 35

clientmemberclient‐specific program. 36

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2) Use of digital stimulation and over‐the‐counter suppositories or 1

over‐the‐counter enema (not to exceed 120ml) only when the CNA 2

demonstrates competence in the Home Health Agency’s Policies & 3

Procedures for the task. (Agencies may choose to delegate this task to 4

the CNA.) 5

f. Catheter Care 6

i) Task includes: 7

1) Care of external, Foley and Suprapubic catheters; 8

2) Changing from a leg to a bed bag and cleaning of tubing and 9

bags as well as perineal care; 10

3) Emptying catheter bags; and 11

4) Transfers, skin care, ambulation and positioning related to the 12

catheter care. 13

ii) The usual frequency of this task shall not exceed two times daily. 14

iii) Catheter care is a skilled task when either: 15

1) Emptying catheter collection bags (indwelling or external) 16

includes a need to record and report the clientmemberclient’s urinary 17

output to the clientmemberclient’s nurse; or 18

2) The indwelling catheter tubing needs to be opened for any 19

reason and the clientmemberclient is unable to do so independently. 20

iv) Special Considerations: Catheter care shall not be the sole purpose of 21

the CNA visit. 22

g. Dressing 23


1) Dressing and undressing with ordinary clothing, including 25

pantyhose or socks and shoes; 26

2) Placement and removal of braces and splints; and 27

3) All transfers and positioning related to dressing and undressing. 28

ii) The usual frequency of this task shall not exceed twice daily. 29

iii) Dressing is a skilled task when: 30

1) ClientMemberClient requires assistance with the application of 31

anti‐embolic or pressure stockings and placement of braces or splints 32

that can be obtained only with a prescription from a qualified physician; 33

or 34

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2) ClientMemberClient is unable to assist or direct care; or 1

3) ClientMemberClient experiences a temporary lack of mobility 2

due to surgery or other exacerbation of illness, injury or disability. 3

iv) Special Considerations: Hand‐over‐hand assistance may be utilized for 4

short term (up to 90 days) training of the clientmemberclient in Activities of 5

Daily Living when there has been a change in the clientmemberclient’s medical 6

condition that has increased the clientmemberclient’s ability to perform this 7

task. 8

h. Exercise/Range of Motion (ROM) 9

i) Task includes: ROM and other exercise programs prescribed by a 10

therapist or qualified physician, and only when the clientmemberclient is not 11

receiving exercise/ROM from a therapist or a doctor on the same day. 12

ii) Exercise/Range of Motion (ROM) is a skilled task when: The 13

exercise/ROM, including passive ROM, is prescribed by a qualified physician and 14

the CNA has demonstrated competency. 15

iii) Special Considerations: The Home Health Agency shall ensure the CNA is 16

trained in the exercise program. The Home Health Agency shall maintain the 17

exercise program documentation in the clientmemberclient record and it shall 18

be evaluated/renewed by the qualified physician or therapist with each Plan of 19

Care. 20

i. Feeding 21


1) Ensuring food is the proper temperature, cutting food into bite‐23

size pieces, and ensuring the food is proper consistency; 24

2) Placing food in clientmemberclient's mouth; and 25

3) Gastric tube (g-tube) formula preparation, verifying placement 26 and patency of tube, administering tube feeding and flushing tube 27 following feeding if the Home Health Agency and supervising nurse 28 deem the CNA competent. 29

ii) The usual frequency of this task shall not exceed three times daily. 30

iii) Feeding is a skilled task when: 31

1) ClientMemberClient is unable to communicate verbally, non-32 verbally or through other means; 33

2) ClientMemberClient is unable to be positioned upright; 34

3) ClientMemberClient is on a modified texture diet; 35

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4) ClientMemberClient has a physiological or neurogenic chewing 1 or swallowing problem; 2

5) ClientMemberClient is on mechanical ventilation; 3

6) ClientMemberClient requires oral suctioning; 4

7) A structural issue (such as cleft palate) or other documented 5 swallowing issues are present; or 6

8) ClientMemberClient has a history of aspirating food. 7


1) There shall be a documented decline in medical condition or an 9 ongoing need documented in the clientmemberclient’s record. 10

2) A Home Health Agency may delegate allow a CNA to perform a 11 syringe feeding and tube feeding if the CNA is to a CNA it deemeds 12 competent. 13

j. Hygiene – Hair Care/Grooming 14

i) Task includes: Shampooing, conditioning, drying, and combing. 15

ii) Task does not include perming, hair coloring, or other extensive styling 16 including, but not limited to, updos, placement of box braids or other 17 elaborate braiding or placing hair extensions. 18

iii) Task may be completed during skilled bath/shower. 19

iv) The usual frequency of this task shall not exceed twice daily. 20

v) Hygiene – Hair Care/Grooming is a skilled task when: 21

1) ClientMemberClient is unable to complete task independently; 22

2) ClientMemberClient requires shampoo/conditioner that is 23 prescribed by a qualified physician and dispensed by a pharmacy; or 24

3) ClientMemberClient has open wound(s) or stoma(s) on the head. 25

vi) Special Considerations: 26


2) Styling of hair is never considered a skilled task. 32

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k. Hygiene – Mouth Care 1

i) Task includes: 2

1) Brushing teeth; 3

2) Flossing; 4

3) Use of mouthwash; 5

4) Denture care; 6

5) Swabbing (toothette); or 7

6) Oral suctioning. 8

ii) The usual frequency of this task is up to three times daily. 9

iii) Hygiene – Mouth Care is a skilled task when: 10

1) ClientMemberClient is unconscious; 11

2) ClientMemberClient has difficulty swallowing; 12

3) ClientMemberClient is at risk for choking and aspiration; 13

4) ClientMemberClient requires oral suctioning; 14

5) ClientMemberClient has decreased oral sensitivity or 15 hypersensitivity; or 16

6) ClientMemberClient is on medications that increase the risk of 17 bleeding of the mouth. 18

iv) Special Considerations: Hand over hand assistance may be utilized for 19 short term (up to 90 days) training of the clientmemberclient in Activities 20 of Daily Living when there has been a change in the clientmemberclient’s 21 medical condition that has increased the clientmemberclient’s ability to 22 perform this task. 23

l. Hygiene – Nail Care 24

i) Task includes: Soaking, filing, and nail trimming. 25

ii) The usual frequency of this task shall not exceed one time weekly. 26

iii) Hygiene – Nail Care is a skilled task when: 27

1) The clientmemberclient has a medical condition that involves 28 peripheral circulatory problems or loss of sensation; 29

2) The clientmemberclient is at risk for bleeding; or 30

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3) The clientmemberclient is at high risk for injury secondary to the 1 nail care. 2

iv) Nail Care shall only be completed by a CNA who has been deemed 3 competent in nail care by the Home Health Agency for this population. 4

v) Special Considerations: Hand over hand assistance may be utilized for 5 short term (up to 90 days) training of the clientmemberclient in Activities 6 of Daily Living when there has been a change in the clientmemberclient’s 7 medical condition that has increased the clientmemberclient’s ability to 8 perform this task. 9

m. Hygiene – Shaving 10

i) Task includes: shaving of face, legs and underarms with manual or 11 electric razor. 12

ii) The usual frequency of this task shall not exceed once daily; task may be 13 completed with bathing/showering. 14

iii) Hygiene – Shaving is a skilled task when: 15

1) The clientmemberclient has a medical condition involving 16 peripheral circulatory problems; 17

2) The clientmemberclient has a medical condition involving loss of 18 sensation; 19

3) The clientmemberclient has an illness or takes medications that 20 are associated with a high risk for bleeding; or 21

4) The clientmemberclient has broken skin at/near shaving site or a 22 chronic active skin condition. 23

iv) Special Considerations: Hand over hand assistance may be utilized for 24 short term (up to 90 days) training of the clientmemberclient in Activities 25 of Daily Living when there has been a change in the clientmemberclient’s 26 medical condition that has increased the clientmemberclient’s ability to 27 perform this task. 28

n. Meal Preparation 29


1) Preparation of food, ensuring food is proper consistency based 31 on the clientmemberclient’s ability to swallow food safely; or 32

2) Formula preparation. 33

ii) The usual frequency of this task shall not exceed three times daily. 34

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iii) Meal Preparation is a skilled task when: ClientMemberClient’s diet 1 requires either nurse oversight to administer correctly, or meals requiring 2 a modified consistency. 3

o. Medication Reminders 4

i) Task includes: 5

1) Providing clientmemberclient reminders that it is time to take 6 medications; 7

2) Handing of pre-filled medication box to clientmemberclient; 8

3) Handing of labeled medication bottle to clientmemberclient; or 9

4) Opening of prefilled box or labeled medication bottle for 10 clientmemberclient. 11

ii) This task may be completed by a CNA during the course of a visit, but 12 cannot be the sole purpose of the visit. 13

iii) A CNA may not perform this task, unless the CNA meets the DORA-14 approved CNA-MED certification, at 3 C.C.R. § 716-1 Chapter 19 15 Section 6. If the CNA does not meet the DORA certifications, the CNA 16 may still ask if the clientmemberclient has taken medications and may 17 replace oxygen tubing and may set oxygen to ordered flow rate. 18

iv) Special Considerations: CNAs shall not administer medications without 19 obtaining the CNA-MED certification from the DORA approved course. 3 20 C.C.R. 716-1 Chapter 19 Section 6. If the CNA has obtained this 21 certification, the CNA may perform pre-pouring and medication 22 administration within the scope of CNA-MED certification at 3 C.C.R. 23 716-1 Chapter 19 Section 3. 24

p. Positioning 25


1) Moving the clientmemberclient from the starting position to a new 27 position while maintaining proper body alignment and support to a 28 clientmemberclient’s extremities, and avoiding skin breakdown; and 29

2) Placing any padding required to maintain proper alignment. 30

3) Positioning as a stand-alone task excludes positioning that is 31 completed in conjunction with other Activities of Daily Living. 32

ii) Positioning is a skilled task when: 33


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2) ClientMemberClient is not able to perform this task 1 independently due to illness, injury or disability; or 2

3) ClientMemberClient has temporary lack of mobility due to 3 surgery or other exacerbation of illness, injury or disability. 4

4) Positioning the clientmemberclient requires adjusting the 5 clientmemberclient’s alignment or posture in a bed, wheelchair, other 6 furniture, assistive devices, or Durable Medical Equipment that has 7 been ordered by a qualified physician. 8

iii) Special Considerations: 9

1) The Home Health Agency shall coordinate visits to ensure that 10 effective scheduling is utilized for skilled Intermittent visits. 11

2) Positioning cannot be the sole reason for a visit. 12

q. Skin Care 13


1) Applying lotion or other skin care product, when it is not 15 performed in conjunction with bathing or toileting tasks. 16

ii) Skin care is a skilled task when: 17

1) ClientMemberClient requires additional skin care that is 18 prescribed by a qualified physician or dispensed by a pharmacy; 19

2) ClientMemberClient has broken skin; or 20

3) ClientMemberClient has a wound(s) or active skin disorder and 21 is unable to apply product independently due to illness, injury or 22 disability. 23



2) This task may be included with positioning. 30

r. Transfers 31


1) Moving the clientmemberclient from one location to another in a 33 safe manner. 34

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ii) It is not considered a separate task when a transfer is performed in 1 conjunction with bathing, bladder care, bowel care or other CNA task. 2

iii) Transfers is a skilled task when: 3


2) ClientMemberClient is not able to perform this task 6 independently due to fragility of illness, injury or disability; 7

3) ClientMemberClient has a temporary lack of mobility due to 8 surgery or other exacerbation of illness, injury or disability; 9

4) ClientMemberClient lacks the strength and stability to stand or 10 bear weight reliably; 11

5) ClientMemberClient is not deemed independent in the use of 12 assistive devices or Durable Medical Equipment that has been 13 ordered by a qualified physician; or 14

6) ClientMemberClient requires a mechanical lift for safe transfers. 15 In order to transfer clientmemberclients via a mechanical lift, the 16 CNA shall be deemed competent in the particular mechanical lift 17 used by the clientmemberclient. 18


1) A second person may be used when required to safely transfer 20 the clientmemberclient. 21

2) Transfers may be completed with or without mechanical 22 assistance. 23

3) Any unskilled task which requires a skilled transfer shall be 24 considered a skilled task. 25

s. Vital Signs Monitoring 26


1) Taking and reporting the temperature, pulse, blood pressure and 28 respiratory rate of the clientmemberclient. 29

2) Blood glucose testing and pulse oximetry readings only when the 30 CNA has been deemed competent in these measures. 31

ii) Vital sign monitoring is always a skilled task. 32


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1) Shall only be performed when delegated by the 1 clientmemberclient’s nurse. Vital signs monitoring cannot be the sole 2 purpose of the CNA visit. 3

2) Vital signs shall be taken only as ordered by the 4 clientmemberclient’s nurse or the Plan of Care and shall be reported 5 to the nurse in a timely manner. 6

3) The CNA shall not provide any intervention without the nurse’s 7 direction, and may only perform interventions that are within the CNA 8 practice act and for which the CNA has demonstrated competency. 9

134. Certified Nurse Aide Limitations 10

a. In accordance with the Colorado Nurse Aide Practice Act, a CNA shall only 11 provide services that have been ordered on the Home Health Plan of Care as 12 written by the Ordering Physician. 13

b. CNAs assist with Activities of Daily Living and cannot perform a visit for the 14 purpose of behavior modification. When a ClientMemberClient’s disabilities 15 involve behavioral manifestations, the CNA shall follow all applicable behavioral 16 plans and refrain from actions that will escalate or upset the clientmemberclient. 17 In such cases the guardian, case manager, behavioral professional or mental 18 health professional shall provide clear direction to the agency for the provision of 19 care. The CNA shall not perform Behavioral Interventions, beyond those listed in 20 c. of this section. 21

c. If the clientmemberclient has a behavior plan created by a behavior or mental 22 health professional, the CNA shall follow this plan within their scope and training 23 to the same extent that a family memberclient or paraprofessional in a school 24 would be expected to follow the plan. 25

d. When an agency allows a CNA to perform skilled tasks that require competency 26 or delegation, the agency shall have policies and procedures regarding its 27 process for determining the competency of the CNA. All competency testing and 28 documentation related to the CNA shall be retained in the CNA's personnel file. 29

e. CNA services can only be ordered when the task is outside of the usual 30 responsibilities of the clientmemberclient’s family memberclient/caregiver. 31

f. Cuing or hand over hand assistance to complete Activities of Daily Living is not 32 considered a skilled task, however, the agency may provide up to 90 days of 33 care to teach a clientmemberclient Activities of Daily Living when the 34 clientmemberclient is able to learn to perform the tasks independently. Cuing or 35 hand over hand care that exceeds 90 days, or is provided when the 36 clientmemberclient has not had a change in ability to complete self-care 37 techniques, is not covered. If continued cuing or hand over hand assistance is 38 required after 90 days, this task shall be transferred to a Personal Care Worker 39 or other competent individual who can continue the task. 40

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g. Personal care needs or skilled CNA services that are the contracted 1 responsibility of an ALF, GRSS or IRSS are not reimbursable as a separate 2 Medicaid Home Health Service. 3

h. Family memberclients/caregivers who meet all relevant requirements may be 4 employed as a clientmemberclient’s CNA, but may only provide services that are 5 identified in this benefit coverage standard as skilled CNA services and that 6 exceed the usual responsibilities of the family memberclient/caregiver. Family 7 memberclient/caregiver CNAs must meet all CNA requirements. 8

i. All CNAs who provide Home Health Services shall be subject to all requirements 9 set forth by the policies of the Home Health Agency, and all applicable State and 10 Federal laws. 11

j. When a CNA holds other licensure(s) or certification(s), but is employed as or 12 functions as a CNA, the services are reimbursed at the CNA rate for services. 13

k. CNA visits cannot be approved for, nor can extended units be billed for the sole 14 purpose of completing personal care, homemaking tasks or instrumental 15 Activities of Daily Living. 16

l. Personal care needs for clientmemberclients ages twenty years and under, not 17 directly related to a skilled care task, shall be addressed through Section 8.535, 18 PEDIATRIC PERSONAL CARE. 19

m. Homemaker Services provided as directly related tasks secondary to skilled care 20 during a skilled CNA visit shall be limited to the permanent living space of the 21 clientmemberclient. Such services are limited to tasks that benefit the 22 clientmemberclient and are not for the primary benefit of other persons living in 23 the home. 24

n. Nursing or CNA visits, or requests for extended visits, for the sole purpose of 25 Protective Oversight are not reimbursable by Medicaid. 26

o. CNA services for the sole purpose of providing personal care or homemaking 27 services are not covered. 28

p. The Department does not reimburse for services provided by two CNAs to the 29 same clientmemberclient at the same time, except when two CNAs are required 30 for transfers, there are no other persons available to assist, and the reason why 31 adaptive equipment cannot be used instead is documented in the Plan of Care. 32 For this exception, the provider may bill for two visits, or for all units for both 33 aides. Reimbursement for all visits or units will be counted toward the maximum 34 reimbursement limit. 35

q. The basic unit of reimbursement for CNA services is up to one hour. A unit of 36 time that is less than fifteen minutes cannot be reimbursed as a basic unit. 37

r. For CNA visits that last longer than one hour, extended units may be billed in 38 addition to the basic unit. Extended units shall be increments of fifteen minutes 39 up to one-half hour. Any unit of time that is less than fifteen minutes cannot be 40 reimbursed as an extended unit. 41

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145. Certified Nurse Aide (CNA) Supervision 1

a. CNA services shall be supervised by a registered nurse, by the physical 2 therapist, or when appropriate, the speech therapist or occupational therapist 3 depending on the specific Home Health Services the clientmemberclient is 4 receiving. 5

b. If the clientmemberclient receiving CNA services is also receiving skilled nursing 6 care or physical therapy or occupational therapy, the supervising registered 7 nurse or therapist shall make supervisory visits to the clientmemberclient's home 8 no less frequently than every 14 days. The CNA does not have to be present for 9 every supervisory visit. However, the registered nurse, or the therapist shall 10 make on-site supervisory visits to observe the CNA in the clientmemberclient's 11 home at least every 60 days. 12

c. If the clientmemberclient is only receiving CNA services, the supervising 13 registered nurse or the physical therapist shall make on-site supervisory visits to 14 observe the CNA in the clientmemberclient's home at least every 60 days. 15

d. The Department does not reimburse for any visit made solely for the purpose of 16 supervising the CNA. 17

e. For all clientmemberclients expected to require CNA services for at least a year, 18 during supervisory visits the supervising nurse shall: 19

i) Obtain input from the clientmemberclient, or the clientmemberclient's 20 designated representative into the Certified Nurse Aide Assignment 21 Form, including all CNA tasks to be performed during each scheduled 22 time period. 23

ii) Document details, duties, and obligations on the Certified Nurse Aide 24 Assignment Form. 25

iii) Assure the Certified Nurse Aide Assignment Form contains information 26 regarding special functional limitations and needs, safety considerations, 27 special diets, special equipment, and any other information pertinent to 28 the care to be provided by the CNA. 29

iv) Obtain the clientmemberclient’s, or the clientmemberclient's authorized 30 representative’s, per section 8.520.7.E.1, signature on the form, and 31 provide a copy to the clientmemberclient at the beginning of services, 32 and at least once per year thereafter. A new copy of the Written Notice of 33 Home Care Consumer Rights form, per section 8.520.7.E.1, shall also be 34 provided at these times. 35

v) Explain the rights listed in the patient’s rights form whenever the Certified 36 Nurse Aide Assignment Form is renegotiated and rewritten. 37

vi) For purposes of complying with this requirement, once per year means a 38 date within one year of the prior certification. 39

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156. If a clientmemberclient does not meet the factors that make a task skilled, as outlined in 1 Section 8.520.5., the clientmemberclient may be eligible to receive those services as 2 unskilled personal care through Section 8.535, PEDIATRIC PERSONAL CARE, or 3 Section 8.489, HOME AND COMMUNITY BASED SERVICES-EBD, PERSONAL CARE. 4

8.520.5.C. Therapy Services 5

1. Therapies are only covered: 6

a. In acute home health care; or 7

b. ClientMemberClients 20 years of age or younger may receive long-term home 8 health therapy when services are medically necessary. 9

c. When the clientmemberclient’s Ordering Physician prescribes therapy services, 10 and the therapist is responsible for evaluating the clientmemberclient and 11 creating a treatment plan with exercises in accordance with practice guidelines. 12

2. The therapist shall teach the clientmemberclient, the clientmemberclient’s family 13 memberclient/caregiver and other memberclients of the Home Health care team to 14 perform the exercises as necessary for an optimal outcome. 15

3. When the therapy Plan of Care includes devices and equipment, the therapist shall assist 16 the clientmemberclient in initiating or writing the request for equipment and train the 17 clientmemberclient on the use of the equipment. 18

4. Home Health Agencies shall only provide physical, occupational, or speech therapy 19 services when: 20

a. Improvement of functioning is expected or continuing; 21

b. The therapy assists in overcoming developmental problems; 22

c. Therapy visits are necessary to prevent deterioration; 23

d. Therapy visits are indicated to evaluate and change ongoing treatment plans for 24 the purpose of preventing deterioration, and to teach CNAs or others to carry out 25 such plans, when the ongoing treatment does not require the skill level of a 26 therapist; or 27

e. Therapy visits are indicated to assess the safety or optimal functioning of the 28 clientmemberclient in the home, or to train in the use of equipment used in 29 implementation of the therapy Plan of Care. 30

5. Physical Therapy 31

a. Physical therapy includes any evaluations and treatments allowed under state 32 law at C.R.S. 12- 41-101 through 130, which are applicable to the home setting. 33

b. When devices and equipment are indicated by the therapy Plan of Care, the 34 therapist shall assist in initiating or writing the request in accordance with Section 35

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8.590 through 8.594.03, Durable Medical Equipment, and shall assist in training 1 on the use of the equipment. 2

c. Treatment must be provided by or under the supervision of a licensed physical 3 therapist who meets the qualifications prescribed by federal regulation for 4 participation in Medicare, at 42 CFR 484.4; and who meets all requirements 5 under state law. Title 42 of the Code of Federal Regulations, Part 484.4 (2013) is 6 hereby incorporated by reference into this rule. Such incorporation, however, 7 excludes later amendments to or editions of the referenced material. These 8 regulations are available for public inspection at the Department of Health Care 9 Policy and Financing, 1570 Grant Street, Denver, CO 80203. The agency shall 10 provide certified copies of the material incorporated at cost upon request or shall 11 provide the requestor with information on how to obtain a certified copy of the 12 material incorporated by reference from the agency of the United States, this 13 state, another state, or the organization or association originally issuing the code, 14 standard, guideline or ruleis hereby incorporated by reference into this rule. Such 15 incorporation, however, excludes later amendments to or editions of the 16 referenced material. These regulations are available for public inspection at the 17 Department of Health Care Policy and Financing, 1570 Grant Street, Denver, CO 18 80203. The agency shall provide certified copies of the material incorporated at 19 cost upon request or shall provide the requestor with information on how to 20 obtain a certified copy of the material incorporated by reference from the agency 21 of the United States, this state, another state, or the organization or association 22 originally issuing the code, standard, guideline or rule. 23

i) i) Physical therapy assistants (PTA) can render Home Health 24 therapy but shall practice under the supervision of a registered physical 25 therapist. 26

d. For clientmemberclients who do not require skilled nursing care, the physical 27 therapist may open the case and establish the Plan of Care. 28

e. Physical therapists are responsible for completing clientmemberclient 29 assessments related to various physical skills and functional abilities. 30

f. Physical therapy includes evaluations and treatments allowed under state law 31 and is available to all acute home health clientmemberclients and pediatric long-32 term Home Health clientmemberclients. Therapy plans and assessments shall 33 contain the therapy services requested; the specific procedures and modalities to 34 be used, including amount, duration, and frequency; and specific goals of therapy 35 service provision. 36

g. Limitations 37

i) Physical therapy for clientmemberclients age 21 or older is not covered 38 for acute care needs when treatment becomes focused on maintenance, 39 and no further functional progress is apparent or expected to occur. 40

ii) Physical therapy is not a benefit for adult long-term home health 41 clientmemberclients. ClientMemberClients 20 years of age or younger 42 may receive Long-Term Home Health therapy services when services 43 are medically necessary. 44

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iii) ClientMemberClients ages 21 and older who continue to require therapy 1 after the acute home health period may obtain long-term therapy 2 services in an outpatient setting. ClientMemberClients shall not be 3 moved to acute home health for the sole purpose of continuing therapy 4 services from a previous acute home health care episode. 5

iv) ClientMemberClients 20 years of age or younger may obtain therapy 6 services for maintenance care through acute home health and through 7 long-term home health. 8

v) Physical therapy visits for the sole purpose of providing massage or 9 ultrasound are not covered. 10

vi) Medicaid does not reimburse for two physical therapists during one visit. 11

vii) The unit of reimbursement for physical therapy is one visit, which is 12 defined as the length of time required to provide the needed care, up to a 13 maximum of two and one-half hours spent in clientmemberclient care or 14 treatment. 15

6. Occupational Therapy 16

a. Occupational therapy includes evaluations and treatments allowed under the 17 standards of practice authorized by the American Occupational Therapy 18 Association, which are applicable to the home setting. 19

b. When devices and equipment are indicated by the therapy Plan of Care, the 20 therapist shall assist in initiating or writing the request and shall assist in training 21 the clientmemberclient on the use of the equipment. 22

c. Treatment shall be provided by or under the supervision of a registered 23 occupational therapist who meets the qualifications prescribed by federal 24 regulations for participation under applicable federal and state laws, including 25 Medicare requirements at 42 CFR 484.4. 26

i) Occupational therapy assistants (OTA) can render Home Health therapy 27 but shall practice under the supervision of a registered occupational 28 therapist. 29

d. For clientmemberclients who do not require skilled nursing care, the occupational 30 therapist may open the case and establish the Plan of Care. 31

e. Occupational therapy includes only evaluations and treatments that are allowed 32 under state law for occupational therapists. 33

f. Occupational therapists shall create a plan and perform assessments which state 34 the specific therapy services requested, the specific procedures and modalities to 35 be used, the amount, duration, frequency, and the goals of the therapy service 36 provision. 37

g. Limitations 38

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i) Occupational therapy for clientmemberclients age 21 or older is not a 1 benefit under acute Home Health Services when treatment becomes 2 maintenance and no further functional progress is apparent or expected 3 to occur. 4

ii) Occupational therapy is not a benefit for adult long-term home health 5 clientmemberclients. 6

iii) ClientMemberClients ages 21 and older who continue to require therapy 7 after the acute home health period may only obtain long-term therapy 8 services in an outpatient setting. 9

iv) ClientMemberClients shall not be moved to acute home health for the 10 sole purpose of continuing therapy services from a previous acute home 11 health care episode. 12

v) ClientMemberClients 20 years of age or younger may continue to obtain 13 therapy services for maintenance care in acute home health and in long-14 term home health. 15

vi) Medicaid does not reimburse for two occupational therapists during one 16 visit. 17

vii) The unit of reimbursement for occupational therapy is one visit, which is 18 defined as the length of time required to provide the needed care, up to a 19 maximum of two and one-half hours spent in clientmemberclient care or 20 treatment. 21

7. Speech Therapy 22

a. Speech therapy services include any evaluations and treatments allowed under 23 the American Speech-Language-Hearing Association (ASHA) authorized scope 24 of practice statement, which are applicable to the home setting. 25

b. When devices and equipment are indicated by the therapy plan of care, the 26 therapist shall assist in initiating or writing the request in accordance with Section 27 8.590 through 8.594.03, Durable Medical Equipment, and shall assist in training 28 on the use of the equipment. 29

c. Treatment must be provided by a speech/language pathologist who meets the 30 qualifications prescribed by federal regulations for participation under Medicare 31 at 42 CFR 484.4. 32

d. For clientmemberclients who do not require skilled nursing care, the speech 33 therapist may open the case and establish the Medicaid plan of care. 34

e. The speech/language pathologist shall state the specific therapy services 35 requested, the specific procedures and modalities to be used, as well as the 36 amount, duration, frequency and specific goals of therapy services on the Plan of 37 Care. 38

f. Limitations 39

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i) Speech therapy for clientmemberclients age 21 or older is not a benefit 1 under acute Home Health Services when treatment becomes 2 maintenance and no further functional progress is apparent or expected 3 to occur. 4

ii) ClientMemberClients cannot be moved to acute home health for the sole 5 purpose of continuing therapy services from a previous acute home 6 health care episode. 7

iii) Speech therapy is not a benefit for adult long-term home health 8 clientmemberclients. 9

iv) Treatment of speech and language delays is only covered when 10 associated with a chronic medical condition, neurological disorder, acute 11 illness, injury, or congenital issue. 12

v) ClientMemberClients 20 years of age or younger may continue to obtain 13 therapy services for maintenance care in acute home health and in long-14 term home health. 15

vi) Medicaid does not reimburse for two speech therapists during one visit. 16

vii) The unit of reimbursement for speech therapy is one visit, which is 17 defined as the length of time required to provide the needed care, up to a 18 maximum of two and one-half hours spent in clientmemberclient care or 19 treatment. 20

8.520.5.D. Home Health Telehealth Services 21

1. The Home Health Agency shall create policies and procedures for the use and 22 maintenance of the monitoring equipment and the process of telehealth monitoring. This 23 service shall be used to monitor the clientmemberclient and manage the 24 clientmemberclient’s care, and shall include all of the following elements: 25

a. The clientmemberclient’s designated registered nurse or licensed practical nurse, 26 consistent with state law, shall review all data collected within 24 hours of receipt 27 of the ordered transmission, or in cases where the data is received after business 28 hours, on the first business day following receipt of the data; 29

b. The clientmemberclient’s designated nurse shall oversee all planned 30 interventions; 31

c. ClientMemberClient-specific parameters and protocols defined by the agency 32 staff and the clientmemberclient’s authorizing physician or podiatrist; and 33

d. Documentation of the clinical data in the clientmemberclient’s chart and a 34 summary of response activities, if needed. 35

i) The nurse assessing the clinical data shall sign and date all 36 documentation; and 37

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ii) Documentation shall include the health care data that was transmitted 1 and the services or activities that are recommended based on the data. 2

2. The Home Health Agency shall provide monitoring equipment that possesses the 3 capability to measure any changes in the monitored diagnoses, and meets all of the 4 following requirements: 5

a. FDA certified or UL listed, and used according to the manufacturer’s instructions; 6

b. Maintained in good repair and free from safety hazards; and 7

c. Sanitized before installation in a clientmemberclient’s home. 8

3. Home Health Telehealth services are covered for clientmemberclients receiving Home 9 Health Services, when all of the following requirements are met: 10

a. ClientMemberClient receives services from a home health provider for at least 11 one of the following diagnoses: 12

i) Congestive Heart Failure; 13

ii) Chronic Obstructive Pulmonary Disease; 14

iii) Asthma; 15

iv) Diabetes; 16

v) Pneumonia; or 17

vi) Other diagnosis or medical condition deemed eligible by the Department 18 or its Designee. 19

b. ClientMemberClient requires ongoing and frequent monitoring, minimum of five 20 times weekly, to manage their qualifying diagnosis as defined and ordered by a 21 physician or podiatrist; 22

c. ClientMemberClient has demonstrated a need for ongoing monitoring as 23 evidenced by: 24

i) Having been hospitalized or admitted to an emergency room two or more 25 times in the last twelve months for medical conditions related to the 26 qualifying diagnosis; 27

ii) If the clientmemberclient has received Home Health Services for less 28 than six months, the clientmemberclient was hospitalized at least once in 29 the last three months; 30

iii) An acute exacerbation of a qualifying diagnosis that requires telehealth 31 monitoring; or 32

iv) New onset of a qualifying disease that requires ongoing monitoring to 33 manage the clientmemberclient in their residence. 34

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d. ClientMemberClient or caregiver misses no more than five transmissions of the 1 provider and agency prescribed monitoring events in a thirty-day period; and 2

e. ClientMemberClient’s home environment has the necessary connections to 3 transmit the telehealth data to the agency and has space to set up and use the 4 equipment as prescribed. 5

4. The Home Health Agency shall make at least one home health nursing visit every 14 6 days to a clientmemberclient using Home Health Telehealth services. 7

5. The Home Health Agency shall develop agency-specific criteria for assessment of the 8 need for Home Health Telehealth services, to include patient selection criteria, home 9 environment compatibility, and patient competency. The agency shall complete these 10 assessment forms prior to the submission of the enrollment application and they shall be 11 kept on file at the agency. 12

6. The clientmemberclient and/or caregiver shall comply with the telehealth monitoring as 13 ordered by the qualifying physician. 14

7. Limitations: 15

a. ClientMemberClients who are unable to comply with the ordered telehealth 16 monitoring shall be disenrolled from the services. 17

b. Services billed prior to obtaining approval to enroll a clientmemberclient into 18 Home Health Telehealth services by the Department or its Designee are not a 19 covered benefit. 20

c. The unit of reimbursement for Home Health Telehealth is one calendar day. 21

i) The Home Health Agency may bill one initial installation unit visit per 22 clientmemberclient lifetime each time when the monitoring equipment is installed 23 in the home. 24

ii) The Home Health Agency may bill the daily rate for each day the telehealth 25 monitoring equipment is used to monitor and manage the clientmemberclient’s 26 care. 27

d. Once per lifetime per clientmemberclient, a Home Health Agency may bill for the 28 installation of the Home Health Telehealth equipment. 29

8.520.6 Supplies 30

8.520.6.A. Reimbursement for routine supplies is included in the reimbursement for nursing, CNA, 31 physical therapy, occupational therapy, and speech therapy services. Routine supplies 32 are supplies that are customarily used during the course of home care visits. These are 33 standard supplies utilized by the Home Health Agency staff, and not designated for a 34 specific clientmemberclient. 35

8.520.6.B. Non-routine supplies may be a covered benefit when approved by the Department or its 36 Designee. 37

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8.520.6.C. Limitations 1

1. A Home Health Agency cannot require a clientmemberclient to purchase or provide 2 supplies that are necessary to carry out the clientmemberclient’s Plan of Care. 3

2. A clientmemberclient may opt to provide his or her own supplies. 4

8.520.7. Documentation 5

8.520.7.A. Home Health Agencies shall have written policies regarding nurse delegation. 6

8.520.7.B. Home Health Agencies shall have written policies regarding maintenance of 7 clientmemberclients’ durable medical equipment, and make full disclosure of these 8 policies to all clientmemberclients with durable medical equipment in the home. The 9 Home Health Agency shall provide such disclosure to the clientmemberclient at the time 10 of intake. 11

8.520.7.C. Home Health Agencies shall have written policies regarding procedures for 12 communicating with case managers of clientmemberclients who are also enrolled in 13 HCBS programs. Such policies shall include, at a minimum: 14

1. How agencies will inform case managers that services are being provided or are being 15 changed; and 16

2. Procedures for sending copies of Plans of Care if requested by case managers. These 17 policies shall be developed with input from case managers. 18

8.520.7.D. Plan of Care Requirements 19

1. The clientmemberclient’s Ordering Physician shall order Home Health Services in writing, 20 as part of a written Plan of Care. The written Plan of Care shall be updated every 60 21 calendar days but need not be provided to the Department or its Designee unless the 22 clientmemberclient’s status has changed significantly, a new PAR is needed, or if 23 requested by the Department or its Designee. 24

2. The initial assessment or continuation of care assessments shall be completed by a 25 registered nurse, or by a physical therapist, occupational therapist or speech therapist 26 when no skilled nursing needs are required. The assessment shall be utilized to develop 27 the Plan of Care with provider input and oversight. The written Plan of Care and 28 associated documentation shall be used to complete the CMS-485 (or a document that is 29 identical in content) and shall include: 30

a. Identification of the attending physician; 31

b. Physician orders; 32

c. Identification of the specific diagnoses, including the primary diagnosis, for which 33 Medicaid Home Health Services are requested. 34

d. The specific circumstances, clientmemberclient medical condition(s) or 35 situation(s) that require services to be provided in the clientmemberclient’s 36 residence rather than in a physician’s office, clinic or other outpatient setting 37

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including the availability of natural supports and the clientmemberclient’s living 1 situation; 2

e. A complete list of supplements, and medications, both prescription and over the 3 counter, along with the dose, the frequency, and the means by which the 4 medication is taken; 5

f. A complete list of the clientmemberclient’s allergies; 6

g. A list of all non-routine durable medical equipment used by the 7 clientmemberclient; 8

h. A list of precautions or safety measures in place for the clientmemberclient, as 9 well as functional limitations or activities permitted by the clientmemberclient’s 10 qualified physician; 11

i. A behavioral plan when applicable. Physical Behavioral Interventions, such as 12 restraints, shall not be included in the home health Plan of Care; 13

j. A notation regarding the clientmemberclient’s physician-ordered dietary 14 (nutritional) requirements and restrictions, any special considerations, other 15 restrictions or nutritional supplements; 16

k. The Home Health Agency shall indicate a comprehensive list of the amount, 17 frequency, and expected duration of provider visits for each discipline ordered by 18 the clientmemberclient’s physician, including: 19

i) The specific duties, treatments and tasks to be performed during each 20 visit; 21

ii) All services and treatments to be provided on the Plan of Care; 22

1) Treatment plans for physical therapy, occupational therapy and 23 speech therapy may be completed on a form designed specifically 24 for therapy Plans of Care; and 25

iii) Specific situations and circumstances that require a PRN visit, if 26 applicable. 27

l. Current clinical summary of the clientmemberclient’s health status, including 28 mental status, and a brief statement regarding homebound status of the 29 clientmemberclient; 30

m. The clientmemberclient’s prognosis, goals, rehabilitation potential and where 31 applicable, the clientmemberclient’s specific discharge plan; 32

i) If the clientmemberclient’s illness, injury or disability is not expected to 33 improve, or discharge is not anticipated, the agency is not required to 34 document a discharge plan; 35

ii) The clientmemberclient’s medical record shall include the reason that no 36 discharge plan is present; 37

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n. The attending physician shall approve the Plan of Care with a dated signature. If 1 an electronic signature is used, the agency shall document that an electronic 2 signature was used and shall keep a copy of the physician’s physical signature 3 on file; 4

o. Brief statement regarding the clientmemberclient’s support network including the 5 availability of the clientmemberclient’s family memberclient/caregiver and if 6 applicable, information on why the clientmemberclient’s family 7 memberclient/caregiver is unable or unwilling to provide the care the 8 clientmemberclient requires; and 9

p. Other relevant information related to the clientmemberclient’s need for Home 10 Health care. 11

3. A new Plan of Care shall be completed every 60 calendar days while the 12 clientmemberclient is receiving Home Health Services. The Plan of Care shall include a 13 statement of review by the physician every 60 days. 14

4. Home Health Agencies shall send new Plans of Care and other documentation as 15 requested by the Department or its Designee. 16

8.520.7.E. Additional Required ClientMemberClient Chart Documentation 17

1. A signed copy of the Written Notice of Home Care Consumer Rights as required by the 18 Department and at 42 CFR 484.10. Title 42 of the Code of Federal Regulations, Part 19 484.10 (2013) is hereby incorporated by reference into this rule. Such incorporation, 20 however, excludes later amendments to or editions of the referenced material. These 21 regulations are available for public inspection at the Department of Health Care Policy 22 and Financing, 1570 Grant Street, Denver, CO 80203. The agency shall provide certified 23 copies of the material incorporated at cost upon request or shall provide the requestor 24 with information on how to obtain a certified copy of the material incorporated by 25 reference from the agency of the United States, this state, another state, or the 26 organization or association originally issuing the code, standard, guideline or ruleis 27 hereby incorporated by reference into this rule. Such incorporation, however, excludes 28 later amendments to or editions of the referenced material. These regulations are 29 available for public inspection at the Department of Health Care Policy and Financing, 30 1570 Grant Street, Denver, CO 80203. The agency shall provide certified copies of the 31 material incorporated at cost upon request or shall provide the requestor with information 32 on how to obtain a certified copy of the material incorporated by reference from the 33 agency of the United States, this state, another state, or the organization or association 34 originally issuing the code, standard, guideline or rule; 35

2. Evidence of a face-to-face visit with the clientmemberclient’s referring provider, or other 36 appropriate provider, as required at 42 CFR 44024.7022. Title 42 of the Code of Federal 37 Regulations, Part 484440.7022 (20163) is hereby incorporated by reference into this rule. 38 Such incorporation, however, excludes later amendments to or editions of the referenced 39 material. These regulations are available for public inspection at the Department of 40 Health Care Policy and Financing, 1570 Grant Street, Denver, CO 80203. The agency 41 shall provide certified copies of the material incorporated at cost upon request or shall 42 provide the requestor with information on how to obtain a certified copy of the material 43 incorporated by reference from the agency of the United States, this state, another state, 44 or the organization or association originally issuing the code, standard, guideline or ruleis 45

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hereby incorporated by reference into this rule. Such incorporation, however, excludes 1 later amendments to or editions of the referenced material. These regulations are 2 available for public inspection at the Department of Health Care Policy and Financing, 3 1570 Grant Street, Denver, CO 80203. The agency shall provide certified copies of the 4 material incorporated at cost upon request or shall provide the requestor with information 5 on how to obtain a certified copy of the material incorporated by reference from the 6 agency of the United States, this state, another state, or the organization or association 7 originally issuing the code, standard, guideline or rule; 8

3. A signed and dated copy of the Agency Disclosure Form as required by the Department, 9 with requirements at 42 CFR 484.12. Title 42 of the Code of Federal Regulations, Part 10 484.12 (2013) is hereby incorporated by reference into this rule. Such incorporation, 11 however, excludes later amendments to or editions of the referenced material. These 12 regulations are available for public inspection at the Department of Health Care Policy 13 and Financing, 1570 Grant Street, Denver, CO 80203. The agency shall provide certified 14 copies of the material incorporated at cost upon request or shall provide the requestor 15 with information on how to obtain a certified copy of the material incorporated by 16 reference from the agency of the United States, this state, another state, or the 17 organization or association originally issuing the code, standard, guideline or rule) is 18 hereby incorporated by reference into this rule. Such incorporation, however, excludes 19 later amendments to or editions of the referenced material. These regulations are 20 available for public inspection at the Department of Health Care Policy and Financing, 21 1570 Grant Street, Denver, CO 80203. The agency shall provide certified copies of the 22 material incorporated at cost upon request or shall provide the requestor with information 23 on how to obtain a certified copy of the material incorporated by reference from the 24 agency of the United States, this state, another state, or the organization or association 25 originally issuing the code, standard, guideline or rule; 26

4. Dates of the most recent hospitalization or nursing facility stay. If the most recent stay 27 was within the last 90 days, reason for the stay (diagnoses), length of stay, summary of 28 treatment, date and place discharged to shall be included in the clinical summary or 29 update; 30

5. The expected health outcomes, which may include functional outcomes; 31

6. An emergency plan including the safety measures that will be implemented to protect 32 against injury; 33

7. A specific order from the clientmemberclient’s qualified physician for all PRN visits 34 utilized; 35

8. Clear documentation of skilled and non-skilled services to be provided to the 36 clientmemberclient with documentation that the clientmemberclient or 37 clientmemberclient’s family memberclient/caregiver agrees with the Plan of Care; 38

9. Accurate and clear clinical notes or visit summaries from each discipline for each visit 39 that include the clientmemberclient’s response to treatments and services completed 40 during the visit. Summaries shall be signed and dated by the person who provided the 41 service. If an electronic signature is used, the agency shall document that an electronic 42 signature was used and keep a copy of the physical signature on file; 43

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10. Documented evidence of Care Coordination with the clientmemberclient’s other 1 providers; 2

11. When the clientmemberclient is receiving additional services (skilled or unskilled) 3 evidence of Care Coordination between the other services shall be documented and 4 include an explanation of how the requested Home Health Services do not overlap with 5 these additional services; 6

12. A plan for how the agency will cover clientmemberclient services (via family 7 memberclient/caregiver or other agency staff) if inclement weather or other unforeseen 8 incident prevents agency staff from delivering the Home Health care ordered by the 9 qualified physician; and 10

13. If foot or wound care is ordered for the clientmemberclient, the Home Health Agency shall 11 ensure the signs and symptoms of the disease process/medical condition that requires 12 foot or wound care by a nurse are clearly and specifically documented in the clinical 13 record. The Home Health Agency shall ensure the clinical record includes an assessment 14 of the foot or feet, or wound, and physical and clinical findings consistent with the 15 diagnosis, and the need for foot or wound care to be provided by a nurse. 16

8.520.8 Prior Authorization 17

8.520.8.A. General Requirements 18

1. Approval of the PAR does not guarantee payment by Medicaid. 19

2. The clientmemberclient and the HHA shall meet all applicable eligibility requirements at 20 the time services are rendered and services shall be delivered in accordance with all 21 applicable service limitations. 22

3. Medicaid is always the payer of last resort and the presence of an approved or partially 23 approved PAR does not release the agency from the requirement to only bill for Medicaid 24 approved services to Medicare or other third party insurance prior to billing Medicaid. 25

a. Exceptions to this include Early Intervention Services documented on a child’s 26 Individualized Family Service Plan (IFSP) and the following services that are not 27 a skilled Medicare benefit (CNA services only, OT services only, Med-box pre-28 pouring and routine lab draws). 29

8.520.8.B. Acute Home Health 30

1. Acute Home Health Services do not require prior authorization. This includes episodes of 31 acute home health for long-term home health clientmemberclients. 32

2. If a clientmemberclient receiving long-term Home Health Services experiences an acute 33 care event that necessitates moving the clientmemberclient to an acute home health 34 episode, the agency shall notify the Department or its Designee that the 35 clientmemberclient is moving from long-term home health to acute Home Health 36 Services. 37

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3. If the clientmemberclient’s acute home health needs resolve prior to 60 calendar days, 1 the Home Health Agency shall discharge the clientmemberclient, or submit a PAR for 2 long-term Home Health Services if the clientmemberclient is eligible. 3

a. If an acute home health clientmemberclient experiences a change in status (e.g. 4 an inpatient admission), that totals 9 calendar days or less, the Home Health 5 Agency shall resume the clientmemberclient’s care under the current acute home 6 health Plan of Care. 7

b. If an acute home health clientmemberclient experiences a change in status (e.g. 8 an inpatient admission), that totals 10 calendar days or more, the Home Health 9 Agency may start a new Acute Home Health episode when the 10 clientmemberclient returns to the Home Health Agency. 11

c. The Home Health Agency shall inform the SEP case manager or the Medicaid 12 fiscal agent within 10 working days of the beginning and within 10 working days 13 of the end of the acute care episode. 14

8.520.8.CB. Long-Term Home Health 15

1. Long-term Home Health Services require prior authorization under Section 8.017.E. 16

2. When an agency accepts an HCBS waiver clientmemberclient to long-term Home Health 17 Services, the Home Health Agency shall contact the clientmemberclient’s case 18 management agency to inform the case manager of the clientmemberclient's need for 19 Home Health Services. 20

3. The complete formal written PAR shall include: 21

a. A completed Department-prescribed Prior Authorization Request Form, see 22 Section 8.058; 23

b. A home health Plan of Care, which includes all clinical assessments and current 24 clinical summaries or updates of the clientmemberclient. The Plan of Care shall 25 be on the CMS-485 form, or a form that is identical in content to the CMS-485, 26 and all sections of the form shall be completed. For clientmemberclients 20 years 27 of age or younger, all therapy services requested shall be included in the Plan of 28 Care or addendum, which lists the specific procedures and modalities to be used 29 and the amount, duration, frequency and goals. If extended aide units, as 30 described in 8.520.9.B. are requested, there shall be sufficient information about 31 services on each visit to justify the extended units. Documentation to support any 32 PRN visits shall also be provided. If there are no nursing needs, the Plan of Care 33 and assessments may be completed by a therapist if the clientmemberclient is 20 34 years of age or younger and is receiving home health therapy services; 35

c. Written documentation of the results of the EPSDT medical screening, or other 36 equivalent examination results provided by the clientmemberclient's third-party 37 insurance; 38

d. Any other medical information which will document the medical necessity for the 39 Home Health Services; 40

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e. If applicable, written instructions from the therapist or other medical professional 1 to support a current need when range of motion or other therapeutic exercise is 2 the only skilled service performed on a CNA visit; 3

f. When the PAR includes a request for nursing visits solely for the purpose of pre-4 pouring medications, evidence that the clientmemberclient's pharmacy was 5 contacted, and advised the Home Health Agency that the pharmacy will not 6 provide medication set-ups, shall be documented; and 7

g. When a PAR includes a request for reimbursement for two aides at the same 8 time to perform two-person transfers, documentation supporting the current need 9 for two-person transfers, and the reason adaptive equipment cannot be used 10 instead, shall be provided. 11

h. Long Term Home Health Services for clientmemberclients 20 years of age or 12 younger require prior authorization by the Department or its Designee using the 13 approved utilization management tool. 14

4. Authorization time frames: 15

a. PARs shall be submitted for, and may be approved for up to a one year period. 16

b. The Department or its Designee may initiate PAR revisions if the Plans of Care 17 indicate significantly decreased services. 18

c. PAR revisions for increases initiated by Home Health Agencies shall be 19 submitted and processed according to the same requirements as for new PARs, 20 except that current written assessment information pertaining to the increase in 21 care may be submitted in lieu of the CMS-485. 22

5. The PAR shall not be backdated to a date prior to the 'from' date of the CMS-485. 23

6. The Department or its Designee shall approve or deny according to the following 24 guidelines for safeguarding clientmemberclients: 25

a. PAR Approval: If services requested are in compliance with Medicaid rules are 26 medically necessary and appropriate for the diagnosis and treatment plan, the 27 services are approved retroactively to the start date on the PAR form. Services 28 may be approved retroactively for no more than 10 days prior to the PAR 29 submission date. 30

b. PAR Denial: 31

i) The Department or its Designee shall notify Home Health Agencies in 32 writing of denials that result from non-compliance with Medicaid rules or 33 failure to establish medical necessity (e.g, the PAR is not consistent with 34 the clientmemberclient's documented medical needs and functional 35 capacity). Denials based on medical necessity shall be determined by a 36 registered nurse or physician. 37

ii) When denied, services shall be approved for 15 additional days after the 38 date on which the notice of denial is mailed to the clientmemberclient. 39

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Services may be approved retroactively for no more than 10 days prior to 1 the PAR submission date. 2

c. Interim Services: Services provided during the period between the provider’s 3 submission of the PAR form to the Department or its Designee, to the final 4 approval or denial by the Department may be approved for payment. Payment 5 may be made retroactive to the start date on the PAR form, or up to 30 working 6 days, whichever is shorter. 7

8.520.8.DC. EPSDT Services 8

1. Home Health Services beyond those allowed in Section 8.520.5, for clientmemberclients 9 ages 0 through 20, shall be reviewed for medical necessity under the EPSDT 10 requirement, as defined at Section 8.280.1. 11

2. Home Health Services beyond those in Section 8.520.5, which are provided under the 12 Home Health benefit due to medical necessity, cannot include services that are available 13 under other Colorado Medicaid benefits for which the clientmemberclient is eligible, 14 including, but not limited to, Private Duty Nursing, Section 8.540; HCBS Personal Care, 15 Section 8.489; Pediatric Personal Care, Section 8.535; School Health and Related 16 Services, Section 8.290, or Outpatient Therapies, Section 8.200.3.A.6, Section 8.200.5 17 and Section 8.200.3.D Exceptions may be made if EPSDT Home Health Services will be 18 more cost-effective, provided that clientmemberclient safety is assured. Such exceptions 19 shall, in no way, be construed as mandating the delegation of nursing tasks. 20

3. PARs for EPSDT home health shall be submitted and reviewed as outlined in Section 21 8.520.8, including all documentation outlined in Section 8.520.8, and any other medical 22 information which will document the medical necessity for the EPSDT Home Health 23 Services. The Plan of Care shall include the place of service for each home health visit. 24

8.520.8.ED. Home Health Telehealth Services 25

1. Home Health Telehealth services require prior authorization. 26

2. The Home Health Telehealth PAR shall include all of the following: 27

a. A completed enrollment form; 28

b. An order for telehealth monitoring signed and dated by the Ordering Physician or 29 podiatrist; 30

c. A Plan of Care, which includes nursing and therapy assessments for 31 clientmemberclients. Telehealth monitoring shall be included on the CMS-485 32 form, or a form that contains identical information to the CMS-485, and all 33 applicable forms shall be complete; and 34

d. For ongoing telehealth, the agency shall include documentation on how 35 telehealth data has been used to manage the clientmemberclient’s care, if the 36 clientmemberclient has been using Home Health Telehealth services. 37

8.520.9 Reimbursement 38

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8.520.9.A. Rates of Reimbursement: Payment for Home Health Services is the lower of the billed 1 charges or the maximum unit rate of reimbursement. 2

1. The maximum reimbursement for any twenty-four hour period, as measured from 3 midnight to midnight, shall not exceed the daily maximum as designated by the 4 Department and in alignment with the Legislative Budget. 5

2. The maximum daily reimbursement includes reimbursement for nursing visits, home 6 health CNA visits, physical therapy visits, occupational therapy visits, speech/language 7 pathology visits, and any combinations thereof.” 8

8.520.9.B. Special Reimbursement Conditions 9

1. Total reimbursement by the Department combined with third party liability and Medicare 10 crossover claims shall not exceed Medicaid rates. 11

2. When Home Health Agencies provide Home Health Services in accordance with these 12 regulations to clientmemberclients who receive Home and Community Based Services 13 for the Developmentally Disabled (HCBS-DD), the Home Health Agency is reimbursed: 14

a. Under normal procedures for home health reimbursement if the 15 clientmemberclient resides in an Intermediate Care Facility for the Intellectually 16 Disabled (ICF/ID), or in IRSS host homes and settings; or 17

b. By the group home provider, if the clientmemberclient resides in a GRSS, 18 because the provider has already received Medicaid funding for the Home Health 19 Services and is responsible for payment to the Home Health Agency. 20

3. Acute Home Health Services for Medicaid HMO clientmemberclients are the 21 responsibility of the Medicaid HMO, including clientmemberclients who are also HCBS 22 recipients. 23

4. Services for a dual eligible clientmemberclient shall be submitted first to Medicare for 24 reimbursement. All Medicare requirements shall be met and administrative processes 25 exhausted prior to any dual eligible clientmemberclient’s claims being billed to Medicaid, 26 as demonstrated by a Medicare denial of benefits, except for the specific services listed 27 in Section 8.520.0.E.4.a below for clientmemberclients which meet the criteria listed in 28 Section 8.520.9.E.4.b below. 29

a. A Home Health Agency may bill only Medicaid without first billing Medicare if 30 both of the following are true: 31

i) The services below are the only services on the claim: 32

1) Pre-pouring of medications; 33

2) CNA services; 34

3) Occupational therapy services when provided as the sole skilled 35 service; or 36

4) Routine laboratory draw services. 37

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ii) The following conditions apply: 1

1) The clientmemberclient is stable; 2

2) The clientmemberclient is not experiencing an acute episode; 3 and 4

3) The clientmemberclient routinely leaves the home without taxing 5 effort and unassisted for social, recreational, educational, or 6 employment purposes. 7

b. The Home Health Agency shall maintain clear documentation in the 8 clientmemberclient’s record of the conditions and services that are billed to 9 Medicaid without first billing Medicare. 10

c. A Home Health Change of Care Notice or Advance Beneficiary Notice of Non-11 Coverage shall be filled out as prescribed by Medicare. 12

5. Services for a dually eligible long-term home health clientmemberclient who has an acute 13 episode shall be submitted first to Medicare for reimbursement. Medicaid may be billed if 14 payment is denied by Medicare as a non-covered benefit and the service is a Medicaid 15 benefit, or when the service meets the criteria listed in Section 8.520.9.E.4 above. 16

6. If both Medicare and Medicaid reimburse for the same visit or service provided to a 17 clientmemberclient in the same episode, the reimbursement is considered a duplication 18 of payment and the Medicaid reimbursement shall be returned to the Department. 19

a. Home Health Agencies shall return any payment made by Medicaid for such visit 20 or service to the Department within sixty (60) calendar days of receipt of the 21 duplicate payment. 22

8.520.9.C. Reimbursement for Supplies 23

1. A Home Health Agency shall not ask a clientmemberclient to provide any supplies. A 24 request for supplies from a clientmemberclient may constitute a violation of Section 25 8.012, PROVIDERS PROHIBITED FROM COLLECTING PAYMENT FROM 26 RECIPIENTS. 27

2. Supplies other than those required for practice of universal precautions which are used 28 by the Home Health Agency staff to provide Home Health Services are not the financial 29 responsibility of the Home Health Agency. Such supplies may be requested by the 30 physician as a benefit to the clientmemberclient under Section 8.590, DURABLE 31 MEDICAL EQUIPMENT AND DISPOSABLE MEDICAL SUPPLES. 32

3. Supplies used for the practice of universal precautions by the clientmemberclient's family 33 or other informal caregivers are not the financial responsibility of the Home Health 34 Agency. Such supplies may be requested by the physician as a benefit to the 35 clientmemberclient under Section 8.590, DURABLE MEDICAL EQUIPMENT AND 36 DISPOSABLE MEDICAL SUPPLIES. 37

8.520.9.D. Restrictions 38

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1. When the clientmemberclient has Medicare or other third-party insurance, Home Health 1 claims to Medicaid will be reimbursed only if the clientmemberclient's care does not meet 2 the Home Health coverage guidelines for Medicare or other insurance. 3

2. When an agency provides more than one employee to render a service, in which one 4 employee is supervising or instructing another in that service, the Home Health Agency 5 shall only bill and be reimbursed for one employee's visit or units. 6

3. Any visit made by a nurse or therapist to simultaneously serve two or more 7 clientmemberclients residing in the same household shall be billed by the Home Health 8 Agency as one visit only, unless services to each clientmemberclient are separate and 9 distinct. If two or more clientmemberclients residing in the same household receive 10 Medicaid CNA services, the services for each clientmemberclient shall be documented 11 and billed separately for each clientmemberclient. 12

4. No more than one Home Health Agency may be reimbursed for providing Home Health 13 Services during a specific plan period to the same clientmemberclient, unless the second 14 agency is providing a Home Health Service that is not available from the first agency. The 15 first agency shall take responsibility for the coordination of all Home Health Services. 16 Home and Community Based Services, including personal care, are not Home Health 17 Services. 18

5. Improper Billing Practices: Examples of improper billing include, but are not limited to: 19

a. Billing for visits without documentation to support the claims billed. 20 Documentation for each visit billed shall include the nature and extent of 21 services, the care provider's signature, the month, day, year, and the exact time 22 in and time out of the clientmemberclient's home. Providers shall submit or 23 produce requested documentation in accordance with rules at Section 8.076.2; 24

b. Billing for unnecessary visits, or visits that are unreasonable in number, 25 frequency or duration; 26

c. Billing for CNA visits in which no skilled tasks were performed and documented; 27

d. Billing for skilled tasks that were not medically necessary; 28

e. Billing for Home Health Services provided at locations other than an eligible 29 place of service, except EPSDT services provided with prior authorization; and 30

f. Billing of personal care or homemaker services as Home Health Services. 31

6. A Home Health Agency that are also certified as a personal care/homemaker provider 32 shall ensure that neither duplicate billing nor unbundling of services occurs in billing for 33 Home Health Services and HCBS personal care services. Examples of duplicate billing 34 and unbundling of services include: 35

a.) One employee makes one visit, and the agency bills Medicaid for a CNA visit, 36 and also bills all of the hours as HCBS personal care or homemaker. 37

b.) One employee makes one visit, and the agency bills for one CNA visit, and bills 38 some of the hours as HCBS personal care or homemaker, when the total time 39

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spent on the visit does not equal at least 1 hour plus the number of hours billed 1 for HCBS personal care and homemaker. 2

c.) Any other practices that circumvent these rules and result in excess Medicaid 3 payment through unbundling of CNA and personal care or homemaker services. 4

7. The DepartmentA Home Health Agency may take action against the offending Home 5 Health Agency, including be terminated termination from participation in Colorado 6 Medicaid in accordance with 10 C.C.R. 2505-10, Section 8.076. 7

8.520.10 Compliance Monitoring Reviews 8

8.520.10.A. General Requirements 9

1. Compliance monitoring of Home Health Services may be conducted by state and federal 10 agencies, their contractors and law enforcement agencies in accordance with 10 C.C.R. 11 2505-10, Section 8.076. 12

2. Home Health Agencies shall submit or produce all requested documentation in 13 accordance with 10 C.C.R. 2505-10, Section 8.076. 14

3. Physician-signed Plans of Care shall include nursing or therapy assessments, current 15 clinical summaries and updates for the clientmemberclient. The Plan of Care shall be on 16 the CMS-485 form, or a form that is identical in content to the CMS-485. All sections of 17 the form shall be completed. All therapy services provided shall be included in the Plan of 18 Care, which shall list the specific procedures and modalities to be used and the amount, 19 duration and frequency. 20

4. Provider records shall document the nature and extent of the care actually provided. 21

5. Unannounced site visits may be conducted in accordance with C.R.S. Section 25.5-4-22 301(14)(b). 23

6. Home Health Services which are duplicative of any other services that the 24 clientmemberclient has received funded by another source or that the clientmemberclient 25 received funds to purchase shall not be reimbursed. 26

7. Services which total more than twenty-four hours per day of care, regardless of funding 27 source shall not be reimbursed. 28

8. Billing for visits or contiguous units which are longer than the length of time required to 29 perform all the tasks prescribed on the care plan shall not be reimbursed. 30

9. Home Health Agencies shall not bill clientmemberclients or families of clientmemberclient 31 for any services for which Medicaid reimbursement is recovered due to administrative, 32 civil or criminal actions by the state or federal government. 33

8.520.11 Denial, Termination, or Reduction in Services 34

8.520.11.A. When services are denied, terminated, or reduced by action of the Home Health Agency, 35 the Home Health Agency shall notify the clientmemberclient. 36

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8.520.11.B. Termination of sServices to ClientMemberclients sStill mMedically eEligible for Coverage 1 of Medicaid Home Health Services: 2

1. When a Home Health Agency decides to terminate services to a clientmemberclient who 3 needs and wants continued Home Health Services, and who remains eligible for 4 coverage of services under the Medicaid Home Health rules, the Home Health Agency 5 shall give the clientmemberclient, or the clientmemberclient's designated 6 representative/legal guardian, written advance notice of at least 30 business days. The 7 attending physician and the Department’s Home Health Policy Specialist shall also be 8 notified. 9

2. Written nNotice to the clientmemberclient, or clientmemberclient’s designated 10 representative/legal guardian shall be provided in person or by certified mail, and shall be 11 considered given when it is documented that the recipient has received the notice. The 12 notice shall provide the reason for the change in services 13

3. The agency shall make a good faith effort to assist the clientmemberclient in securing the 14 services of another agency. 15

4. If there is indication that ongoing services from another source cannot be arranged by the 16 end of the advance notice period, the terminating agency shall ensure clientmemberclient 17 safety by making referrals to appropriate case management agencies or County 18 Departments of Social Services; and the attending physician shall be informed. 19

5. Exceptions will be made to the requirement for 30 days advance notice when the provider 20 has documented that there is immediate danger to the clientmemberclient, Home Health 21 Agency, staff, or when the clientmemberclient has begun to receive Home Health 22 Services through a Medicaid HMO. 23

statement of basis and purpose - cohealthinfo.com · initial review final adoption 07/14/17...

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