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TO: |
Interested Parties |
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FROM: |
Mollie Baldwin, OES & Jane Connors, Office of MaineCare Services |
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DATE: |
January 13, 2006 |
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SUBJECT: |
Section 40, MaineCare Home Health Benefits for Age 21 and older |
Section 40 Policy Change Highlights effective
January 20, 2006:
Section 40.01:
Definitions
New definitions
have been added to clarify therapy eligibility criteria changes such as
extensive assistance, functionally significant improvement, one person physical
assist and rehabilitation potential
Section
40.02-Eligibility for care
·
Being
determined NF eligible has been eliminated as an eligibility criteria for
Section 40 services.
· Section 40.02-E- 13 & 14 Therapies: Visit limits for PT,OT & ST therapy have been eliminated.
·
The policy change effective January 20, 2006 includes
new requirements when requesting prior authorization for therapies. The admit
/start of care form has been revised under the therapy section to accommodate
documentation of the items now required by policy. A referral request for
therapies must include a copy of physician documentation that the person has
rehabilitation potential.
·
There are additional criteria (see Section 40.05-C-5a)
when a person needs continued physical or occupational therapy. Once the
rehabilitation potential has been
established by the MD, one of the following criteria must also be met:
o treatment following an acute hospital stay for a condition affecting range of motion, muscle strength and physical functional abilities.
o treatment after a surgical procedure performed for the purpose of improving physical function.
o treatment in those situations in which a physician has documented that the member has, in the preceding thirty (30) days, required extensive assistance (defined in Section 40.01-23) with at least one person physical assist (defined in Section 40.01-24) in the performance of one (1) or more of the following activities of daily living: eating, toileting, locomotion, transfer or bed mobility.
· Every 2 months, the doctor will review the case and decide if the member still qualifies for these services.
How do the therapy requirements change the prior
authorization process?
· OES has revised the referral attachment and will require that on referral for PA for therapy that documentation of the rehabilitation potential must be submitted with the referral request in order to be considered complete. For members receiving psychiatric medication services only, who then want to access any therapy, the referral has to include not only the rehabilitation documentation but also documentation related to one of the following criteria:
Required
therapy is related to the following circumstances (one of the following must
be checked and documentation provided):
£
treatment
following an acute hospital stay for a condition affecting range of motion, muscle strength and
physical functional abilities.
£
treatment
after a surgical procedure performed for the purpose of improving physical
function.
£
treatment
in those situations in which a physician has documented that the member has, in
the preceding thirty (30) days, required extensive assistance (defined in
Section 40.01-23) with at least one person physical assist (defined in Section
40.01-24) in the performance of one (1) or more of the following activities of
daily living: eating, toileting, locomotion, transfer or bed mobility.
If the referral
does not include all the required information on receipt, the referral will be
considered incomplete. The official referral date will not be entered and
considered for the start of eligibility until all information is received. This
type of delay in the date will definitely impact on payment for the provider
and may result in non –payment for some services.
Section
40.02-5: The policy now
incorporates into it the practice that was implemented July 1, 2004,
where home health agencies are allowed to serve members meeting the eligibility
requirements for Section 40, MaineCare Home Health for up to 120 days before PA
is required from GHS.
Current
Procedure: If the member requires a 2nd
Certification Period, the agency must submit re-certification paperwork (Admit
Form, 485 for the 2nd Cert Period and reason out-patient services
are contraindicated) to OES within 5 calendar days following the start of the
second certification period. Indicate
if the paperwork is for the 1st or 2nd Certification
Period, by checking the appropriate box on the revised Admit Form. Enter the services that are being delivered
as certified by the physician. Enter
the start date for each of those services.
If disciplines have been added or discontinued between the 1st
and the 2nd Cert Period, make the corrections as appropriate, on the
Admit Form for the 2nd Cert Period.
The member’s medical condition must require skilled services on a
part-time or intermittent basis, or otherwise no less than twice per
month.
Ø If member has had 120 days when PA is
requested, assessment management can no longer be authorized for additional
certification periods unless the member’s needs meet the “Unstable”
definition as defined in Section 40.01-20.
Ø Teaching/Training
is only a covered service for 120 days per admission. If
member has had 120 days of teaching/training do not request PA for this service
as the maximum allowed has been accessed unless
the member’s needs meet the “Unstable” definition as defined in Section
40.01-20.
MECMS
Classification system: With the implementation of the
MECMS claims management system a new classification system was implemented.
Previously there were 4 classification codes for HH. Now there are 13
classification codes. Each code describes the disciplines allowed under the
code and whether or not that code can coexist with other program classification
codes. The area most impacted is home health aid services. Many of the LTC
policies now clearly define that a member may not receive services viewed as
duplicate when paid for under another MaineCare program. For example: If a member is in an Assisted
Living facility where personal care is a covered service, policy does not allow
for HHA services under Section 40 to be reimbursed. The new classification
system is very discrete and has built into the logic the policy
parameters.
The
classification system feeds MECMS and replaces the classification system in
Welfre.
o
Claims
will kick if a provider bills for a service not allowed under policy while the
member receives a similar service from another provider reimbursed by
MaineCare.
o
If
an agency provides a service beyond the end date of the classification, the
claim will be rejected.
o
If
an agency does not submit the admit/start of care forms the claims will be
rejected because OES will not have entered any classification into the system.
This includes Psychiatric Medication services.
Updates to a plan of care where an additional discipline is added must
also be received so the appropriate classification code that allows the added
discipline will be entered.
o
If
a member being served by an agency enters a hospital or facility and the agency
does not discharge the member the potential for payment problems increases if
services are resumed without any notification to OES. Members move from program
to program and in and out of facilities to access other benefits. When the program
or the benefit involved requires classification codes, these codes are updated
as the member accesses different benefits.
When Goold assesses a member for LTC and authorizes the benefit we
revise the classification system to reflect the change. This may mean a closure
of the HH code based on policy and whether or not the new benefit can be
provided concurrently with HH.
§
For
example: a member may need to access the 30 day Community MaineCare benefit for
NF. OES receives from GHS the NF outcome and closes the HH classification and
opens the NF classification. If the member returns home within the 30 days and
HH resumes services, OES will have shutdown the HH for NF care based on the
assessment outcome. If HH agency does not tell us services have been resumed
claims submitted will kick due to classification dates.
What
has changed?
OES
has revised the admit start of care form to include a resumption of services
date field. Please begin to submit this
form when you have temporarily suspended services to a member under an active
certification period due to a hospitalization and a LTC assessment for NF
placement or community LTC.
Many
times discharge planners make referrals to GHS and a HH agency concurrently. If
Goold assesses and offers the waiver, the outcome will reach OES before any HH
start of care paperwork has been received. Once a member signs the waiver
choice letter at the time of the assessment the waiver classification is
entered and HH is not allowed under the EW/ADW benefit. It is allowed under the
PDW as long as no personal care provided by a HHA.
Attached
are all the revised documents used to communicate with the department as
required under section 40.
All
documents can be found at: http://www.maine.gov/dhhs/beas/homehealth/homehealth.htm
Copies
of the rules are available at : http://www.maine.gov/bms/rules/gen_recently_adopted.shtml
Feel
free to call either Lorraine Lachapelle or myself at 287-9200 or 1-800-262-2232.
CC: Jane Connors, Office of Medical Services
Barbara McGill Office of Medical
Services
Lorraine Lachapelle, OES
Vicki Purgavie, Home Care Alliance