MaineCare Home Health Questions & Answers

We have patients with indwelling catheters who may have a regular visit once a month for catheter change, but sometimes need prn weekend or evening visits to change a plugged or leaking catheter. Will prn visits be available for these patients under community long term care, or will they need to go to the ER? If patients have a history of this, could the home health care plan be written to include 2 potential visits/mo?
Response: Section 96, Private Duty Nursing & Personal Care Services is designed to serve individuals who require a skilled nursing service on a monthly basis. PRN visits are available under Section 96, Private Duty Nursing Services. A monthly catheter change, beyond the acute phase, is a non-covered service under Section 40.07(P) Home Health Services.
If GOOLD/the department decide to change the care plan, will they obtain physician orders to do so? If the physician still wants the care plan at the same level, will the patient be responsible for payment?
Response: It is not the Department's role to obtain a physician's orders for services. As the payor, MaineCare will reimburse home health services that have been authorized by the Department or its authorized agent Goold Health Systems. In accordance with Chapter I, Section 1.06-4, members may be charged for a non-covered service, only if prior to the provision of the service, the provider has clearly explained to the member that the service is not covered by MaineCare and that he or she will be financially liable for payment of such a service. Providers must document in the member's record that notification of financial liability for non-covered services has been made. In the case of home health services, if the physician's recommendations for care differ from the Goold assessor's authorized care plan, the member must be informed that MaineCare's authorized agent, Goold Health Systems, has authorized services in an amount and scope appropriate to meet the member's needs and that only these services will be covered by MaineCare.
If a patient is open to therapy as the skilled service, may a nurse also go in for venipuncture? (this is how it works with Medicare).
Response: No. Under Section 40, Home Health Services, a nurse may perform a venipuncture only in conjunction with another skilled nursing service delivered during the same visit. Members who require venipuncture services on a regular basis can receive these under Section 96, Private Duty Nursing.
If there are patients who are referred for once a month visits for catheters or injections, who are not currently receiving home health, may GOOLD refer to us if they have to be put on a waiting list for long term care?
Response: A member must meet the eligibility requirements in order to receive coverage under this Section 40. A member will not be referred to Home Health for a once per month nursing service.
Nursing Client who is currently registered with BEAS prior to July 1, 2003 and not in their initial certification period: do we need to reregister with BEAS when we send in the request for Goold Assessment 5 days prior to the end of their authorized period?
Response: If a member has been receiving MaineCare HH and the admit /start of care form has been submitted to BEAS, the classification dates will be maintained in the claims system (Welfre) according to the start of care information. When Goold completes the Prior Authorization, Goold submits the outcome to BEAS and BEAS will update the classification dates in Welfre based on the assessment outcome. See example #1 in Marianne Ringel's memo to Home Health Agencies (dated 7/2/03)
Nursing Client who is currently registered with BEAS and is in their initial certification period: do we need to reregister with BEAS when we send in a request for Goold Assessment 5 days prior to the end of the initial cert period?
Response: If the initial certification period ends before Septembers 1, 2003, an admit/ start of care form must be submitted to BEAS. BEAS will extend the dates of classification for 60 days and return a confirmation stating the dates. At the end of that classification period a referral must be made to Goold at least five days prior to reassessment due date for PA.
Example: Initial certification period of 6/15/03 to 8/15/03.
A request to BEAS by submitting the admit start of care for 8/15/2003 and HCFA 485. BEAS will extend the reassessment date from 8/15/2003 to 10/15/2003. BEAS will return a fax confirmation documenting the extension of HH to 10/15/2003.

If at anytime after September 1, 2003, the home health agency determines the member no longer meets the medical eligibility criteria in Section 40.02, a discharge notice must be issued. If the member needs any long-term care services, submit the discharge notice and the referral request for a Long Term Care Advisory to Goold.

If continuation of home health services is medically necessary beyond October 15, 2003, make a timely referral (5 days prior to the end of certification period) for an assessment. This assessment will be performed using the new eligibility criteria.
OT, PT, and SLP: The July 2nd memo from Marianne Ringel on the Section 40 changes, example #4 states, "A new certification and updated admit/start of care form must be submitted to BEAS for Data Entry into the Claims System. "When does the updated admit/soc form need to be submitted to BEAS? July 1, 2003? Also would a new 485 need to be sent along with the updated form?
Response: A new certification and updated admit/start of care form must be submitted to BEAS for data entry into the claims system July 1,2003. A copy of the current certification form must also be submitted.
How should a home care agency direct patients and physicians on the new Section 40 Regs when the following occurs: Patients are not homebound, however, doctors have written letters to us and verbalized that these patients have poor follow-through and will decompensate without in-home treatment. These patients usually have multiple physicians involved for their multiple diagnoses and have acute problems with at least one of their diagnoses on a 2-4 time a month basis. They don't usually require 3x a week visits nor can they grasp the idea that the current problem was one that they had previously so they have ongoing assessment and teaching needs beyond two months. They can usually get by with weekly visits to direct follow through with the appropriate physician. I am at a loss as to how to direct physicians who insist that these patients require home visits and they will not sign orders for discharge.
Resonse: Homebound status is no longer an eligibility requirement for Section 40, Home Health Services. However, Section 40.02-3(C) sets forth that home health services shall not be provided if services are available and safely accessible to the member on an outpatient basis. The condition of the member must require skilled nursing care no less than twice per month, or otherwise, OT, PT or ST. Section 40 HH services are not designed to deliver ongoing or long term nursing observation and assessment or teaching and training services. The Department believes 120 days (two certification periods) is a reasonable standard for providing these services. Assessment and management is available for a new or recent condition (within the past 30 days). MaineCare will only reimburse services as described under Section 40 and which have prior authorization from Goold Health Systems (the Department's authorized agent), when necessary.
How should we direct patients regarding ongoing care who have multiple diagnoses that we teach about one diagnosis over two certification periods and then they have a problem that we need to teach about for another period of time? Would we have to discharge them after the first two certification periods because that's all that is allowed under teaching and training or could we continue to see them for different teaching needs for a short time after the initial 2 cert. periods? I think that they could qualify under the unstable definition, however, they probably wouldn't need 3x a week visits. If we document a conversation with the physician 1 time a week and visit 2x a week would that meet the unstable definition?
Response: If the member develops a new condition while receiving home health services for another condition, the plan of care can be amended to cover the necessary observation, assessment, teaching and training services around the new condition, during the current certification period. And if necessary, the observation, assessment, teaching and training services can continue into another certification period if prior authorized by Goold Health Systems. However, if the medical condition is not a new or recent condition, then the member must meet the definition Section 40.01-20 Unstable Medical Condition in order for professional nursing assessment, observation and management services to continue beyond 120 days. Unstable patients in need of services require at least three visits per week, according to the definition. All continuing services beyond the first certification period, require prior authorization by Goold.