Provider Information

Section 40, Home Health Services
Clarification of Sec. 40.02-3(C)(3) and (D)(4)

Section 40.02-3 (C)(3) Severe and disabling mental illness. A recipient who meets the eligibility criteria set forth in Section 17.02, Community Support Services, AND requires medication administration or medication monitoring is exempt from the homebound requirement.

Discussion This eligibility criteria is designed to provide eligibility for severely mentally disabled persons who require in-home MEDICATION SERVICES. Many recipients need to have psych medications delivered to them in their homes (residential setting) because these recipients will not comply with receiving this service on an out patient basis.

This Section does not exempt recipients who need mental health services/ psychotherapy services from the homebound requirements. Only individuals who need medication services are exempt from the homebound requirement.

Section 40.02-3(D)(4) Prior Authorization (PA) requirements. A patient who qualifies under 40.02-3(C)(3) and requires medication administration as his/her ONLY services, shall be exempt from prior authorization for these services. If the patient requires any additional home health services, these shall require prior authorization.

Discussion Psych medication services do not require PA. If the recipient also needs psychotherapy or any other mental health services or any skilled nursing services or any home health aide services (ie any services other than psych medication services), then these additional services must meet all Section 40.02 requirements and must be prior authorized.

Example 1: A recipient qualifies for psych medication services and also requires psychotherapy. Prior authorization from Goold is required for the psychotherapy service-this is a skilled nursing service. The "free" initial certification period does not apply to recipients classified for Sec.40.02-3(C)(3) medication services. The physician must certify that the patient can not safely receive psychotherapy on an outpatient basis. Also under Section 40.05(A) (3) services are required on an intermittent or part-time basis-this means that psychotherapy can be covered only on an intermittent or part-time basis, under this section.

Example 2: A recipient qualifies for psych medication services and also requires skilled nursing for wound care. Prior authorization from Goold is required for skilled nursing/ wound care.

Example 3: A recipient does not meet Section 17 eligibility, but requires psychotherapy. This is a skilled nursing service, therefore prior authorization for this service by Goold is required after the "initial (annual) certification" period. The client is NOT exempt from the homebound requirements (however under Section 40.02-3 (C)(2) the physician may certify that due to the patient's condition, the safe use of outpatient services is contraindicated-must provide documentation).

Example 4: A recipient qualifies for psych medication services and also requires Home Health Aide services. The Home Health Aide services must be prior authorized by Goold.

The "Sec. 17 exemption" applies only to medication services. All other additional services must be viewed as skilled nursing services, and require prior authorization. Psychotherapy is considered a skilled nursing service and must be delivered by a specialized Psychiatric nurse, not a Registered Nurse. Psych medication services can be delivered by a Registered Nurse; a specialized Psychiatric nurse is not required.