Medical Assessments: MaineCare Benefits

July 2, 2003

TO:Home Health Agencies

FROM: Marianne Ringel, Director, Policy & Provider Services, Bureau of Medical Services

SUBJECT: Medical Assessments: MaineCare Benefits Manual, Chapter II, Section 40, Home Health Services

With the adoption of the new rule Section 40, Home Health Services, MaineCare Benefits Manual, there will be changes to some procedures. This letter concerns the transition from the current policies and procedures related to assessments and reassessments to the new policies and procedures, as they apply to members age 21 years and older. Implementation changes are highlighted below.

Section 40.02-5, Prior Authorizations (PA) requirements, For nursing services, home health aide services, and medical social services, the new rule eliminates the “yearly initial certification period,” (up to 62 days) that used to begin in July at the start of each state fiscal year. Now, an initial certification period will be established upon each admission or readmission by the home health agency. Prior authorization by the Department’s agent (Goold Health Systems) is required in order for services to continue uninterrupted, beyond any initial certification period, regardless of whether a new fiscal year has begun. This requirement applies to all members (age 21 years and older), including those members currently receiving services.

Effective with the new rule, the home health agency is responsible for assuring that a member meets the medical eligibility requirements for all admissions and readmissions for the initial certification period. Prior authorization by Goold Health Systems is required for continued services beyond the initial certification period. The home health agencies should request an assessment five (5) days prior to the end of a member’s certification period, if continued services are needed. Timely requests for PA will eliminate the risk of gaps in payment.

Revised Section 40.02, medical eligibility criteria, The revised eligibility criteria are effective for all admissions on or after July 1, 2003.

The newly adopted eligibility criteria shall apply to members currently receiving services beginning with requests to continue services that are submitted on or after September 1, 2003.

Starting September 1, 2003, home health agencies should issue discharge notices to members currently receiving services who do not meet the new medical eligibility requirements. For example, at that time members will no longer be covered under Section 40.07(O) if a monthly injection is the sole skilled nursing service provided during the visit; nor for (P) monthly catheter changes, beyond the acute phase. Members who are no longer eligible for services under Section 40 may continue to be covered pursuant to Section 40.08-3, Awaiting Placement, until a new provider begins to deliver services, if the member is eligible to receive services under another MaineCare benefit, as determined by a Goold assessment. Following are some examples:

Example #1: A member receiving home health services whose current certification expires July 7, 2003 and the agency anticipates continued service to this member:

Submit a request to Goold for a revision to extend the PA for 60 days to 9/4/2003 without reassessment as a result of the elimination of the annual initial certification. MeCare revisions only allow Goold to enter this information even thought there will not be a reassessment.

If services are to continue beyond September 4, 2003;
Submit 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. If the member appears no longer eligible for MaineCare, it is the responsibility of the home health provider to issue a discharge notice prior to referring the member to Goold for an assessment.

Example #2: Prior authorized eligibility 3/30/03-9/30/03 approved by Goold. Certification periods: 3/03-5/03, 5/03-7/03, 7/03-9/03.

If at anytime after September 1, 2003, the HHA 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 Section 40 services are to continue, in this case, beyond September 30, 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.

Example #3: Certification period of 6/15/03 to 8/15/03. Goold prior authorized eligibility from 2/15/03 to 8/15/03.

A request to Goold for a revision to extend the PA for 60 days to 10/15/2003 is required.
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.

Occupational Therapy, Physical Therapy, and Speech & Language Therapy

There is no change in procedures for receiving 20 visits for physical or occupational, or 35 speech and language therapy visits each SFY without prior authorization.

Example #4: Certification for period of 6/9/03 to 8/9/03 for PT 1-2 times weekly. As of July 1, 2003 a new benefit period begins. PA not required until 20 visits have been provided in each fiscal year. In this case, the member may get, if eligible, twenty PT visits after July 1, 2003, even though some visits were previously used in SFY 2003. A new certification and updated admit/start of care form must be submitted to BEAS for data entry into the claims system. This is only required if PT will extend beyond August 9, 2003 in this example.

Psychiatric MedicationProcedures do not change for members who are eligible under Section 40.02-4, for psychotropic medication services. Home health agencies should continue to submit a new admit/start of care form, as well as a Section 17 certification form for psychotropic medication administration or monitoring. BEAS will endter eligibility date from July 1, to August 31, 2003. Section 17, Community Support Services policy has changed effective July 1, 2003 and there are new requirements for eligibility under this revised policy. The Section 17 certification required for psychiatric medication services under Section 40 requires the certification to be completed by someone within their scope of licensure as described in Section 17.09-1C or D. BDS is revising the certification form. This mailing included a copy of the new Section 17 rules. Any home health service in addition to the psychotropic medication benefit requires prior authorization from Goold.

Example #5: Member receives psychotropic medication services and has been provided ongoing home health services to meet this need. As of July 1, 2003, if services are to continue, submit a new of Admit/Discharge form to BEAS with a new Section 17 certification and the current HCFA 485. This allows BEAS to reenter the classification into the claims system to avoid any gaps in reimbursement. BEAS will enter a reassessment end date of August 31, 2003.

This extension will allow home health agencies to review Section 17 and prepare to complete the Section 17 certification based on the new eligibility criteria for Section 17. These forms are reviewed and Department staff will follow-up with HHA whenever necessary. If the member has been receiving psychotropic medication services over a long period of time it may be appropriate to transfer the member to Section 96, Private Duty Nursing & Personal Care Services.

New forms and letters will be sent out to home health providers and posted on the Bureau of Elder and Adult Services website at www.maine.gov/dhs/oes/homehealth. The final rules, Chapters II & III, Section 40, Home Health Services, are available online at: www.maine.gov/bms/rulemaking/

If you have any questions regarding this policy, please contact Michelle Quintal, Provider Relations Specialist at 287-9270, or 1-800-321-5557, option 9 or TDD/TTY: (207) 287-1828 or 1-800-423-4331.

Thank you for your continued service to MaineCare members.

cc: Mollie Baldwin, Manager, Long Term Care, OES

cc: Michelle Quintal, Bureau of Medical Services

Office information

Medical Assessments: MaineCare Benefits

Occupational Therapy, Physical Therapy, and Speech & Language Therapy