Alabama Administrative Code Chapter 560-X-12 — Home Health

560 Alabama Medicaid Agency

Ala. Admin. Code r. 560-X-12-.01 Home Health Care-General

(1) Alabama Medicaid Home Health Care services are available for all Medicaid eligible persons of any age who meet the admission criteria on the basis of a reasonable expectation that a patient's medical, nursing, and social needs can adequately be met in the patient's place of residence.

(2) Anyone may refer a person who is in need of home health care, under the care of a physician, and in need of part-time nursing, to a participating agency.

History

• Author: Georgette Harvest, Associate Director, Project Development/Policy Unit, Long Term Care Division
• Authority: Title XIX, Social Security Act; 42 C.F.R. 9440.70; State Plan.
• Rule effective October 1, 1982. Amended: Filed February 5, 2001; effective March 12, 2001.

Ala. Admin. Code r. 560-X-12-.02 Admission Criteria

(1) To be eligible for home health care, a recipient must meet all of the following criteria:

(a) The recipient’s illness, injury, or disability prevents the recipient from going to a physician’s office, clinic or other outpatient setting for required treatment; as a result, he or she would, in all probability, have to be admitted to a hospital or nursing home because of complications arising from lack of treatment.

(b) The recipient is unable to function without the aid of supportive devices, such as crutches, a cane, wheelchair or walker and requires the use of special transportation or the assistance of another person.

History

• Author: Mattie Jackson, Program Manager, Program Management Unit, Long Term Care Division
• Authority: Titles XVIII and XIX, Social Security Act; 42 C.F.R. §440.70; State Plan.
• Rule effective October 1, 1982. Amended effective December 12, 1988. Amended: Filed February 5, 2001; effective March 12, 2001. Amended: Filed May 11, 2012; effective June 15, 2012.

Ala. Admin. Code r. 560-X-12-.03 Provider Requirements For Participation

(1) Only instate agencies are eligible for participation.

(2) A home health agency is a public agency, private non-profit organization or proprietary agency which is primarily engaged in providing part-time or intermittent skilled nursing services and home health aide services to patients in their homes.

(3) To become a Medicaid home health care provider, the home health agency must:

(a) Be certified to participate as a Medicare provider;

(b) Be certified by the Division of Health Care Facilities of the Alabama Department of Public Health as meeting specific statutory requirements and as meeting the Conditions of Participation;

(c) Request in writing to Alabama Medicaid Agency (Medicaid) to become a provider of Medicaid home health care, and enclose a copy of the agency's most recent cost study report showing discipline costs; and

(d) Agree to sign and to comply with the terms set forth in the agreement with Medicaid.

(4) Medicare cost reports must be available for review by the Alabama Medicaid Agency upon request.

(5) A copy of any Medicare audit adjustment or settlement must be submitted to Medicaid within thirty (30) days of receipt by the home health agency.

History

• Author: Priscilla Miles, Associate Director, LTC Program Management Unit
• Authority: Title XIX, Social Security Act; 42 C.F.R. §440.70; State Plan.
• Rule effective October 1, 1982. Amended effective February 9, 1988; September 9, 1988. Amended: Filed November 21, 2002; effective December 26, 2002.

Ala. Admin. Code r. 560-X-12-.04 Provider Termination And/Or Change Of Ownership

(1) A participating agency has the right to withdraw from the Medicaid program after giving written notice to Medicaid of its intent at least thirty (30) days in advance.

(2) The state may terminate the home health agency's participation in the Medicaid program in cases involving fraud or willful or grossly negligent noncompliance.

(3) Medicaid must be notified in writing within thirty (30) days of the date of agency owner and/or name change. The existing contract will be terminated and a new contract must be signed if the agency desires to continue participation in the Medicaid program.

History

• Authority: Title XIX, Social Security Act; 42 C.F.R. §434.6; State Plan.
• Rule effective October 1, 1982.

Ala. Admin. Code r. 560-X-12-.05 Covered Services

(1) If ordered by the patient's physician or non-physician practitioner (NPP), and authorized by Medicaid, a professional registered nurse employed by a certified home health agency can provide part-time or intermittent nursing services to a patient.

(a) The registered nurse is responsible for a nursing care plan, which is made in accordance with the written plan of care.

(b) Restorative, preventive, maintenance, and supportive services are covered.

(2) Licensed Practical Nurse Services.

(a) If ordered by a patient's physician or NPP, a licensed practical nurse, supervised by a professional registered nurse, employed by a participating home health agency, can provide intermittent or part-time nursing services to the patient when assignment is made by the professional registered nurse.

(b) LPN services are assigned and provided in accordance with existing state law.

(3) Home Health Aide/Orderly Services.

(a) A home health aide/orderly can provide personal care and services as specified in the plan of care.

(b) These services can be provided on a part-time basis only when they are supervised by the nurse who is responsible for the care of the patient and services are authorized by Medicaid.

(4) Supervisory visits by the registered nurse must be performed at least every 60 days when services are provided by the LPN, home health aide, or orderly.

History

• Author: Renee Adams, Administrator, LTC Program Management and Support Unit
• Authority: Title XIX, Social Security Act; 42 C.F.R. §441.15; State Plan.
• Rule effective October 1, 1982. Amended effective August 9, 1985. Amended: Filed November 8, 2006; effective December 13, 2006. Amended: Published October 30, 2020; effective December 14, 2020.

Ala. Admin. Code r. 560-X-12-.06 Noncovered Services

(1) There is no coverage under the Medicaid Home Health care plan for visits by paramedical personnel, physical therapists, speech therapists, occupational therapists, and inhalation therapists.

(2) Sitter service, private duty nursing service, medical social workers, and dietitians are not covered by Medicaid.

(3) Supervisory visits made by a professional registered nurse to evaluate appropriateness of services being rendered to a patient by an LPN, aide, or orderly and considered as administrative cost to the agency and may not be billed as skilled nursing services.

(4) The registered nurse will provide and document in the case record on-site supervision of the LPN, home health aide, or orderly at least every 60 days. The registered nurse will conduct on-site supervision more frequently if warranted by complaints or suspicion of substandard performances by the worker.

History

• Author: Samantha McLeod, Administrator, LTC Program Management Unit
• Authority: Title XIX, Social Security Act; 42 C.F.R. §441.15; State Plan.
• Rule effective October 1, 1982. Amended: Filed November 8, 2006; effective December 13, 2006.

Ala. Admin. Code r. 560-X-12-.07 Supplies, Appliances, And Equipment

(1) Such items as are specified by Medicaid are available for use in the home.

(2) See the chapter covering supplies, appliances, and durable medical equipment for further information.

History

• Authority: Title XIX, Social Security Act; 42 C.F.R. §440.70; State Plan.
• Rule effective October 1, 1982.

Ala. Admin. Code r. 560-X-12-.08 Certification And Recertification

(1) An eligible Medicaid recipient may be considered for home health services (i.e., nursing services and home health aide services) upon the initial written prescription or order signed and place by a physician licensed in the State of Alabama or an authorized non-physician practitioner (NPP).

(2) The ordering physician or NPP must sign and place the initial prescription or order for home health services only after the required face-to-face visit with the recipient is conducted.

(3) Subsequent written prescriptions or orders for refills, ancillary supplies, repairs or services, or re-certifications do not require the ordering physician’s or NPP’s signature or an additional face-to-face visit.

(4) Either an authorized physician or one of the following authorized non-physician practitioners working under a collaborative agreement under Alabama law must conduct the required face-to-face visit and write the initial prescription or order for home health services:

(a) Certified registered nurse practitioners or clinical nurse specialists;

(b) Certified nurse midwifes;

(c) Physician assistants (PA) under the supervision of the physician; or

(d) Attending acute or post-acute physicians, if recipients are admitted to home health services immediately after discharge from an acute or post-acute stay.

(5) The physician or NPP must document the clinical findings of the required face-to-face visit for the initial written prescription or order for home health services in the recipient’s medical record.

(6) The required face-to-face visit for the initial written prescription or order for home health services must be conducted no more than 90 days before or 30 days after the start of service. The face-to-face visit must be related to the primary reason why the recipient requires home health services. The ordering physician or NPP must provide written documentation to the home health provider regarding the recipient’s condition, which justify that the recipient meets home health criteria. The ordering physician or NPP must be an active Medicaid provider licensed in the State of Alabama. The required face-to-face visit may be conducted using telehealth systems.

(7) The ordering physician or NPP must recertify care every sixty (60) days if home health services continue to be necessary.

(8) For more information on the requirements for placing the initial written prescription or order for certain medical supplies, equipment, and appliances, please refer to Chapter 13—Durable Medical Equipment (DME), Supplies, Appliances, Prosthetics, Orthotics and Pedorthics (POP).

History

• Author: Renee R. Adams, Program Manager, Home Health, Long Term Care Division
• Authority: Title XIX, Social Security Act; 42 C.F.R. §440.70; State Plan.
• Rule effective October 1, 1982. Amended: Filed February 5, 2001; effective March 12, 2001. Amended: Filed February 10, 2017; effective March 27, 2017. Amended: Filed August 10, 2018; effective September 24, 2018. Amended: Published October 30, 2020; effective December 14, 2020.

Ala. Admin. Code r. 560-X-12-.09 Visits

(1) A visit is a personal contact in the place of residence of a patient made for the purpose of providing a covered service by a health worker on the staff of a certified Medicaid home health agency.

(a) Home health care visits to Medicaid recipients must be medically necessary and in accordance with a Medicaid Home Health Certification form established by a licensed physician or non-physician practitioners (NPP). Home Health records are subject to onsite audits and desk reviews by the professional staff of the Alabama Medicaid Agency.

(b) Home health care visits are limited to one hundred four (104) per calendar year.

(2) If a Medicaid recipient receiving home health visits is institutionalized and is referred to home health upon discharge from the institution, a new Medicaid Home Health Certification form must be completed and retained by the home health agency.

History

• Author: Ruth Chambliss, Christine Luna, Theresa D. Richburg
• Authority: Title XIX, Social Security Act; 42 C.F.R. §441.15; State Plan.
• Rule effective October 1, 1982. Amended effective July 8, 1983; January 8, 1986; January 13, 1988; February 9, 1989. Amended: Published October 30, 2020; effective December 14, 2020.

Ala. Admin. Code r. 560-X-12-.10 Medicare/Medicaid Eligible Recipients

(1) Persons eligible for Medicare and Medicaid are entitled to all services available under both programs, but a claim must be filed with Medicare if the services are covered by Medicare. A patient may not receive home visits under both programs simultaneously. If Medicare terminates coverage, Medicaid may provide visits.

(2) Medicare deductibles and co-insurance amounts for eligible Medicare/Medicaid recipients are not applicable for Home Health services. (Section 930 - PL 96-499)

History

• Authority: Title XIX, Social Security Act; 42 C.F.R. §431.625; State Plan.
• Rule effective October 1, 1982.

Ala. Admin. Code r. 560-X-12-.11 Billing Of Medicaid Recipients By Providers

(1) The Home Health Agency agrees to accept as payment in full the amount paid for covered home health services, and cannot make any additional charges to the recipient, sponsor, or family of the recipient.

(2) Medicaid recipients may be billed by providers for noncovered services. See Rule 560-X-12-.06 for a listing of noncovered services.

(3) Medicaid recipients may be billed for home health services provided by agencies which do not have a contract with the Alabama Medicaid Program.

History

• Author: Henry C. LeCroy
• Authority: Title XIX, Social Security Act; 42 C.F.R. §447.15; State Plan.
• Rule effective July 9, 1984.