A Summary of Proposed rules to revise Medicaid Home Health Service definition as required by section 6407 of the Affordable Care Act

Summary of CMS Document dated JULY 12, 2011 entitled: “Improving Regulations and Regulatory Review”

FY2012 Medicaid Proposed Rule

Proposes to amend Medicaid Home Health Services regulations to clarify face-to-face requirements (section 6407 of the ACA) as well as “definitions of included medical supplies, equipment and appliances, and clarify that states may not limit services delivered in the home, or to services furnished to individuals who are home-bound”.

Gen. info:

“Title XIX the Social Security Act requires that, in order to receive Federal Medicaid matching funds, the state must offer certain basic services to the categorically needy populations specified in the Act. Home health care for Medicaid eligible individuals who are entitled to nursing facility services is one of these mandatory service. These regulations require an individual’s physicians to order home health services as part of a written plan of care reviewed every 60 days… Section 6407 of the patient protection and Affordable Care Act of 2010 as amended by section 10605 affects the home health benefit under both the Medicare and Medicaid programs”.

A.       Home Health Services as it applies to the Olmsted Act:

1.        May not be limited to “homebound” clients. Must be “suitable for use in any non-institutional setting in which normal life activities take place”.

2.       Must have face t o face encounter with medical practitioner to be defined as Physician, Physician Assistant, Nurse Practitioner and Clinical Nurse specialist. Not to be done by a Nurse Midwife. This encounter must occur 90 days prior to or 30 days after start of services. This is a written plan of care to be relavent for the recipient’s need for services.

3.       DME terminology to change to define supplies as “healthcare related items that are consumable or disposable, or cannot withstand repeated use by more than one individual” (take catheters for example). Medical equipment and appliances are further defined as “items that are primarily and customarily used to serve a medical purpose, generally not useful to an individual in the absence of an illness or injury, can withstand repeated use, and can be reusable or removed” ( ex. wheelchairs, shower chairs, hospital beds, hoyer lifts, etc)

Comments:

The clarification that services may not be limited to homebound clients is essential to providing appropriate services to individuals who wish to partake in activities in the community whether it be for recreational or vocational purposes. Potentially essential products such as wheelchairs or any assistive mobility devices are necessary not only for individuals to function in the home but to carry out activities of daily living while out of home and in the community. This terminology advances the integration of the Olmstead decision by allowing disabled individuals to be entitled to any services they require in any non-institutionalized setting.

Requirements for face-to-face encounters with an individual’s Physician or Non-Physician Practitioner for approval of home health services 90 days prior where 30 days after administration will allow for the most up-to-date patient information to be incorporated in their plan of care.

Finally, the clarifications of durable medical equipment as “healthcare related items that are consumable or disposable, or cannot withstand repeated use by more than one individual” is essential, and the first real-life example that comes to mind would be the way in which it would help individuals who use intermittent catheterization kits, and who need a steady supply of sterile material. Currently many individuals in need of disposable urological devices are left with limited supplies further increasing the risk of infection due to overuse of materials which are intended for one-time use. Furthermore having Medical equipment and appliances defined as “items that are primarily and customarily used to serve a medical purpose, generally not useful to an individual in the absence of an illness or injury, can withstand repeated use, and can be reusable or removed” would allow individuals in need of certain devices greater chances of approval. For example an individual with extreme mobility issues in need of transfers into a wheelchair may require a ceiling track lift similar to those used in nursing home facilities for ease and safety during transfers on part of the caregiver as well as the recipient of care.

These overall changes and clarifications to home health services as stipulated by CMS and HHS seem to integrate many aspects of the Olmstead decision in order to restrict states in the way that they defined where and how their home health services and equipment are provided in order to allow individuals with disabilities to receive the services they normally would at home in any non-institutionalized setting which should foster a greater integration of the disabled into the workforce and community.

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