CurrentAlabama MedicaidPolicy N/A

Home Health — Coverage Criteria

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State rules governing eligibility, provider participation, covered and noncovered home health services, certification/recertification, visit limits, and billing for Alabama Medicaid home health programs. Applies to participating home health agencies, ordering clinicians, and Medicaid recipients in Alabama.

Policy Summary

PayerAlabama Medicaid

PolicyHome Health — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateDec 14, 2020

Last ReviewOct 20, 2020

Next Review DateN/A

Key ActionObtain a written order and Medicaid authorization after the required face-to-face visit before providing home health services.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

104annual visit limit

60 daysrecertification interval

90d before / 30d afterface-to-face timing

60 daysRN supervisory interval

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CurrentAlabama MedicaidPolicy N/A

Home Health — Coverage Criteria

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Sign up for all Alabama Medicaid policy alerts

Know when Alabama Medicaid releases new policies or updates existing guidance.

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Policy Summary

PayerAlabama Medicaid

PolicyHome Health — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateDec 14, 2020

Last ReviewOct 20, 2020

Next Review DateN/A

Key ActionObtain a written order and Medicaid authorization after the required face-to-face visit before providing home health services.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

104annual visit limit

60 daysrecertification interval

90d before / 30d afterface-to-face timing

60 daysRN supervisory interval

provider eligibility

Covered Services & Limits

Covered Home Health Services

Covered when ALL of the following are met

Eligibility and clinical necessity: Recipient is Medicaid-eligible and there is a reasonable expectation that the patient's medical, nursing, and social needs can be met in the home; the recipient's illness, injury, or disability prevents attendance at a physician's office, clinic, or other outpatient setting for required treatment and without treatment would likely require hospital or nursing home admission

Admission criteria per state rule

Order and authorization: An initial written prescription/order for home health services is signed by a physician licensed in Alabama or an authorized non-physician practitioner after the required face-to-face visit, and services are authorized by Medicaid prior to provisionface-to-face within 90 days before to 30 days after start

Ordering clinician must document clinical findings of the face-to-face visit in the recipient's medical record and provide written documentation to the home health provider; ordering clinician must be an active Alabama Medicaid provider

Service type and supervision: Covered services include part-time or intermittent skilled nursing (registered nurse), LPN services (when supervised by an RN), and home health aide/orderly services as specified in the plan of care; restorative, preventive, maintenance, and supportive services are coveredRN supervision >= every 60 days when LPN/aide/orderly provide services

RN responsible for nursing care plan and must perform supervisory on-site visits at least every 60 days

Recertification: The ordering physician or authorized NPP must recertify home health care if services continuerecertify every 60 days

Home Health Certification forms and recertifications must be completed and retained by the home health agency; records are subject to audit

The policy lists specific visit types that are not covered under Alabama Medicaid Home Health. Visits by paramedical personnel, physical therapists, speech therapists, occupational therapists, and inhalation therapists are not covered. Additionally, sitter services, private duty nursing, medical social workers, and dietitians are not covered under the Medicaid Home Health plan. Providers should ensure services fall within covered professional categories before billing Medicaid.

On-site supervisory visits by a registered nurse that are performed solely to evaluate the appropriateness of services provided by an LPN, home health aide, or orderly are considered administrative costs to the home health agency and may not be billed as skilled nursing services. The policy also requires the RN to provide and document on-site supervision of LPNs, aides, or orderlies at least every 60 days, with more frequent supervision if complaints or performance concerns arise. Agencies must document these supervisory contacts in the patient case record but should not bill them as skilled nursing visits.

Home health care visits for Medicaid recipients are limited to one hundred four (104) visits per calendar year. Visits that exceed this annual limit are not covered and may be denied. Agencies and ordering clinicians must monitor cumulative visit counts and obtain any necessary transition planning prior to reaching the limit.

Visit Limits, Recertification, and Face-to-Face Timing

inv-05: Annual visit limit — <= 104 visits per calendar year

Annual visit limitMaximum of 104 home health visits per calendar year

Coverage consequenceVisits exceeding 104 per calendar year are not covered and may be denied

DocumentationHome Health Certification form required and records are subject to onsite audits and desk reviews by Alabama Medicaid

inv-06: Recertification interval — recertify every 60 days

Recertification intervalOrdering physician or authorized NPP must recertify care every 60 days if services continue

Form retentionRecertifications must be completed and retained by the home health agency

Orders, Documentation, Authorization & Denials

Prior Authorization

Medicaid authorization and clinician order required

Services must be ordered by the patient's physician or an authorized non‑physician practitioner (NPP) and authorized by Alabama Medicaid prior to provision; covered nursing and aide services are provided only if ordered and authorized as specified in the rules.

Orders must come from the patient's physician or an authorized NPP.
Medicaid authorization is required before services are provided.

Note

Provider action checklist — orders, authorization, certification, recertification

Complete and timely actions required by providers to ensure payment and compliance: obtain the initial written order after the required face‑to‑face visit, secure Medicaid authorization before services start, complete and retain Home Health Certification forms, and recertify every 60 days while services continue.

Obtain the initial written prescription/order signed by a physician or authorized NPP only after the required face‑to‑face visit (see face‑to‑face timing).

Program Background

Alabama Medicaid Home Health provides part-time or intermittent skilled nursing and home health aide services for Medicaid-eligible recipients whose medical, nursing, and social needs can be met in the home and who would otherwise be at risk of institutionalization. Covered services include restorative, preventive, maintenance, and supportive care when ordered by an authorized clinician and authorized by Medicaid. Providers must follow certification, face-to-face, supervision, and visit-limit requirements to ensure services meet program rules and remain payable.

Key Definitions

inv-15: Home health agency definition — public, private non-profit, or proprietary agency primarily engaged in providing part-time or intermittent skilled nursing services.

DefinitionA public agency, private non-profit, or proprietary agency primarily engaged in providing part-time or intermittent skilled nursing services and home health aide services to patients in their homes

Certification requirementProvider must be certified for Medicare and by the Alabama Department of Public Health

Service scopeProvides part-time or intermittent skilled nursing and home health aide services as specified in the written plan of care

inv-16: Admission criteria — Recipient's condition prevents attendance at outpatient settings and would likely require hospital/nursing home admission without home health.

Admission necessityRecipient's illness, injury, or disability prevents attendance at a physician's office, clinic, or other outpatient setting for required treatment

Policy Summary

PayerAlabama Medicaid

PolicyHome Health — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateDec 14, 2020

Last ReviewOct 20, 2020

Next Review DateN/A

Key ActionObtain a written order and Medicaid authorization after the required face-to-face visit before providing home health services.

SourceLink

On This Page

Regulatory referenceSee Rule No. 560-X-12-.08 (7) for recertification requirement

inv-07: Face-to-face timing window — must occur no more than 90 days before or 30 days after start of service

Face-to-face timing windowRequired face-to-face visit must be conducted no more than 90 days before or 30 days after the start of service

Visit purposeFace-to-face visit must be related to the primary reason the recipient requires home health services

Documentation requirementOrdering physician or NPP must document clinical findings of the face-to-face visit in the recipient's medical record and provide written documentation to the home health provider

Submit for and receive Medicaid authorization before providing services.

Complete and retain the Medicaid Home Health Certification form; if the recipient is discharged from an institution and referred back to home health, complete a new Certification form.

Recertify care every 60 days if services continue.

Documentation Required

Document face‑to‑face clinical findings

The ordering physician or authorized NPP must document the clinical findings of the required face‑to‑face visit in the recipient's medical record and provide written documentation to the home health provider justifying that the recipient meets home health criteria.

Document clinical findings of the face‑to‑face visit in the recipient's medical record.
Provide written documentation to the home health provider that justifies home health eligibility.

Documentation Required

Certification and 60‑day recertification — retain records

Home Health Certification forms must be completed and retained by the home health agency; the ordering physician or NPP must recertify care every sixty (60) days while services continue. Records are subject to onsite audits and desk reviews by Alabama Medicaid.

Complete and retain the Medicaid Home Health Certification form for each episode of care.
Recertify every 60 days if home health services continue.
Maintain records for potential onsite audits and desk reviews by Alabama Medicaid.

Prior Authorization

Initial written order must follow required face‑to‑face visit (90/30 window)

An initial written order for home health services must be signed by a physician licensed in Alabama or an authorized NPP only after the required face‑to‑face visit; the face‑to‑face must occur no more than 90 days before or 30 days after the start of service and must be related to the primary reason for home health.

Initial prescription/order signed only after required face‑to‑face visit.
Face‑to‑face timing window: within 90 days before to 30 days after start of service.
Face‑to‑face visit must relate to the primary reason the recipient requires home health; telehealth is permitted.

Denial Risk

Annual visit limit — 104 visits/year (denial risk)

Home health visits are limited to one hundred four (104) visits per calendar year; services beyond this annual limit are not covered and may be denied.

Limit: 104 visits per calendar year.
Claims for visits exceeding 104 in a calendar year are not covered and may be denied.

Risk without treatmentWithout treatment the recipient would, in all probability, require admission to a hospital or nursing home due to complications

Functional supportRecipient is unable to function without supportive devices (e.g., crutches, cane, wheelchair, walker) and may require special transportation or assistance