ModifiedKansas Department of Health and EnvironmentPolicy N/A

Home Health Benefits — Coverage Criteria

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Defines Kansas Medicaid home health services coverage, program management, utilization, and recommendations for beneficiaries and providers receiving skilled nursing, home health aide, and therapeutic services in the home.

Policy Summary

PayerKansas Department of Health and Environment

PolicyHome Health Benefits — Coverage Criteria

Policy CodePolicy N/A

Change TypeMaterial updates to prior authorization, visit limits, and reimbursement (proposed and implemented)

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization for HCBS beneficiaries and for non-HCBS beneficiaries receiving more than two telehealth visits per week; include HCBS waiver and attendant choice information on PA requests.

SourceLink

POLICY UPDATE CHANGES

A telehealth policy implemented November 1, 2007 requires prior authorization for home telehealth visits for HCBS beneficiaries and for non-HCBS beneficiaries receiving more than two telehealth visits per week.

Prior authorization request form was modified in January 2008 to capture HCBS waiver information and beneficiary choice of self-directed or agency-directed attendant services.

Proposed program structure to distinguish acute versus long-term home health benefits including limits (e.g., 120 visits for acute care) and different reimbursement rates.

Limit on routine home health aide visits without prior authorization to two visits per week for non-HCBS beneficiaries.

Proposed reimbursement increase for the first 15-minute acute home health visit (G0154) from $30 to $35.

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ModifiedKansas Department of Health and EnvironmentPolicy N/A

Home Health Benefits — Coverage Criteria

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Sign up for all Kansas Department of Health and Environment policy alerts

Know when Kansas Department of Health and Environment releases new policies or updates existing guidance.

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Policy Summary

PayerKansas Department of Health and Environment

PolicyHome Health Benefits — Coverage Criteria

Policy CodePolicy N/A

Change TypeMaterial updates to prior authorization, visit limits, and reimbursement (proposed and implemented)

Effective DateN/A

Next Review DateN/A

SourceLink

POLICY UPDATE CHANGES

Prior authorization request form was modified in January 2008 to capture HCBS waiver information and beneficiary choice of self-directed or agency-directed attendant services.

Proposed program structure to distinguish acute versus long-term home health benefits including limits (e.g., 120 visits for acute care) and different reimbursement rates.

Limit on routine home health aide visits without prior authorization to two visits per week for non-HCBS beneficiaries.

Proposed reimbursement increase for the first 15-minute acute home health visit (G0154) from $30 to $35.

145avg agencies

~5,000beneficiaries (approx.)

730visits/year w/o PA

1visits/day w/o PA

120proposed acute limit

Nov 1, 2007telehealth PA start

Coverage and Visit Authorization

Standard coverage and visit authorization

Covered when ALL of the following are met

General home health coverage: Services are skilled nursing, home health aide, and therapeutic skilled services provided in the beneficiary's place of residence per 42 CFR 440.70.

Skilled nursing requires a physician's order; home health aide services must be supervised by an RN and supported by a nursing care plan; supervisory visits for aides are required at least every two weeks when patient is under a skilled plan of care.

Visit limits without prior authorization: One skilled nursing visit and one home health aide visit per day are allowed without prior authorization; Kansas allows a maximum total of at least 730 visits per year without prior authorization.1 per day; 730 per year

Prior authorization is required for multiple skilled nursing visits per day and for individuals on HCBS waivers.

Telehealth coverage

Telehealth visits are covered when ALL of the following are met:

Telehealth coverage criteria: The home telehealth visit provides a skilled nursing service or frequent monitoring of an unstable chronic condition; the plan of care documents the need for skilled-level monitoring or assessment; and the visit supplements (does not substitute) face-to-face home health services provided by an RN or LPN.

Prior authorization is required for telehealth visits for HCBS beneficiaries and for non-HCBS beneficiaries who receive more than two telehealth visits per week; telehealth visits are no longer approved for non-skilled services.

Acute vs Long-term benefit criteria (proposed)

Acute home health services are covered under these proposed constraints:

Acute care criteria: Services meet medical necessity for an acute skilled need; total visits billed as acute home health do not exceed 120 visits without transition to the long-term benefit; and prior authorization documents efforts to promote beneficiary/caregiver independence and exploration of alternative resources.120 visits

If acute visits exceed 120, beneficiaries would transition to a long-term home health benefit with different (lower) reimbursement and designated long-term billing codes.

Home health aide visit limits

Home health aide visits without prior authorization are limited as follows:

Aide visit limit: Non-HCBS beneficiaries may receive up to two home health aide visits per week without prior authorization; home health aide visits are intended to assist with activities of daily living (bathing, toileting, grooming) and related supportive tasks.2 visits/week

Home health aide tasks do not include homemaker services such as housekeeping and meal preparation; visits beyond the two-per-week limit require prior authorization documenting medical necessity.

Place of residence for the purpose of Kansas Medicaid home health coverage does not include nursing facilities, hospitals, or intermediate care facilities for individuals with intellectual disability (ICF/MRs). Home health services apply only when skilled nursing, home health aide, or therapeutic services are delivered in the beneficiary’s private residence as defined in the program.

Services that are primarily homemaker tasks (for example, housekeeping and meal preparation) are not considered home health aide duties and are outside the home health benefit. Providers billing home health aide visits must document that visits deliver covered aide tasks (such as personal hygiene, linen changes, maintenance exercises, medication assistance, vital signs, bowel/bladder procedures, and non‑sterile dressing changes) rather than homemaker or chore services.

For beneficiaries with psychiatric diagnoses, daily oral medication administration alone does not meet medical necessity for skilled nursing. The program has found that administration of oral psychoactive medications as a standalone task does not require the skill of a licensed nurse and therefore is not sufficient to justify skilled nursing visits without additional skilled needs documented.

Home telehealth visits are approved only when they provide a skilled nursing service or frequent monitoring of an unstable chronic condition. Telehealth visits that do not deliver a skilled service or do not meet the frequent‑monitoring threshold are not approved; beginning November 1, 2007 prior authorization is required for telehealth for HCBS beneficiaries and for non‑HCBS beneficiaries receiving more than two telehealth visits per week.

Diagnosis, Procedure Codes and Limits

Top billed ICD codes (primary diagnoses)ICD-10

4019	Unspecified essential hypertension
25002	Diabetes Mellitus without mention of complication, TYPE II OR UNSPECIFIED TYPE, Uncontrolled
25001	Diabetes Mellitus without mention of complication, TYPE I (JUVENILE TYPE), Not stated as uncontrolled
25091	Diabetes with Unspecified Complication, TYPE I (JUVENILE TYPE), Not stated as uncontrolled
25003	Diabetes Mellitus without Mention of Complication, TYPE I (JUVENILE TYPE), Uncontrolled
29590	Unspecified schizophrenia, unspecified condition
4280	Congestive heart failure, unspecified
311	Depressive disorder, not elsewhere classified
29530	Paranoid schizophrenia, unspecified condition

Diagnostic groupingsICD-9

ICD 250-25093	Diabetes (includes Insulin V5867)
ICD 290-319	Mental disorders
ICD 3911-4599	Hypertension/cardiology (circulatory)
ICD 4610-5199	Airway/lung conditions
ICD 707-7099	Skin ulcers/wounds (plus listed trauma ranges in doc)

Mentioned procedure codes and reimbursementHCPCS

G0154

first 15-minute acute home health visit

Reimbursement notesmixed

G0154 Rate

Proposed increase from $30 to $35 for the first 15-minute acute home health visit

Skilled nursing billing codes (general reference)HCPCS

G/T codes

existing codes currently used for skilled nursing visits (referenced generally)

inv-13: Acute home health visit limit — 120 visits

Acute home health visit limit120 visits (acute benefit limit before transition to long-term benefit)

Consequence if exceededBeneficiaries requiring >120 visits receive services through a long-term benefit with different reimbursement

Billing implicationAcute services billed using existing G/T codes; long-term uses designated lower-reimbursed codes

inv-14: Home health aide visits without prior authorization — 2 visits per week

Aide visits without prior authorizationTwo home health aide visits per week allowed for non‑HCBS beneficiaries without prior authorization

Prior Authorization, Documentation, and Provider Responsibilities

Prior Authorization

Prior authorization required for HCBS and multiple daily skilled visits

Prior authorization is required for home health services provided to individuals on HCBS waivers and for beneficiaries receiving multiple skilled nursing visits per day; one skilled nursing visit and one home health aide visit per day are allowed without prior authorization. Kansas allows up to at least 730 total visits per year without prior authorization, but prior authorization is required for the HCBS waiver population and for multiple skilled nursing visits per day.

One skilled nursing visit and one home health aide visit per day allowed without prior authorization.
Prior authorization required for individuals on HCBS waivers.
Prior authorization required for beneficiaries receiving multiple skilled nursing visits per day.
Kansas allows a maximum total of at least 730 visits per year without prior authorization.

Prior Authorization

Proposed expansion of prior authorization (telehealth already PA)

The department proposes expanding prior authorization to all home health services; telehealth already requires prior authorization under the November 1, 2007 policy. Expansion would require PA requests to demonstrate medical necessity, document efforts to promote beneficiary/caregiver independence, and explore other resources for health maintenance tasks.

Policy Background and Program Scope

Home health provides skilled nursing and therapeutic services delivered in the beneficiary’s residence and aligned with Medicare requirements (see 42 CFR 440.70). Skilled nursing requires a physician’s order and the specialized knowledge of an RN or LPN; home health aide services must be supervised by an RN, with a documented nursing care plan and periodic supervisory visits to support aide activities.

Key Definitions

inv-26: Home health agency — Definition of agency.

DefinitionA public or private organization primarily engaged in providing skilled nursing and other therapeutic services; where applicable must be licensed or approved under state or local law

Primary functionsProvides skilled nursing, therapeutic services, and may arrange services through contracted staff

Licensing requirementAgency must be licensed under state or local law or approved by the licensing agency as meeting conditions of participation where applicable

inv-27: Home health visit — Definition of a visit.

DefinitionAn episode of personal contact with the beneficiary by staff of the home health agency or others under arrangements with the agency for the purpose of providing a covered service

Purpose

Policy Summary

PayerKansas Department of Health and Environment

PolicyHome Health Benefits — Coverage Criteria

Policy CodePolicy N/A

Change TypeMaterial updates to prior authorization, visit limits, and reimbursement (proposed and implemented)

Effective DateN/A

Next Review DateN/A

SourceLink

On This Page

Current vs proposed allowance

Current allowance up to 365 aide visits/year will be curtailed under proposed change

Scope of aide tasksHome health aide visits assist with ADLs (bathing, toileting, grooming) and exclude homemaker tasks (housekeeping, meal preparation)

inv-15: Telehealth frequency prior auth threshold — More than 2 telehealth visits per week for non-HCBS beneficiaries

Telehealth prior authorization thresholdPrior authorization required when a non‑HCBS beneficiary receives more than two telehealth visits per week (also required for all HCBS beneficiaries)

Clinical requirement for approvalPlans of care are reviewed and only telehealth visits that require a skilled level of care or frequent monitoring of an unstable chronic condition are approved

Program implementation dateTelehealth prior authorization policy implemented November 1, 2007

Telehealth prior authorization implemented Nov 1, 2007; PA required for HCBS beneficiaries and non-HCBS beneficiaries with >2 telehealth visits/week.
Proposed expansion to require prior authorization for acute and long-term home health services.
PA requests must demonstrate medical necessity and document attempts to promote independence and use of alternative resources.

Documentation Required

Include HCBS waiver, attendant choice, and plan-of-care in PA requests

Providers must submit prior authorization requests that document HCBS waiver participation, indicate whether the beneficiary chooses self-directed or agency-directed attendant services, and include the plan of care documentation supporting skilled need.

Prior authorization request form modified (Jan 2008) to capture HCBS waiver info and beneficiary choice of self-directed vs agency-directed attendant services.
Plans of care must document skilled needs for telehealth approvals.

Step Therapy

Prefer community/alternative resources and self-direction before continued skilled home health

Program changes encourage providers to identify and transition beneficiaries to alternative community resources (e.g., Community Mental Health Centers) and to use self-directed HCBS attendants where appropriate before approving continued skilled agency home health services.

Multiple daily skilled nursing visits for oral medication administration may be more appropriately provided by Community Mental Health Centers.
Self-direction (K.S.A 65-6201) permits beneficiaries to choose attendants and may reduce need for skilled nursing visits.

Documentation Required

Submit nursing care plan, physician orders, and supervisory visit documentation

A nursing care plan that outlines specific duties of the home health aide is required, must be returned to the physician for approval, and supervisory visits by an RN are required at least every two weeks when the patient is under a skilled service plan of care. Skilled nursing services require a physician's order.

Nursing care plan outlining aide duties is required and returned to the physician for approval.
Skilled nursing services require a physician's order.
Supervisory visit of a home health aide required at least every two weeks under a skilled plan of care.

Documentation Required

PA documentation must show HCBS waiver status and attendant selection

Prior authorization requests must include HCBS waiver participation and the beneficiary's choice of self-directed versus agency-directed attendant services; plans of care must document skilled need to support approvals.

PA form captures HCBS waiver services and beneficiary choice of self-directed or agency-directed attendant (modified January 2008).
Documentation should demonstrate skilled level of care for telehealth and other services subject to PA.

Denial Risk

PA triggers: HCBS participants and multiple daily skilled visits (denial risk if missing)

Requests that trigger prior authorization include services for individuals on HCBS waivers and requests for multiple skilled nursing visits per day; lack of prior authorization or failure to demonstrate medical necessity may result in denial or post-pay review.

Multiple skilled nursing visits per day require prior authorization.
HCBS waiver recipients require prior authorization.
Lack of PA or documented medical necessity has led to discontinuation and denials (including telehealth).

Prior Authorization

Telehealth PA required; missing PA or skilled documentation risks denial

Prior authorization is required for home telehealth visits for HCBS beneficiaries and for non-HCBS beneficiaries who receive more than two telehealth visits per week; when prior authorization or documentation of skilled need is lacking, telehealth services were discontinued and claims were denied.

Telehealth policy (Nov 1, 2007) requires PA for HCBS beneficiaries and non-HCBS beneficiaries with >2 telehealth visits/week.
Plans of care are reviewed and only those requiring skilled care or frequent monitoring of unstable chronic conditions are approved.
Telehealth visits not supported as skilled have been discontinued and resulted in reduced expenditures.

Denial Risk

PA required for services beyond aide and acute visit limits; exceeding limits risks denial

Under proposed program changes, prior authorization will be required for acute and long-term home health services; services that exceed allowed aide visit limits (e.g., beyond two aide visits per week without PA) or exceed 120 acute visits without transition to long-term benefit risk denial or reclassification.

Limit acute care to 120 visits; beyond that beneficiaries move to long-term benefit with different reimbursement.
Non-HCBS beneficiaries will be allowed only two home health aide visits per week without express prior authorization; visits beyond this require PA.
Services beyond allowed aide visits or beyond 120 acute visits without appropriate PA risk denial or reclassification.

Conducted to deliver a covered skilled nursing or therapeutic service as described in the plan of care

Providers who may performStaff of the home health agency or others under arrangements with the home health agency

inv-28: Home telehealth visit — Definition: interactive audio/video by RN/LPN to supplement face-to-face services.

DefinitionA visit via interactive audio and video telecommunications systems by a registered nurse or licensed practical nurse to supplement face-to-face home health services (not substitute)

Approval criteriaPrior authorization required for HCBS beneficiaries and for non‑HCBS beneficiaries receiving >2 telehealth visits/week; plans of care must show skilled need or frequent monitoring

Reimbursement noteTelehealth reimbursement aligned to a 15‑minute in‑home skilled nursing visit after policy implementation

inv-29: Home health aide — Definition of aide tasks.

DefinitionHome health aide tasks include personal hygiene, linen changes, maintenance exercises, medication assistance, vital signs, bowel/bladder procedures, and non‑sterile dressing changes

ExclusionsDoes not include homemaker tasks such as housekeeping and meal preparation (these fall under HCBS waivers)

Supervision requirementHome health aide services require RN supervision and a nursing care plan with periodic supervisory visits

inv-30: Self-directed caregiver (K.S.A 65-6201) — Self-direction allowances under Kansas statute permit performance of health maintenance activities by beneficiaries' chosen caregivers.

Statutory referenceK.S.A. 65-6201 permits self‑directed caregivers to perform health maintenance activities that beneficiaries could safely perform for themselves if not for their disability

Effect on service choiceSelf-direction allows beneficiaries to choose attendants and may expand services self‑directed caregivers can provide compared to agency‑directed attendants

Impact on prior authorizationPrior authorization forms were modified to capture beneficiary choice of self‑directed vs agency‑directed attendant services and HCBS waiver participation