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    v1.0.28
    OpenPayerPolicy UpdatesHome Health & HospiceMississippi Medicaid Home Health Coverage Update |…
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    CurrentMississippi Division of MedicaidPolicy N/A

    Home Health Services Coverage Criteria (Part 215, Chapter 1)

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    Defines covered home health services, eligibility requirements, provider qualifications, visit limits, and out-of-state provisions for beneficiaries under Mississippi Medicaid; affects beneficiaries and home health agencies/providers.

    Policy Summary
    PayerMississippi Division of Medicaid
    PolicyHome Health Services Coverage Criteria (Part 215, Chapter 1)
    Policy CodePolicy N/A
    Change TypeRevised (administrative) — aligns with MS SPA 24-0006
    Effective DateJul 1, 2024
    Last ReviewJul 1, 2024
    Next Review DateN/A
    Key ActionEnsure physician or allowed NPP documents a related face-to-face encounter within 90 days before or 30 days after service start and review/sign recertification every 60 days.
    SourceLink
    POLICY UPDATE CHANGES

    Rule language was revised to correspond with MS SPA 24-0006 effective 07/01/2024.

    36max visits / FY
    60 daysrecertification interval
    90d / 30dface-to-face timing
    60 days

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    RN supervisory visit

    Medically Necessary Home Health Coverage

    Medically Necessary Home Health Coverage Criteria

    Covered when ALL of the following are met

    Covered Services: Service is one of: intermittent or part-time skilled nursing provided by an RN or LPN under RN supervision; home health aide visits provided by an agency-employed aide; durable medical equipment, medical supplies, and appliances as described in Miss. Admin. Code Title 23, Part 209

    RN must be licensed and graduate of an approved school; home health aide must complete MSDH‑approved training; supervisory RN visit for aides every 60 days

    Visit Limit: Total home health visits do not exceed 36 in a state fiscal year<=36 per state fiscal year
    Medical Necessity and Setting: Services are medically necessary and reasonable for treatment of the beneficiary's disability, illness, or injury; beneficiary is unable to travel to an outpatient setting or is too fragile/unstable to receive services in an outpatient setting; services are provided at the beneficiary's place of residence (not a hospital, nursing facility, ICF‑IID except where that facility is not required to provide the service, or any setting where inpatient Medicaid payment for room and board could be made)
    Physician/NPP Involvement: Beneficiary must be seen by a physician or allowed non‑physician practitioner at least every 60 days for recertification; services must be provided pursuant to an order by a physician, nurse practitioner, or physician assistant and a written plan of care reviewed every 60 days; recertification must be signed and dated by the reviewing physician or allowed NPPevery 60 days

    Face‑to‑face encounter must be documented no more than 90 days before or 30 days after start of services and must relate to the primary reason for home health

    Agency Certification and Compliance: Home health agency must be Medicare‑certified and comply with all applicable state and federal laws and requirements

    Out‑of‑state agencies must request a provider number and meet home health agency requirements

    Home health services must be provided at the beneficiary’s place of residence, defined as any setting in which normal life activities take place, except for the following excluded settings: hospital, nursing facility, intermediate care facility for individuals with intellectual disabilities (except when that facility is not required to provide the home health service), and any setting where payment could be made under Medicaid for inpatient services that include room and board. Services furnished in those excluded settings are not covered as home health under this rule.

    Services are not covered unless they are medically necessary and reasonable for treatment of the beneficiary’s disability, illness, or injury. Any home health service that does not meet medical necessity or reasonableness criteria is excluded from coverage.

    Service Categories, Visit Limits, and Codes

    Covered service categoriesmixed
    Skilled nursing visitsIntermittent or part-time skilled nursing services provided during the visit by a registered nurse (RN) or a licensed practical nurse (LPN) under the supervision of a RN employed by a home health agency in accordance with MSDH-DHFLC standards or an RN when no home health agency exists in the area. RN must be a graduate of an approved school of professional nursing and licensed in the state in which they practice.
    Home health aide visitsHome health aide services provided directly by an aide employed by a home health agency in accordance with MSDH-DHFLC standards. Aide must have completed a state-established or other home health aide training program approved by MSDH-DHFLC. Supervisory RN visit required every 60 days. Home health aide services may be provided without requirement of receiving skilled nursing services.
    Durable medical equipment, medical supplies and appliancesDurable medical equipment, medical supplies, and appliances as described in Miss. Admin. Code Title 23, Part 209.
    Visit limitUp to thirty-six (36) home health visits per state fiscal year.
    inv-05: Annual visit limit — 36 home health visits per state fiscal year
    Annual visit limitUp to 36 home health visits per state fiscal year
    ScopeApplies to all covered home health services (skilled nursing, home health aide visits, DME/supplies)
    Counting periodState fiscal year
    Consequence of exceedanceServices may be denied when total home health visits exceed 36 in a state fiscal year

    Provider Requirements, Documentation, and Denial Risks

    Prior Authorization

    Out-of-State Provider Requirements: request provider number and meet home health agency requirements

    Out-of-state home health agencies must request a Mississippi Medicaid provider number and meet all home health agency requirements; reimbursement for services furnished in another state is subject to the residency and medical-necessity rules in the policy.

    • Out-of-state providers are required to request a provider number and meet all home health agency requirements.
    • Reimbursement for services furnished in another state is allowed only when residency and medical-necessity conditions in Rule 1.3.K–L are met (e.g., medical emergency, inability to return to MS without harm, services more readily available out-of-state, customary cross-border use, and beneficiary residency less than 30 days in the other state).
    Step Therapy

    Step therapy: none specified

    No step-therapy requirements are specified in the policy.

    Key Terms

    inv-12: Place of residence — defines acceptable settings where normal life activities take place, excluding institutional settings
    DefinitionAny setting where normal life activities take place
    Exclusions — institutional settingsDoes not include hospitals, nursing facilities, or intermediate care facilities for individuals with intellectual disabilities (except when that facility is not required to provide the home health service)
    Exclusions — inpatient payment settingsExcludes any setting where inpatient Medicaid payment including room and board is possible
    Implication for eligibilityHome health services must be provided at the beneficiary's residence as defined to be covered

    Policy Background and Scope

    Home health services include intermittent or part‑time skilled nursing visits delivered by a registered nurse (RN) or a licensed practical nurse (LPN) under RN supervision; home health aide visits provided directly by agency‑employed aides with completion of an approved training program and supervisory RN visits every 60 days; and covered durable medical equipment, medical supplies, and appliances as described in Part 209. The RN must be a graduate of an approved school of professional nursing and licensed in the state of practice, and agencies must comply with MSDH‑DHFLC standards.

    Policy Changes and Effective Dates

    2024-11-01revisionLatest

    Rule language revised to correspond with MS SPA 24-0006 (effective 07/01/2024).

    2021-07-01revision

    Rule revised (effective 07/01/2021).

    2019-07-01revision

    Rule revised (effective 07/01/2019).

    Policy Summary
    PayerMississippi Division of Medicaid
    PolicyHome Health Services Coverage Criteria (Part 215, Chapter 1)
    Policy CodePolicy N/A
    Change TypeRevised (administrative) — aligns with MS SPA 24-0006
    Effective DateJul 1, 2024
    Last ReviewJul 1, 2024
    Next Review DateN/A
    Key ActionEnsure physician or allowed NPP documents a related face-to-face encounter within 90 days before or 30 days after service start and review/sign recertification every 60 days.
    SourceLink
    On This Page
    Medically Necessary Home Health CoverageService Categories, Visit Limits, and CodesProvider Requirements, Documentation, and Denial RisksKey TermsPolicy Background and ScopePolicy Changes and Effective Dates
    Documentation Required

    Face-to-face encounter timing requirement

    The beneficiary's physician or allowed non-physician practitioner must document a related face-to-face encounter that occurred no more than 90 days before or 30 days after the start of home health services; the encounter must relate to the primary reason the beneficiary requires home health.

    • Face-to-face timing: no more than 90 days before or 30 days after the start of services.
    • Face-to-face must be related to the primary reason for home health services.
    Documentation Required

    Orders and plan of care: physician/NP/PA orders required; 60-day review and signed recertification

    Home health services must be provided pursuant to an order written by a physician, nurse practitioner, or physician assistant as part of a written plan of care; the plan of care must be reviewed every 60 days and recertification must be signed and dated by the reviewing physician or allowed NPP.

    • Orders: written by physician, NP, or PA in accordance with State law.
    • Plan-of-care review interval: every 60 days.
    • Recertification: occurs at plan-of-care review and must be signed and dated by the reviewing physician or allowed NPP.
    Denial Risk

    Denial risk and service limits

    Services may be denied if they are not medically necessary, exceed the limit of 36 home health visits per state fiscal year, are furnished in settings excluded from home health coverage, or if required documentation (face-to-face encounter, orders, plan of care, recertification) is missing or untimely.

    • Visit limit: Division covers up to thirty-six (36) home health visits per state fiscal year.
    • Non-covered settings: hospitals, nursing facilities, intermediate care facilities for individuals with intellectual disabilities (except as noted), or any setting where Medicaid inpatient payment including room and board is possible.
    • Documentation triggers for denial: missing/untimely physician/NPP face-to-face, missing orders or plan of care, or missing/unsigned/undated recertification.