CurrentNeighborhood Health Plan of Rhode IslandPolicy 020

Home Health Care Services - Skilled & Non-Skilled

Defines coverage, eligibility, and service requirements for medically necessary home health care, home care (non-skilled), home health (skilled), and private duty nursing for Neighborhood Health Plan of Rhode Island members across specified lines of business.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyHome Health Care Services - Skilled & Non-Skilled

Policy CodePolicy 020

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionUse Neighborhood's prior authorization request forms on the website and ensure required physician orders and documentation (including a physician‑approved plan of care renewed at least every 60 days) are submitted for authorization.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

3service categories covered

90 daysroutine nursing reassessment

8 hrs/dayintermittent services

35 hrs/wkpart-time threshold

S9097…codes listed

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04/08/26last reviewed

Coverage and Medical Necessity Criteria

Medical necessity criteria for Home Care and Home Health Services

Home Care Services (non-skilled) are reasonable and necessary when ALL of the following are met:

Home Care Services basic criteria: Member's need for care services are due to a physical, intellectual and/or developmental disability that causes a barrier to completing ADLs and/or IADLs.

Assessment-based care planning: Documentation from the member's physician, the home health agency, and/or Neighborhood Care Manager must support evaluation of age, weight, ADL/IADL assistance levels, caregiver availability, hours attending other programs, bowel/bladder continence, mobility, diagnosis impact, and recent/potential readmission.

Regulatory nursing assessments: Nursing assessments and reassessments are required per regulatory requirements: at admission, and with reassessments every ninety (90) days, with changes in condition, or with resumption of care after inpatient admission.every 90 days

Homebound criteria (two-part): Member meets both Criteria 1 and Criteria 2 to be considered homebound: Criteria 1 — needs supportive devices (e.g., crutches, canes, wheelchairs, walkers), special transportation, assistance of another person, or has a condition making leaving home medically contraindicated; Criteria 2 — has a normal inability to leave home and leaving requires considerable and taxing effort due to medical symptoms or use of assistive devices.

Service type definitions: Home health services include part-time or intermittent skilled nursing; skilled rehabilitative therapy (PT/OT/ST); qualified home health aide services when part of a skilled plan of care; medical social services, durable medical equipment, disposable medical supplies used during authorized visits, and nutritional counseling when essential to a skilled plan of care.intermittent = up to 8 hours/day up to 21 days; part-time = <=35 hours/week

Private duty nursing description: Private Duty Nursing (PDN) is individual, continuous skilled nursing care provided by licensed nurses, intended for members with complex medical conditions whose care requires continuous skilled nursing greater than two (2) hours per day and cannot be provided by lower-level personnel.>2 hours/day

Home Health Services - General

Home health care services are covered when they are short-term, prescribed by a treating practitioner, delivered in the member's residence, and aimed at restoring or maintaining maximal function; skilled services must be medically necessary and provided by licensed professionals.

Home Health Services Coverage: Services are prescribed by a treating practitioner (M.D., D.O., P.A., or N.P.), delivered in the member's residence, and intended to help recovery after illness, injury, hospital stay, or surgery, or to manage chronic conditions to prevent or prolong hospitalization; services are provided intermittently to restore or maintain function and must meet InterQual criteria for medical necessity.

Private Duty Nursing (PDN) Criteria

PDN is reasonable and necessary when ALL of the following are met:

PDN All Conditions: (1) There is a physician-approved written plan of care with short- and long-term goals specified that is renewed at least every sixty (60) days; (2) The member can be safely maintained in the home in the absence of nursing care; (3) The member's condition requires continuous skilled nursing care greater than two (2) hours per day that can only be conducted by an RN or LPN according to practice standards; (4) The services provided are reasonable and necessary and within the scope of practice of a licensed nurse; (5) Medical necessity criteria are met within the most recent InterQual Level of Care: Private Duty Nursing (PDN) Assessment.>2 hours/day

PDN regulatory assessments: All regulatory nursing assessments and reassessments will be covered per regulatory requirements: assessment at admission and reassessments every sixty (60) days, with changes in condition, or with resumption of care after inpatient admission.

Coverage and Eligibility

Coverage stance varies by line of business and setting.

Non-covered Benefits for Specific Lines of Business: Home Care Services (personal care, homemaking, combo care) and Private Duty Nursing are not covered benefits for Health Benefits Exchange (HBE), Extended Family Planning (EFP) Members, and Duals CONNECT.

Situations in which services are not covered: Services are not covered if the member is resident in a nursing facility, hospital, or licensed residential care facility; if the member is receiving LTSS waiver services from BHDDH; or if services are provided to anyone other than the member.

Respite coverage limits: Respite or relief care is covered only for INTEGRITY for Duals line of business and for children (20 and younger) in MED, SUB, and CSN lines of business.

IEP services: Services identified in a child's Individual Education Plan (IEP) as necessary for a Free and Appropriate Education (FAPE) are covered by the Local Education Agency/school district, not by Neighborhood.

Provider Requirements

Providers and agencies must meet state regulatory and operational requirements.

State law compliance: Providers must comply with Rhode Island General Laws and applicable Rhode Island Department of Health regulations, including RI General Laws and 210-RICR-20-051, and the RI Medicaid Provider Reference Manual Home & Community Based Services.

Assignment restrictions: Providers may not assign direct care staff to members with whom the staff resides, to members with defined family relationships (parent-child, grandparent-grandchild, sibling, spouse), or to members for whom the staff has guardianship, power of attorney, or is the authorized representative on the member's Medicaid application.

Licensure and travel: Nurses, nursing assistants, and homemakers must be licensed/certified in the state where services are performed; no additional hours may be requested, authorized, or billed specifically for travel; Neighborhood will not approve 2:1 coverage during travel or during transportation.

Transportation and vehicle requirements:

Home health services are not considered to include services provided in institutional settings. Institutional settings — including hospitals, skilled nursing facilities, intermediate care facilities for the developmentally disabled, and other institutional facilities providing medical, nursing, rehabilitative, or related care — are explicitly not considered a 'home setting'. Day care or adult day care settings likewise do not meet the home-setting definition. The policy allows the member's residence to include private homes, apartments, the home of a friend or family member, group homes, homeless shelters, temporary residences, or community settings when the member has established that location as their place of residence for the time services are provided.

Services that are not medically necessary or are excluded include those provided in institutional settings and those that do not include a skilled need. Personal care provided in the absence of a skilled nursing or therapy need is not covered. Custodial services, respite, companionship, general supervision, infant/child sitting, or childcare provided solely to assist a caretaker are excluded. Services are also not covered when a family member or other caregiver already adequately meets the member’s needs, when services can be safely self-administered by a non-medical person, or when the service is provided to anyone other than the member. See the General Exclusions and Limitations for additional non-covered items such as drugs/biologics, ESRD program services, prosthetic devices, and respiratory care services.

Private Duty Nursing (PDN) is not covered when the services are custodial in nature or when care can be provided by a lower-level professional (for example, a CNA). For adult members, PDN requires an approved LTSS-HCBS waiver from EOHHS; adults without an approved waiver are not eligible for PDN. Agencies must follow the policy’s general exclusions and limitations for additional guidance on PDN authorization and coverage.

Transportation is excluded from home health coverage as a separately billable service. Agencies may provide transportation only when incidental to approved plan-of-care services, but no separate payment will be made and no additional hours may be requested or billed specifically for transportation. Any inclusion of transportation in a treatment plan must be directly related to accomplishing approved home care treatment objectives. Providers must meet vehicle, insurance, driver history, and safety requirements when transporting members, and Neighborhood will not approve 2:1 coverage during transportation.

Services consisting solely of general household tasks or homemaker-only support (for example, routine housework) are not covered as skilled home health when there is no temporary caregiver responsibility or other skilled need. Homemaker services that are not an essential part of a skilled home care program are excluded. The policy emphasizes that lack of an available caregiver alone does not make homemaker-only services medically necessary to avoid institutionalization.

Services that can be safely self-administered by a non-medical person without direct supervision and services provided solely for general good or welfare (for example, general exercise programs or diversionary activities) are excluded. Similarly, visits where venipuncture is the only purpose and comparable community care exists are not considered medically necessary. Reimbursement is not available for services provided to anyone other than the member, and parents or legally/financially responsible individuals are not eligible for reimbursement to provide home care services.

Home Care Services (including personal care, homemaking, and combo care) and Private Duty Nursing are not covered benefits for specific lines of business: Health Benefits Exchange (HBE), Extended Family Planning (EFP), and Duals CONNECT. Additionally, services are not covered if the member is a resident of a nursing facility, hospital, or licensed residential care facility, or if the member is receiving LTSS waiver services from BHDDH.

Codes, Billing, and Plan-of-Care Intervals

Home care service HCPCS/CPT-like codes listedHCPCSCovered

S5125	Attendant care services; per 15 minutes.
S5125 U1	Combination of personal care and homemaking performed by a nursing assistant, rendered at the same time, per 15 minutes.
S5125 U1 U9	High Acuity combination of personal care and homemaking, rendered at the same time, per 15 minutes when the Minimum Data Set (MDS) reflects high acuity.
S5130	Homemaker service, NOS; per 15 minutes.
T1001	Nursing assessment/evaluation, per diem.

Other HCPCS-like codesHCPCS

S9097

Home visit for wound care.

Covered CPT/HCPCS CodesmixedCovered

T1030	Nursing care, in the home, by registered nurse, per diem.
T1031	Nursing care, in the home, by licensed practical nurse, per diem.
G0151	Services performed by a qualified physical therapist in the home health or hospice setting, each 15 minutes.
G0152	Services performed by a qualified occupational therapist in the home health or hospice setting, each 15 minutes.
G0153	Services performed by a qualified speech-language pathologist in the home health or hospice setting, each 15 minutes.
G0156	Services of home health/hospice aide in home health or hospice settings, each 15 minutes.
S5125	Attendant care services; per 15 minutes.

Nursing assessment and time-based nursing codesHCPCSCovered

T1002	RN services, up to 15 minutes.
T1003	LPN/LVN services, up to 15 minutes.
T1001	Nursing assessment/evaluation, per diem.

Covered CPT Codesmixed

No codes listed

Plan of Care Renewal Interval — renewed at least every 60 days

Plan of care renewal intervalPhysician-approved written plan of care must be renewed at least every 60 days.

Applies toHome Health Services and Private Duty Nursing (PDN).

Authorization, Documentation, and Provider Responsibilities

Prior Authorization

Authorization and Waiver Interactions

Authorizations for home care services above Preventive Services require an approved LTSS‑HCBS waiver from EOHHS. For Medicaid members, LTSS services are an out‑of‑plan benefit and must be accessed through Medicaid Fee‑for‑Service; once a waiver is approved, authorizations and claims are managed and reimbursed through FFS, not Neighborhood. INTEGRITY for Duals members: Neighborhood care management will coordinate with waiver programs and complete assessments to help determine medically necessary home care hours; close collaboration between HHAs and Neighborhood case management is strongly encouraged to reduce authorization delays.

Approved LTSS‑HCBS waiver required for services beyond Preventive Services
LTSS eligibility determined by EOHHS, not Neighborhood
Medicaid members: LTSS = FFS for authorizations/claims

Prior Authorization

PDN Prior Authorization / Waiver Requirement

Private Duty Nursing (PDN) requires an approved LTSS‑HCBS waiver for adult members. PDN is reasonable and necessary only when there is a physician‑approved written plan of care renewed at least every 60 days, the member requires continuous skilled nursing care >2 hours/day that only an RN/LPN can provide, and InterQual PDN Level of Care criteria are met. PDN is not covered when services are custodial or can be provided by a lower‑level professional (e.g., CNA).

Key Definitions and Terms

Homebound — definition and criteria for being considered homebound

Definition (two-part)Member considered homebound when both: (1) they need supportive devices, special transportation, assistance of another person, or have a condition making leaving home medically contraindicated; and (2) there is a normal inability to leave home and leaving requires considerable and taxing effort (e.g., dyspnea, weakness, frailty, confusion, pain, use of crutches/wheelchair or need for assistance).

Absence allowanceIf the member leaves home, absences must be infrequent and for short periods (e.g., religious service, funeral, or for health care treatments).

Not bedridden requirementMember does not have to be bedridden to be considered homebound.

Combined Homemaker/Personal Care (Combo Care) — combined services definition

DefinitionCombined Homemaker/Personal Care (Combo Care) consists of a combination of homemaker and personal care services rendered by the same home health aide during the same shift.

Background and Scope

Home health care services are intended to provide a range of skilled and supportive services in the member’s residence when medically necessary to minimize functional deterioration or prevent placement in more restrictive settings. Covered services include skilled nursing, skilled rehabilitative therapies (PT/OT/ST), qualified home health aide services when part of a skilled plan of care, medical social services when essential to the skilled plan, durable medical equipment and disposable supplies, and nutritional counseling when integral to a skilled plan. The overarching purpose is to restore or maintain maximal function and avoid institutionalization.

Policy Review and Revision History

2026-04-08policy_reviewLatest

Policy last reviewed; reaffirmed coverage stance that Home Care Services (personal care, homemaking, combo care) and Private Duty Nursing are not covered benefits for HBE, EFP, and Duals CONNECT lines of business, and restated non-covered settings and conditions.

note

Document also specifies coverage exceptions and delivery/billing requirements (respite coverage limits, IEP services billed to LEA) on same review date.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyHome Health Care Services - Skilled & Non-Skilled

Policy CodePolicy 020

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

SourceLink

On This Page

Agencies may provide transportation incidental to an approved plan of care but transportation is excluded from payment; vehicle insurance, registration, inspection, driver history, and child safety restraints must meet state requirements; no separate payment or additional hours will be approved for transportation.

PDN requires approved LTSS‑HCBS waiver for adults
Physician approved written plan of care with short/long term goals; renew ≥ every 60 days
Continuous skilled nursing >2 hours/day and InterQual PDN LOC must be met
PDN not authorized for custodial care or when lower‑level staff suffice

Prior Authorization

Prior Authorization Required via Neighborhood Forms

Prior authorization requests must be submitted using Neighborhood's prior authorization request forms available on Neighborhood's website. Providers can access forms by navigating: Providers → Provider Resources → Forms → 'Click here for a list of prior authorization request forms'. For coding guidance, reference the Authorization Quick Reference Guide. A phone messaging system is available at 1‑800‑963‑1001 for assistance.

Use Neighborhood prior authorization request forms on www.nhpri.org
See Authorization Quick Reference Guide for coding
Provider assistance: 1‑800‑963‑1001

Prior Authorization

Waiver Requirement Affects Authorization

When members have not been approved for LTSS by EOHHS they are limited to Preventive Services only. An approved LTSS‑HCBS waiver is required to receive services above Preventive Services. For INTEGRITY for Duals, Neighborhood coordinates referrals and assessments to assist waiver determination and service authorization.

No more than Preventive Services without LTSS waiver
Approved LTSS‑HCBS waiver required for services beyond Preventive Services
Neighborhood coordinates with waiver programs for INTEGRITY for Duals

Denial Risk

Non‑Covered Situations

Home Care Services and PDN are not a covered benefit for Health Benefits Exchange (HBE), Extended Family Planning (EFP), and Duals CONNECT lines of business. Services are not covered when the member resides in an institutional facility (nursing facility, hospital, licensed residential care), when services are provided to anyone other than the member, or when LTSS waiver services are already being received from BHDDH. When a family member or other caregiver adequately meets the member's needs, additional agency services are not medically necessary.

HBE, EFP, Duals CONNECT: Home Care and PDN not covered
Not covered for residents of nursing facilities/hospitals/licensed residential facilities
Not covered when services are for persons other than the member
Services duplicative of BHDDH LTSS waiver are excluded
Services unnecessary when family/caregiver adequately provides care

Documentation Required

Required Orders, Plans of Care, and Assessment Intervals

A physician's order is required for Home Care Services in all lines of business except when services are part of a Long Term Supports & Services Plan of Care. All non‑LTSS home care services must be furnished under a written plan of care; LTSS services must be furnished under a written person‑centered plan per 42 C.F.R. §441.301(c)(2) and a written plan of care per 216‑RICR‑40‑10‑17. PDN requires a physician‑approved written plan of care with short and long‑term goals, renewed at least every 60 days. Regulatory nursing assessments and reassessments are required at admission and thereafter every 60 (PDN) to 90 (home care) days, with interim reassessments for condition changes or resumption of care after inpatient admission.

Physician's order required except when part of LTSS Plan of Care
Non‑LTSS: written plan of care per 216‑RICR‑40‑10‑17
LTSS: person‑centered plan per 42 C.F.R. §441.301(c)(2) plus written plan of care
PDN plan of care renewed ≥ every 60 days
Assessments: admission, every 90 days (home care) and every 60 days (PDN), and with condition changes or after inpatient admission

Billing Rule

Service Provider‑Level Requirements

Personal care—including when combined with homemaker services—may only be billed when delivered by a nursing assistant and cannot be billed when delivered by a homemaker. Home care services must comply with state regulations (210‑RICR‑20‑05‑1) and agency providers must notify Neighborhood within one business day if they cannot fulfill authorized hours and coordinate with another Neighborhood‑contracted agency to meet member needs. Transportation is excluded from separate payment and no additional hours may be billed specifically for transport.

Personal care billed only when delivered by a nursing assistant; homemaker delivery is not billable as personal care
Agencies must notify Neighborhood within one business day if unable to fulfill authorized hours and coordinate coverage
Providers must comply with RI regulations and plan‑of‑care requirements
Transportation is excluded from home health coverage; no separate payment or additional hours for transport

Note

(No additional provider‑action items identified.)

Payment/acuity noteHome Health Agencies may receive higher reimbursement for combination services when the member is assessed as high acuity and RN submits the MDS for review.

Provider requirementServices must be rendered by a licensed Home Health Aide/Certified Nursing Assistant (HHA/CNA) or Homemaker as appropriate.

Private Duty Nursing definition — continuous skilled nursing >2 hours/day for complex conditions

DefinitionPrivate Duty Nursing (PDN) is individual, continuous skilled nursing care provided by licensed nurses when the member's condition requires continuous skilled care greater than two (2) hours per day that can only be conducted by an RN or LPN.

Service basisCoverage provided on a per-hour or per-block-hours basis, not intermittent visit basis.

Intent and limitationsIntended to support caregiver(s) to maintain the member at home and not to replicate nursing home services; caregiver must be able to safely care for the member in agency's absence.

Skilled care — definition of skilled care services delivered in home

DefinitionSkilled care consists of medically necessary services provided in the member's home by licensed health care professionals, including medical/psychological evaluation, wound care, medication teaching, pain management, disease education and management, and therapy services (PT/OT/ST).

Setting and intentDelivered in the member's residence, prescribed by a treating practitioner, and intended to restore or maintain maximal function or prevent hospitalization.

Utilization reviewNeighborhood uses Change HealthCare InterQual® criteria for medical necessity reviews of home health services.

HCBS / LTSS-HCBS — person-centered home/community services and LTSS eligibility

DefinitionHome and Community Based Services (HCBS) are person-centered services delivered in the home and community to address functional limitations and enable people to remain at home.

LTSS-HCBS eligibilityEligibility for LTSS-HCBS is determined by EOHHS and individuals must meet Medicaid LTSS eligibility requirements and a high level of care need for certain services (e.g., PDN).

Role in coverageAdult members may qualify for homecare through HCBS waivers; an approved LTSS-HCBS waiver is required for adult PDN services.

Family relationship (assignment restrictions) — prohibited family relationships between staff and member

Prohibited family relationshipsDirect care staff may not be assigned to a member with whom they have a family relationship: parent-child (including stepparent/stepchild), grandparent-grandchild (including step), sibling (including stepsibling), or spouse.

ScopeRestriction applies regardless of whether the member is the parent or child and regardless of the age of the child or grandchild.

Regulatory basisAssignment restrictions are required to comply with RI General Laws and 210-RICR-20-051.

Direct care staff restrictions — prohibitions on assigning staff who reside with or are guardians/POA for member

Residency and legal authority restrictionsDirect care staff may not be assigned to members with whom they reside, for whom they have any type of guardianship, hold power of attorney, or are the authorized representative on the member's Medicaid application.

Licensure during travelNurses, nursing assistants, and homemakers must be licensed/certified in the state where services are performed; no additional hours authorized for travel and Neighborhood will not approve 2:1 coverage during travel.

Provider responsibilityProviders must comply with applicable RI statutes and regulations governing assignment and staffing.