DHS 107.11(2)(2) Covered home health services. Services provided by an agency certified under s. DHS 105.16 which are covered by MA are those reasonable and medically necessary services required to treat the recipient’s condition. Covered services must meet all of the following criteria: DHS 107.11(2)(b)(b) The services are provided in a place other than a hospital or nursing home. DHS 107.11(2)(c)1.1. Skilled nursing services provided under a plan of care which requires less than 8 hours of skilled nursing care per day and specifies which level of care the nurse is qualified to provide. Skilled nursing services are any of the following: DHS 107.11(2)(c)1.a.a. Nursing services performed by a registered nurse, or by a licensed practical nurse under the supervision of a registered nurse, according to the written plan of care and accepted standards of medical and nursing practice, in accordance with ch. N 6. DHS 107.11(2)(c)1.b.b. Services which, due to the recipient’s medical condition, may be only safely and effectively provided by an RN or LPN. DHS 107.11(2)(c)1.d.d. Teaching and training of the recipient, the recipient’s family or other caregivers requiring the skills on an RN or LPN. DHS 107.11(2)(c)2.2. Home health aide services and medical supplies, equipment, and appliances. Home health services are any of the following: DHS 107.11(2)(c)2.a.a. Medically oriented tasks which cannot be safely delegated by an RN as determined and documented by the RN to a personal care worker who has not received special training in performing tasks for the specific individual, and which may include, but are not limited to, medically oriented activities directly supportive of skilled nursing services provided to the recipient. These may include assistance with and administration of oral, rectal and topical medications ordinarily self-administered and supervised by an RN according to 42 CFR 483.36 (d), ch. DHS 133, and ch. N 6, and assistance with activities directly supportive of current and active skilled therapy and speech pathology services and further described in the Wisconsin medical assistance home health agency provider handbook. DHS 107.11(2)(c)2.b.b. Assistance with the recipient’s activities of daily living only when provided on conjunction with a medically oriented task that cannot be safely delegated to a personal care worker as determined and documented by the delegating RN. Assistance with the recipient’s activities of daily living consists of medically oriented tasks when a reasonable probability exists that the recipient’s medical condition will worsen during the period when assistance is provided, as documented by the delegating RN. A recipient whose medical condition has exacerbated during care activities sometime in the past 6 months is considered to have a condition which may worsen when assistance is provided. Activities of daily living include, but are not limited to, bathing, dressing, grooming and personal hygiene activities, skin, foot and ear care, eating, elimination, ambulation, and changing bed positions. DHS 107.11(2)(c)3.3. Therapy and speech pathology services which the agency is certified to provide. DHS 107.11(2)(e)(e) The services are provided with supervision from, and coordination of all nursing care by, a registered nurse. DHS 107.11(2m)(2m) Additional requirements for covered home health services. DHS 107.11(2m)(a)(a) Covered services provided under sub. (2) must only be safely and effectively performed by a skilled therapist or speech pathologist or by a certified therapy assistant who receives supervision by the certified therapist according to 42 CFR 484.32. DHS 107.11(2m)(b)(b) Based on the assessment by the recipient’s physician of the recipient’s rehabilitation potential, services provided under sub. (2) are expected to materially improve the recipient’s condition within a reasonable, predictable time period, or are necessary to establish a safe and effective maintenance program for the recipient. DHS 107.11(2m)(c)(c) In conjunction with the written plan of care, a therapy evaluation shall be conducted prior to the provision of services under sub. (2) by the therapist or speech pathologist who will provide the services to the recipient. DHS 107.11(2m)(d)(d) The therapist or speech pathologist shall provide a summary of activities, including goals and outcomes, to the physician at least every 62 days, and upon conclusion of therapy services DHS 107.11(3)(3) Prior authorization. Prior authorization is required to review utilization of services and assess the medical necessity of continuing services for: DHS 107.11(3)(a)(a) All home health visits when the total of any combination of skilled nursing, home health aide, physical and occupational therapist and speech pathologist visits by all providers exceeds 30 visits in a calendar year, including situations when the recipient’s care is shared among several certified providers; DHS 107.11(3)(b)(b) All home health aide visits when the services are provided in conjunction with private duty nursing under s. DHS 107.12 or the provision of respiratory care services under s. DHS 107.113; DHS 107.11(3)(d)(d) All home health aide visits when 4 or more hours of continuous care is medically necessary; and DHS 107.11(4)(a)(a) The written plan of care shall be developed and reviewed concurrently with and in support of other health sustaining efforts for the recipient in the home. DHS 107.11(4)(c)(c) Services provided to a recipient who is a resident of a community-based residential facility shall be rendered according to the requirements of ch. DHS 83 and shall not duplicate services that the facility has agreed to provide. DHS 107.11(4)(d)1.1. Except as provided in subd. 2., home health skilled nursing services provided by one or more providers are limited to less than 8 hours per day per recipient as required by the recipient’s medical condition. DHS 107.11(4)(d)2.2. If the recipient’s medical condition worsens so that 8 or more hours of direct, skilled nursing services are required in a calendar day, a maximum of 30 calendar days of skilled nursing care may continue to be reimbursed as home health services, beginning on the day 8 hours or more of skilled nursing services became necessary. To continue medically necessary services after 30 days, prior authorization for private duty nursing is required under s. DHS 107.12 (2). DHS 107.11(4)(e)(e) An intake evaluation is a covered home health skilled nursing service only if, during the course of the initial visit to the recipient, the recipient is admitted into the agency’s care and covered skilled nursing services are performed according to the written physician’s orders during the visit. DHS 107.11(4)(f)(f) A skilled nursing ongoing assessment for a recipient is a covered service: DHS 107.11(4)(f)1.1. When the recipient’s medical condition is stable, the recipient has not received a covered skilled nursing service, covered personal care service, or covered home visit by a physician service within the past 62 days, and a skilled assessment is required to re-evaluate the continuing appropriateness of the plan of care. In this paragraph, “medically stable” means the recipient’s physical condition is non-acute, without substantial change or fluctuation at the current time. DHS 107.11(4)(f)2.2. When the recipient’s medical condition requires skilled nursing personnel to identify and evaluate the need for possible modification of treatment; DHS 107.11(4)(f)3.3. When the recipient’s medical condition requires skilled nursing personnel to initiate additional medical procedures until the recipient’s treatment regimen stabilizes, but is not part of a longstanding pattern of care; or DHS 107.11(4)(g)(g) Teaching and training activities are covered services only when provided to the recipient, recipient’s family or other caregiver in conjunction with other covered skilled nursing care provided to the recipient. DHS 107.11(4)(h)(h) A licensed nurse shall administer medications to a minor child or to an adult who is not self-directing, as determined by the physician, to direct or administer his or her own medications, when a responsible adult is not present to direct the recipient’s medication program. DHS 107.11(4)(i)(i) Services provided by an LPN which are not delegated by an RN under s. N 6.03 are not covered services. DHS 107.11(4)(j)(j) Skilled physical and occupational therapy and speech pathology services are not to include activities provided for the general welfare of the recipient or activities to provide diversion for the recipient or to motivate the recipient. DHS 107.11(4)(k)(k) Skilled nursing services may be provided for a recipient by one or more home health agencies or by an agency contracting with a nurse or nurses only if the agencies meet the requirements of ch. DHS 133 and are approved by the department. DHS 107.11(4)(L)(L) RN supervision and administrative costs associated with the provision of services under this section are not separately reimbursable MA services. DHS 107.11(4)(m)1.1. A home health aide may provide assistance with a recipient’s medications only if the written plan of care documents the name of the delegating registered nurse and the recipient is aged 18 or more; DHS 107.11(4)(m)2.2. Home health aide services are primarily medically oriented tasks, as determined by the delegating RN, when the instability of the recipient’s condition as documented in the medical record is such that the recipient’s care cannot be safely delegated to a personal care worker under s. DHS 107.112; DHS 107.11(4)(m)3.3. A home health aide visit which is a covered service shall include at least one medically oriented task performed during a visit which cannot, in the judgment of the delegating RN, be safely delegated to a personal care worker; and DHS 107.11(4)(m)4.4. A home health aide, rather than a personal care worker, shall always provide medically oriented services for recipients who are under age 18. DHS 107.11(5)(5) Non-covered services. The following services are not covered home health services: DHS 107.11(5)(b)(b) Skilled nursing services provided for 8 or more hours per recipient per day; DHS 107.11(5)(c)(c) More than one initial visit per day by a home health skilled nurse, home health aide, physical or occupational therapist or speech and language pathologist; DHS 107.11(5)(e)(e) Services requiring prior authorization that are provided without prior authorization; DHS 107.11(5)(f)(f) Supervision of the recipient when supervision is the only service provided at the time; DHS 107.11(5)(i)(i) Medications administration by a personal care worker or administration by a home health aide which has not been delegated by an RN according to the relevant provisions of ch. DHS 133. DHS 107.11(5)(j)(j) Skilled nursing services contracted for by a home health agency unless the requirements of s. DHS 133.19 are met and approved by the department; DHS 107.11(5)(k)(k) Occupational therapy, physical therapy or speech pathology services requiring only the use of equipment without the skills of the therapist or speech pathologist; DHS 107.11(5)(L)1.1. Solely for the purpose of ensuring that a recipient who has a demonstrated history of noncompliance over 30 days complies with the medications program; DHS 107.11(5)(L)2.2. To administer or assist with medication administration of an adult recipient who is capable of safely self-administering a medication as determined and documented by the RN; DHS 107.11(5)(L)3.3. To inject a recipient who is capable of safely self-injecting a medication, as described and documented by the RN; DHS 107.11(5)(L)4.4. To prefill syringes for self-injection when, as determined and documented by the RN, the recipient is capable of prefilling or a pharmacy is available to prefill; and DHS 107.11(5)(L)5.5. To set up medication for self-administration when, as determined and documented by the RN, the recipient is capable or a pharmacy is available to assist the recipient; DHS 107.11(5)(m)(m) Home health services to a recipient who is eligible for covered services under the medicare program or any other insurance held by the recipient; DHS 107.11(5)(n)(n) Services that are not medically appropriate. In this paragraph,“medically appropriate” means a service that is proven and effective treatment for the condition for which it is intended or used; DHS 107.11(5)(q)(q) A visit made by a skilled nurse, physical or occupational therapist or speech pathologist solely to train other home health workers; DHS 107.11(5)(r)(r) Any home health service included in the daily rate of the community-based residential facility where the recipient is residing; DHS 107.11(5)(s)(s) Services when provided to a recipient by the recipient’s spouse or parent if the recipient is under age 18; DHS 107.11(5)(u)(u) Any service which is performed in a place other than the recipient’s residence; and DHS 107.11(6)(a)(a) Definition. In this subsection, “part-time, intermittent care” means skilled nursing services provided in a recipient’s home under a plan of care which requires less than 8 hours of skilled care in a calendar day. DHS 107.11(6)(b)1.1. Part-time, intermittent nursing care may be provided by an independent nurse certified under s. DHS 105.19 when an existing home health agency cannot provide the services as appropriately documented by the nurse, and the physician’s prescription specifies that the recipient requires less than 8 hours of skilled nursing care per calendar day and calls for a level of care which the nurse is licensed to provide as documented to the department. DHS 107.11(6)(b)2.2. Services provided by an MA-certified registered nurse are those services prescribed by a physician which comprise the practice of professional nursing as described under s. 441.001 (4), Stats., and s. N 6.03. Services provided by an MA-certified licensed practical nurse are those services which comprise the practice of practical nursing under s. 441.001 (3), Stats., and s. N 6.04. An LPN may provide nursing services delegated by an RN as delegated nursing acts under the requirements of ss. N 6.03 and 6.04 and guidelines established by the state board of nursing. DHS 107.11(6)(b)3.3. A written plan of care shall be established for every recipient admitted for care and shall be signed by the physician and incorporated into the recipient’s medical record. A written plan of care shall be developed by the registered nurse or therapist within 72 hours after acceptance. The written plan of care shall be developed by the registered nurse or therapist in consultation with the recipient and the recipient’s physician and shall be signed by the physician within 20 working days following the recipient’s admission for care. The written plan of care shall include, in addition to the medication and treatment orders: DHS 107.11(6)(b)3.b.b. Methods for delivering needed care, and an indication of which, if any, professional disciplines are responsible for delivering the care; DHS 107.11(6)(b)3.c.c. Provision for care coordination by an RN when more than one nurse is necessary to staff the recipient’s case; DHS 107.11(6)(b)3.d.d. Identification of all other parties providing care to the recipient and the responsibilities of each party for that care; and DHS 107.11(6)(b)3.e.e. A description of functional capabilities, mental status, dietary needs and allergies.
/code/admin_code/dhs/101/107
true
administrativecode
/code/admin_code/dhs/101/107/11/4/b
Department of Health Services (DHS)
Chs. DHS 101-109; Medical Assistance
administrativecode/DHS 107.11(4)(b)
administrativecode/DHS 107.11(4)(b)
section
true
