subchapter 25O – home and community-based services
section .0100 – Reserved for future codification
10a ncac 25o .0100 reserved for future codification
section .0200 – Home Health Services
10A NCAC 25O .0201 HOME HEALTH SERVICES
(a) Home health services shall be provided by Medicare
certified home health agencies under a plan of care authorized by the patient's
(b) Covered home health services include nursing services,
services of home health aides, speech therapy, physical therapy, occupational
therapy, medical supplies, equipment and appliances.
(c) Purchase or rental of durable medical equipment,
excluding braces, is a covered home health service after prior approval has
(d) A plan of care which is signed by the physician and
which details the services to be provided must be on file.
(e) Services of a home health aide for provision of
personal care shall not be covered as a home health service except when
provided under appropriate professional supervision as part of care necessary
to restore, rehabilitate or maintain health, including care for the terminally
History Note: Authority G.S. 108‑25(b); 108A‑25(b);
108A‑54; 42 C.F.R. 440.70; 42 C.F.R. 440.230(d);
Eff. February 1, 1976;
Readopted Eff. October 31, 1977;
Amended Eff. August 1, 1986; April 1, 1999; February 1,
Paragraph (a) transferred from 10A NCAC 22O .0103 Eff.
May 1, 2012;
Paragraphs (b)-(e) transferred from 10A NCAC 22O .0406
Eff. May 1, 2012.
10A NCAC 25O .0202 PERSONAL CARE SERVICES
(a) The Division of Medical Assistance will cover personal
care services in accordance with federal law. The provision of personal care
services must be physician authorized and must meet the following criteria:
(1) The recipient of the service must have a
medical diagnosis that warrants a physician's care and that recipient must be
under the direct and ongoing care of the physician prescribing PCS.
(2) The recipient's medical condition must be
stable at maintenance level.
(3) There must be a medical necessity for the
provision of personal care services.
(b) An enrolled provider must be a State licensed home care
agency located within North Carolina that is approved in its license to provide
in-home aide services.
(c) Reimbursement is not available for personal care
services exceeding 80 hours per recipient per calendar month.
(d) Reimbursement for personal care services is not
available to a given recipient on the same day another substantially equivalent
service is provided. Substantially equivalent services include home health
aide services, and personal care services provided through In‑home Aide
services at Level II and Level III ‑ Personal Care as defined in 10A NCAC
06A .0103(2) and 10A NCAC 06A .0103(4).
(e) A member of the recipient's immediate family may not be
employed by a provider agency to provide personal care services reimbursed by
Medicaid. Immediate family members are defined as spouses, children, parents,
grandparents, grandchildren, siblings, including corresponding step‑ and
History Note: Authority G.S. 108A‑25(b); 108A‑54;
108A‑55; S.L. 2002-126; S.L. 1985, c. 479, s. 86; 42 C.F.R. 440.170(f);
Eff. January 1, 1986;
Amended Eff. April 1, 1993; December 1, 1991;
Temporary Amendment Eff. December 27, 2002 (Paragraphs
Temporary Amendment Expired October 12, 2003 (Paragraphs
Paragraphs (a)-(b) transferred from 10A NCAC 22O .0120
Eff. May 1, 2012 (previously recodified from 10 NCAC 26B .0119 Eff. October 1,
1993 and recodified from 10 NCAC 26B .0120 Eff. January 1, 1998;
Paragraphs (c)-(e) transferred from 10A NCAC 22P .0410
Eff. May 1, 2012.
10A NCAC 25O .0203 HOME INFUSION THERAPY
(a) Self‑administered Home Infusion Therapy (HIT) is
covered when it is medically necessary and provided through an enrolled HIT
agency as prescribed by a physician. "Self‑administered" means
that the patient or an unpaid primary caregiver is capable, able, and willing
to administer the therapy following teaching and with monitoring. The
following therapies are included in this coverage when self‑administered:
(1) Total parenteral nutrition;
(2) Enteral nutrition;
(3) Intrathecal and intravenous chemotherapy;
(4) Intravenous antibiotic therapy;
(5) Pain management therapy, including
subcutaneous, epidural, intrathecal, and intravenous pain management therapy.
(b) An agency must be a home care agency licensed in North
Carolina for the provision of infusion nursing services to qualify for
enrollment as a HIT provider.
In addition to enrolled HIT providers, agencies enrolled to
provide durable medical equipment may provide the supplies, equipment, and
nutrient formulae for enteral infusion therapy.
History Note: Authority G.S. 108A‑25(b); 42
C.F.R. 440.230; 42 C.F.R. 440.260;
Eff. March 1, 1993;
Recodified from 10 NCAC 26B .0123 Eff. October 1, 1993;
Recodified from 10 NCAC 26B .0124 Eff. April 1, 1994;
Recodified from 10 NCAC 26B .0125 Eff. January 1, 1998;
Transferred from 10A NCAC 22O .0125 Eff. May 1, 2012.
10A NCAC 25O .0204 PRIVATE DUTY NURSING
(a) Medically necessary private duty nursing (PDN) services
are provided when they are prescribed by a physician and prior approved by the
Division of Medical Assistance or its designee.
(b) A patient must reside in the patient's private
residence to receive PDN services. Recipients who are in domiciliary care
facilities (such as rest homes, group homes, family care homes, and similar
settings) and those who are in hospitals, nursing facilities, intermediate care
facilities for the mentally retarded, rehabilitation centers, and other
institutional settings are not eligible for this service. PDN services are not
covered while an individual is being observed or treated in a hospital
emergency room or similar environment.
(c) Private duty nursing services are considered medically
necessary when the person must require substantial and complex continuous
nursing care by a licensed nurse. Professional judgment and a thorough
evaluation of the medical complexity and psychosocial needs of the patient are
involved in determining the need for PDN. The following situations represent
the usual types of cases that may require PDN, though the list is not meant to
be all inclusive:
(1) Patient requires prolonged intravenous nutrition
or drug therapy with needs beyond those covered by home infusion therapy
(2) Patient is dependent on a ventilator for
(3) Patient is dependent on other device‑based
respiratory support, including tracheostomy care, suctioning, and oxygen
(d) This service is only approvable based on the need for
PDN services in the patient's private residence. An individual with a medical
condition that necessitates this service normally is unable to leave the home
without being accompanied by a licensed nurse and leaving the home requires
considerable and taxing effort. An individual may utilize the approved hours
of coverage outside of his residence during those hours when the individual's
normal life activities take the patient out of the home. The need for nursing
care to participate in activities outside of the home is not a basis for
authorizing PDN services or expanding the hours needed for PDN services.
(e) A person may not receive Personal Care Services,
Skilled Nursing Visits, and Home Health Aide Services reimbursed by Medicaid
during the same hours of the day as PDN services.
(f) The patient's spouse, child, parent, grandparent,
grandchild, or sibling, including corresponding step and in-law relationship
may not be employed by the provider agency when reimbursed by Medicaid to
provide PDN services to the patient.
(g) Medicaid payments for PDN are made only to agencies
enrolled with the Division of Medical Assistance as providers for the service.
An enrolled provider must be a State licensed home care agency located within
North Carolina that is approved in its license to provide nursing services.
History Note: Authority
G.S. 108A‑25(b); 108A‑54; 42 C.F.R. 440.80;
Eff. May 1, 1990;
Amended Eff. April 1, 1993; June 1, 1992;
Recodified from 10 NCAC 26B .0121 Eff. October 1, 1993;
Recodified from 10 NCAC 26B .0122 Eff. January 1, 1998;
Transferred from 10A NCAC 22O .0122 Eff. May 1, 2012.