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

physician.

(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

been obtained.

(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

ill.

 

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,

1980;

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

in‑law relationships.

 

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

(c)-(e));

Temporary Amendment Expired October 12, 2003 (Paragraphs

(c)-(e));

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

services.

(2)           Patient is dependent on a ventilator for

prolonged periods.

(3)           Patient is dependent on other device‑based

respiratory support, including tracheostomy care, suctioning, and oxygen

support.

(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.