Benefit: Home Health Services

Definition: Home health services are provided in a beneficiary’s home or other authorized setting to promote, maintain or restore health or to reduce the effects of illness and disability. Medicaid reimbursable services include:

• Home visit services provided by a registered nurse or a licensed practical nurse;
• Home visits provided by a qualified home health aide;
• Private duty nursing;
• Personal care services;
• Therapy (occupational/physical therapy and speech-language problems) services; and
• Medical supplies, appliances and durable medical equipment.

Limits:  Medicaid reimbursement for home health services must be determined medically necessary and also meet the following limitations:

• Dually eligible Medicaid/Medicare recipients must receive Medicare reimbursable home health services from a Medicare-enrolled home health agency;
• Nursing and home health aide visit services are limited to:
• A total of four visits by nurses and/or aides per day, per recipient, and
• A total of 60 visits by nurses and/or aides per lifetime, per recipient, without precertification;
• Private duty nursing, personal care and therapy services are limited to children 20 years of age or younger who are medically complex. Private duty nursing and personal care services must be prior authorized by Medicaid or its authorized agent; and
• Private duty nursing and personal care services are limited to:
• Two to 24 hours of private duty nursing per day, per recipient; and
• Two to 24 hours of personal care provided by home health aides per day, per recipient.

Exceptions:  Exceptions to the 60-visit limit for children and adults must be requested through the Medicaid reviewing agency. Prior authorization requests should be submitted before services are provided.

Co-pays: $2 copay for home health services, per provider, per day, unless exempt.

Reform items that can vary: Number of visits, dollar limits or copays may vary.