AMOUNT DURATION AND SCOPE OF MEDICAL AND REMEDIAL CARE AND SERVICES PROVIDED
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1 STATE PLAN UNDER TITLE XIX Of THE SOCIAL SECURITY ACT STATE OF LOUISIANA Attachment 3.I-A Item 7, Page I AMOUNT DURATION AND SCOPE OF MEDICAL AND REMEDIAL CARE AND SERVICES PROVIDED LIMITATIONS ON THE AMOUNT. DURATION AND SCOPE OF CERTAfN ITEMS OF PROVIDED CITATION 42 CFR Medical and Remedial Care and Services Item 7. Hme Health Services Hme Health services must be prvided by licensed Hme Health agencies that meet all f the requirements f participatin in Medicare at 42 CFR Part 484. A. Hme health services are patient care services prvided in the patient's hme under the rder f a physician that are necessary fr the diagnsis and treatment f the patient's illness r injury, includlng ne r mre f the fllwing services: nursing as defined in the State's nurse practice acl, physical therapy; speech pathlgy and audilgy services; ccupatinal therapy, hme health aide services; r medical supplies, equipment. and appliances suitable fr use in the hme. Residence des nt include a hspital r a nursing facility. B. Hme health services shall be based n an expeclatjn that the care and services are medically reasnable and apprpriate fr the treatment f an illness r injury, and that!.he services can be perfrmed in!.he recipient's place f residence. A written plan f care fr services shall be evaluated and signed by the physician every 60 days. This plan f care shall be maintained in the recipient's medical recrds by the hme health agency. C. Reserved E [DE ; TI1- _ 0 t -() 7, STATE~~''' Q OA-,E RECG }() DATE APP\i'O_ I( f'ate EFc= --:-/ -.-~I - 1 { /0-112b H(,,'t~ ~ _. ". _ A _. \ TN# l,~ b Apprval Date.1-2. ~ -,,! EfTecti ve Date _...:.../_-...;.,1_-...:.../...;.,1 TN#
2 STATE PLAN UNDER TITLE XLX OF THE SOCIAL SECURITY ACT STATE OF LOUISIANA Attachment 3.I A Item 7, Page 2 AMOUNT DURATION AND SCOPE OF MEDICAL AND REMEDIAL CARE AND SERVICES PROVIDED LIMITATIONS ON THE AMOUNT, DURATION AND SCOPE OF CERTAIN ITEMS OF PROVIDED D. Reserved U RSED ; TN Q..1: -2,-,"-- ~ STATE _ h!k.< ;-. s ~------~--- J~ 11.- CL - - DAi E ~EC L _12:~ -/0 DATE AI p '''u_ 2.:.2S -J I nate '::FF _ /- / - / / 10 - flj4 A HC.rA ~ f... TNIl / Apprval Date ~ - 2- ~ - 1 I Effective Date I-I -) I TN#
3 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT { 'SDICAL ASSISTANCE PROGRAM '-",-. ATE OF LOUISIANA Attachment 3.I-A Item 7, Page 3 AMOUNT DURATION AND SCOPE OF MEDICAL AND REMEDlAL CARE AND SERVICES PROVIDED LIMITATIONS ON THE AMOUNT, DURA non AND SCOPE OF CERTAIN ITEMS OF PROVIDED «II J I j~,~~ q -! ~ '\:) g Ifll I\Il ~ I. ' I ~ I,~M ; 1 ~ 3 f~ f;:, (,) ii L~ {]) llun..~ "- w cr:: «w ~!;( w UJ UJ t I-'!;(!;;:!;;: 0 (J) :c E. Limitatins n Hme He alth services are as fllws: I Hme health services are limited t 50 skilled nursing and/r aide visits, ne service per day fr recipients wh are 21 years f age and lder. 2. The service limitatin in E.1. abve is nt applicable fr recipients wh are frm birth up t the age f 21. Hwever, hme health services prvided t recipients up t the age f 21 are subject t pst-payment review in rder t determine if the recipient's cnditin warrants high utilizatin. 3. the service limitatin f 50 hme health visits per year is nt applicable fr physical therapy, ccupatinal therapy, r speech pathlgy and audilgy services. 4. Fr Title XVmfTitle XIX (Medicare/Medicaid recipients), the Bureau f Health Services Financing will make payment fr aide visits if nly aide visits are required, subject t the 50 visits per calendar year I imitatin. EPSDT RECIPIENTS ARE EXCLU DED FROM SERVICE LIMIT A nons Item 7.a. Item 7.b. Intermittent r part-time nursing services prvided by a Hme Health Agency. Skilled nursing services are nursing services prvided n a part-time r intermittent basis by a registered nurse r licensed practical nurse that are necessary fr the diagnsis and treatment f a patient's illness r injury. These services shall be cnsistent with: 1. established Medicaid plicy; 2. the nature and severity f the recipient's illness r injury; 3. the particular medical needs f the patient; and 4. the accepted standards f medical and nursing practice. Hme Health Aide Services prvided by a Hme Health Agency. Hme health aide services are direct care services t assist in the treatment f the patient's illness r injury prvided under the supervisin f a registered nurse and in cmpliance with the standards f nursing practice gverning delegatin, induding assistance with the activities f daily living such as TN# TN # as -1+ Apprval Date (I" ZZ - 04 SUPERSEDES TN-. q 5 :l.±-- Effective Date _-,,~,- --,L... I_-...,-4.L-_
![~ '\:) g Ifll I\Il ~ I. ' I ~ I,~M ; 1 ~ 3 f~ f;:, (,) ii L~ {]) llun..~ "- w cr:: «w ~!;( w UJ UJ t I-'!;(!;;:!;;: 0 (J) 0 0 0 :c E.](/docs-images/43/6561489/images/page_3.jpg "Limitatins n Hme He alth services are as fllws: I Hme health services are limited t 50 skilled nursing and/r aide visits, ne service per day fr recipients wh are 21 years f age and lder. 2. The service limitatin in E.")
4 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT <;TA TE OF LOUISIANA Attachment 3. I'-A Item 7, Page 4 AMOUNT DURATION AND SCOPE OF MEDICAL AND REMEDIAL CARE AND SERVICES PROVIDED LIMIT A TIONS ON THE AMOUNT, DURA non AND SCOPE OF CERTAIN ITEMS OF PROVIDED mbility, transferring, walking, grmmg, bathing, dressing r undressing, eating, r tileting Item 7.c. Medical supplies, equipment, and appliances suitable fr use in the hme. Prir authrizatin is required fr the purchase f supplies and the rental, purchase, r repair f medical equipment and appliances befre payment can be issued. Prviders f medical equipment, appliances and supplies shall submit requests fr apprval f all repairs, rentals, and purchases f items t the Prir Authrizatin Unit (PAU) by whm authrizatin is made. Supplies and equipment are nt rented r purchased fr an individual in a hspital ; upn discharge, if the discharge plan includes the items, they are prvided by Medicaid in the utpatient setting. Fr Medicaid beneficiaries enrlled in Medicare Part B and fr whm medical equipment, appliances and supplies are cvered by Medicare, n prir authrizatin is required. Medicare is billed prir t Medicaid. EXCEPT: Fr dual eligibles (MedicarelMedicaid beneficiaries), a few items which are nt cvered by Medicare may be cvered by Medicaid if prir authrizatin is btained. If the item is nt cvered by Medicare, the request will be prcessed as if it were being prcessed fr r- -,nn-medicare beneficiaries. «IReqUests ' I and appliances shall be cnsidered when: I wh has a serius impairment t: J ~ \- lithe purchase f supplies and the rental, purchase r repair f medical equipment \t) lr) ~ I,~91: ~I ~,I 0 the item is medically necessary because it is needed by a beneficiary,,,i I "'I, cr- ~I~I Q ~ ", 2 '1 I enhancefuwrthell-being ;.. ~ - prevent er ImpaIrment; r :i it tt ~ I increase self-care r reduce care prvided by thers; a::.::( ttl -r the item is nt available thrugh anther agency at n cst (i.e. _~Jj ~ ~I Vcatinal Rehabilitatin); TN# Apprval Date? -j!.& ~ C Effective Date 1-/ - cj L," TN# '7. 1'2- I <1- S f}"""",... ~ n It:.- '-h, evy.., -<- C n.. / '... k.,) Vz.Y~ p<r- [;.",,..«...1 F / -
5 ST ATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT ST ATE OF LOUISIANA Attachment 3.!'-A Item 7, Page 5 L AMOUNT DURATION AND SCOPE OF MEDICAL AND REMEDIAL CARE AND SERVICES PROVIDED LIMITATIONS ON THE AMOUNT, DURATION AND SCOPE OF CERTAIN ITEMS OF PROVIDED the item is cvered by Medicaid; n equally effective and less cstly curse f treatment is available r suitable; and the item is primarily medical in nature and is nt a cnvenience item. Requirements fr Apprval A request fr purchase f supplies r rental/purchase f medical equipment and appliances will be cnsidered fr apprval when the request includes: «medical infrmatin frm a physician, including: - a written prescriptin frm a licensed physician; - the diagnsis related t the request; - the length f time that the supplies, equipment, r appliance will be needed; and - ther medical infrmatin t supprt the need fr the requested item. a statement as t whether the beneficiary's age and circumstances indicate that he can adapt t r be trained t use the item effectively; a medical care plan which includes a training prgram fr any appliance which requires skill and knwledge t use; any ther pertinent infrmatin, such as measurements t assure crrect size f appliance; and a written price qutatin including any cst fr an initial adjustment, freight charges, delivery and/r set up f the item. Purchase vs. Rental If equipment is needed temprarily, it may be mre cst effective fr Medicaid t pay fr rental f the item. Cnsideratin is given t the length f time the equipment is needed and the ttal rental fr that perid f time and the purchase price f the item. Equipment is purchased, nt rented, if the ttal cst f rental exceeds the purchase price. TN# ()5 -/.:5 Super~~~ Dc.. r_~f) ;.~ :.c, :. l r-:>_~ ~:: \."~ F ',~.i 1:";\(.;[: " ' _'" ".:. J-'.,... ~. _ '- TN# Apprval Date /J.. -/9-S Effective Date '7 - I - 05
6 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT STATE OF LOUISIANA Attachment 3.I-A Item 7, Page 6 AMOUNT DURATION AND SCOPE OF MEDICAL AND REMEDIAL CARE AND SERVICES PROVIDED LIMITATIONS ON THE AMOUNT, DURATION AND SCOPE OF CERTA IN ITEMS OF PROVIDED MED ICA L AND REMEDIAL CA RE AND SERVICES DESCRIBED AS FOLLOWS Item 7.d. Physical therapy, ccupatinal therapy, r speech pathlgy and audilgy services prvided by a Hme Health Agency. I, Physical therapy serv ices are rehabilitative services necessary fr the treatment f the patient's illness r injury, r restratin and maintenance f functin affected by the patient's illness r injury. These services are prvided with the expectatin, based n the physician's assessment f the patient's rehabilitative ptential, that the patient's cnditin will imprve materially within a reasnable and generally predictable perid f time, r that the services are necessary fr the establishment f a safe and effective maintenance prgram. Prviders must meet the qualificatins at 42 CFR Occupatinal therapy services are medically prescribed treatment t imprve r restre a functin which has been impaired by illness r injury, r t imprve the individual's ability t perfrm thse tasks required fr independent functining when the functin has been permanently lst r reduced by illness r injury. Prviders must meet the qualificatins at 42 CFR Speech pathlgy and audilgy se rvices are thse services necessary fr the diagnsis and treatment f speech and language disrders that result in cmmunicatin disabilities, and fr the diagnsis and treatment f swallwing disrders (dysphagia), regardless f a cmmunicatin disability. Prviders must meet the qualificatins at 42 CFR '- '.-~.----r~-"'"i L TN# (!)Q-05 TN# ()fj.. 15 Apprval Date 5 -:;.:.,,- Q 9' Effective Date J - f -0 l'
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