Home Health Aide Services

(A) Conditions of Payment. Home health aide services are payable only if all of the following conditions are met: (1) home health aide services are medically necessary to (a) directly support curative, rehabilitative, or preventative aspects of nursing or therapy services provided by the home health agency; and/or (b) provide hands-on assistance throughout the task or until completion, with at least two activities of daily living (ADLs) defined as: bathing, grooming, dressing, toileting/continence, transferring/ambulation, and eating. (2) the frequency and duration of the home health aide services must be ordered by the physician or ordering non-physician practitioner and must be included in the plan of care for the member; (3) the services are medically necessary to provide personal care to the member, to maintain the member’s health, or to facilitate treatment of the member’s injury or illness; (4) prior authorization, where applicable, has been obtained where required in compliance with 130 CMR 403.410; (5) the home health aide is supervised by a registered nurse or therapist for nursing services or therapy services, respectively, employed or contracted by the same home health agency as the home health aide. In the event that the home health agency contracts for, rather than directly employs, home health aides, such aides must be supervised in accordance with 42 CFR §484.80(h) and 130 CMR 403.419(C); (6) all services provided by the home health aide must be delivered at the direction of the registered nurse or therapist supervising the home health aide. The individualized patient care instructions must be included in the member’s plan of care or attached to the member’s plan of care; and (7) the home health aide has completed a training and competency evaluation program as specified in 42 CFR 484.80(a)(b)(c) and the servicing home health agency has documented the home health aide’s competency in all subject areas as described in 42 CFR 484.80(b)(3) within the last 12 months. (B) Payable Home Health Aide Services Provided Pursuant to Nursing or Therapy Services. Payable home health aide services when home health aide services are provided pursuant to nursing or therapy services include, but are not limited to (1) personal-care services; such as bathing, dressing, grooming, caring for hair, nail, and oral hygiene, which are needed to facilitate treatment or to prevent deterioration of the member’s health, changing the bed linen, shaving, deodorant application, skin care with lotions and/or powder, foot care, ear care, feeding, assistance with elimination, routine catheter care, and routine colostomy care; (2) simple dressing changes that do not require the skills of a registered or licensed nurse; (3) medication reminders for medications that are ordinarily self-administered and that do not require the skills of a registered or licensed nurse; (4) assistance with activities that are directly supportive of skilled therapy services; and (5) routine care of prosthetic and orthotic devices. (C) Payable Home Health Aide Services for ADL Supports Only. Home health aide services for ADL supports are only reimbursable if the member has two or more ADL needs that require hands-on assistance. This service requires a non-skilled nursing visit for assessment of the member and assessment and supervision of the home health aide care plan once every 60 days. Payable home health aide services for ADL supports only include: (1) hands-on assistance with ADLs as described in 130 CMR 403.402; (2) IADL support services provided incidental to hands-on ADL assistance; (3) monitoring or supervision provided incidental to or concurrently with hands-on ADL support; (4) personal care services as described in 130 CMR 403.416(B)(1) if provided in addition to hands-on ADL support as described in 130 CMR 403.402. (D) Nonpayable Home Health Aide Services. The MassHealth agency does not pay for homemaker, respite, or chore services provided to any MassHealth member in the absence of ADL needs. It is not permissible for home health agencies to bill MassHealth for home health aide services for the primary purpose of providing nonpayable home health aide services, or incidental services as described in 130 CMR 403.416(E). Additionally, home health aide services are nonpayable for monitoring of anticipatory and unpredictable services. (E) Incidental Services. When a home health aide visits a member to provide a health-related service, the home health aide may also perform some incidental services that do not meet the definition of a home health aide service (for example, light cleaning, preparing a meal, removing trash). However, the purpose of a home health aide visit must not be to provide these incidental services and home health aide visits are not reimbursable if used to primarily conduct incidental services, since they are not health-related services.