Home Health Services and Face-to-Face Encounter Requirements Guest Presenters Alexandra Koloskus, JD Matt Colussi Our Mission Improving health care access and outcomes for the people we serve while demonstrating sound stewardship of financial resources 1
Home Health Services Overview Home Health services consist of skilled nursing, certified nurse aide (CNA) services, physical therapy, occupational therapy, and speech/language pathology services that are provided by a licensed and certified Home Health agency. Home Health services are available to Colorado Medicaid clients who need intermittent skilled care in their place of residence or in the community. Home Health services are divided into two service types: Ø Acute Home Health services are provided for the treatment of acute conditions/episodes (such as postsurgical care) for up to 60 days without prior authorization. Ø Long-Term Home Health is available for clients who require ongoing Home Health Services beyond the 60 day Acute Home Health period. Long-Term Home Health services require prior authorization. Home Health Services Overview Clients ages 20 and younger: Ø Are assessed for Long-Term Home Health services using the Pediatric Assessment Tool (PAT) and the client s plan of care. Ø Through EPDST, may receive PT, OT and SLP in Acute and Long-Term Home Health periods. Clients ages 21 and older: Ø For clients 21 years of age or older, PT, OT and SLP shall only be provided in the Acute Home Health episode. 2
Utilization and Expenditure Trends Utilization & Expenditure Trends Fiscal Years 2011-2015 Statistics FY 12-13 FY 13-14 FY 14-15 FY 15-16 Total Medicaid Clients 808,100 1,109,853 1,338,330 1,440,312 Total Expenditures $177,039,478 $207,317,907.20 $244,525,640.10 $276,181,802.47 Total Number of Clients Utilizing Benefit 13,190 15,845 18,962 20,813 Number of Providers 150 152 153 167 Acute Home Health Expenditures $18,779,047 $23,081,327.63 $30,893,384.77 $32,703,502.53 Long-Term Home Health Expenditures $158,181,727 $184,155,594.04 $213,543,191.91 $243,382,023.80 LTHH CNA Expenditures $115,023,319 $129,285,429.17 $147,780,736.30 $169,269,623.21 LTHH All Other Expenditures $43,158,408 $54,870,164.87 $65,762,455.61 $74,112,400.59 Number of Pediatric Clients Served (Ages 0-20) 4,290 5,510 6,449 7,402 Pediatric Expenditures $87,740,366 $90,235,982.04 $125,680,438.74 $149,695,107.39 Telehealth Expenditures $10,314.67 $20,122.70 $22,579.50 $9,044.54 3
Face-to-Face Encounter Requirements for Prescribing of Home Health Services CMS Final Rule: CMS 2348-F Guest Presenters Alexandra Koloskus, JD Matt Colussi Background February 2, 2016 CMS published a final rule revising the Medicaid Home Health service definition consistent with section 6407 of the Affordable Care Act to add two basic requirements: 1. For Home Health services, physicians or certain federally authorized nonphysician practitioners (NPPs) document the occurrence of a face-to-face encounter with the Medicaid-eligible beneficiary within specific time frames. 2. Home Health services may not be limited to services furnished in the home and can now be provided in the community. Colorado has a compliance date of July 1, 2017. 4
1. Face to Face (F2F) Encounter: For the initial ordering of Home Health services: I. The Ordering Physician must document the occurrence of a face-to-face encounter II. The encounter must be related to the primary reason the client requires Home Health services III. The encounter must occur no more than 90 days before or 30 days after the start of Home Health services A. Who Does This Apply To? A face-to-face encounter is required for initial orders for Home Health services and for all episodes initiated with the completion of a start-of-care OASIS assessment on or after July 1, 2017. A face-to-face encounter is NOT required for re-certifications of Home Health services. Existing clients already receiving Home Health services will NOT require a new face-to-face visit (they will be grandfathered in). Dual-Eligibile clients: If the source of payment for the client s care has changed from Medicare to Medicaid, and a face-to-face encounter was performed at the start of Home Health services, a new face-to-face encounter is NOT required. In this circumstance, the Medicare F2F documentation will meet the Medicaid F2F requirement 5
B. Who Can Conduct a F2F Encounter? Federally authorized practitioners include: a. The ordering physician. In order to be an ordering physician, the physician must be enrolled with Health First Colorado. b. The physician who cared for the patient in an acute or post-acute care facility (from which the patient was directly admitted to home health). c. The Non-Physician Practitioner (NPP): (1) A nurse practitioner (NP) or clinical nurse specialist (CNS) who is working in collaboration with the ordering physician or the acute/post-acute care physician;; (2) A certified nurse midwife;; (3) A physician assistant (PA) under supervision of the ordering physician. C. F2F Documentation Requirements The face-to-face encounter must be documented on the ordering physician s plan-of-care and must include: a. The primary reason the patient requires Home Health services, b. The date of the face-to-face encounter and c. The identity of the practitioner (physician or NPP) who conducted the face-to-face encounter. 6
D. F2F Documentation Guidelines ü Clients discharged from a hospital to Home Health services are not required to receive a separate face-to-face encounter, as long as a physician or allowed NPP performs the face-toface encounter in the hospital and communicates the clinical findings of the face-to-face encounter to the ordering physician in the community. ü Clinical findings can be communicated in the form of clinical and progress notes and discharge summaries. ü There is no federal prohibition on a NPP documenting the face-to-face encounter and having the physician sign the documentation. Questions? 7
2. Home Health in the Community Final Federal Rule Clarifies: I. Medicaid Home Health services cannot be restricted to homebound individuals II. Medicaid Home Health services can be provided outside of the home and in the community when the client is participating in normal life activities I. Other than in a hospital, NF, ICF-ID or any setting in which payment could be made under Medicaid for inpatient services that include room and board. v Utilization Review mechanisms still apply (LTC evaluations and Pediatric Assessment Tool) Home Health in the Community Cont. Non-Emergency Medical Transportation (NEMT) is available for transportation to and from medical appointments. More information available in hyperlink and by emailing NEMT@state.co.us The face-to-face visit with a Federally authorized provider is reimbursable using procedure codes. Health First Colorado anticipates that the visits will be reimbursable office visits. 8
Questions? Department Updates and Info Home Health Rule 10 CCR 8.520 Regulatory Efficiency Rule Review Process complete Rule going to Medical Services Board in June to update face-to-face requirements, including HHIC, and to move BCS content into rule. Electronic Visit Verification (EVV) per 21 st Century Cures Act: Home Health by 2023, Personal Care by 2019 9
Department Updates and Info Rate increases effective July 1, 2017- HH and PDN rates increased by 1/3 rd of the gap between current rates and LUPA (Low Utilization Payment Adjustment). s- HH and PDN rates increased by 1/3 rd of the gap between current rates and LUPA Questions? Alexandra.Koloskus@state.co.us 10