Medicaid/BadgerCare Plus

Face-to-face requirements and policy changes for home health services, durable medical equipment and disposable medical supplies.

 

In response to the federal Medicaid Home Health Final Rule (CMS-2348-F), new policy effective for dates of services on and after July 1, 2018, include:

  • Members are required to have a face-to-face visit with a physician or authorized non-physician practitioner (NPP) for the initial prescription of home health services and certain DME and DMS.
  • Certain DME and DMS as defined by Centers for Medicare and Medicaid (CMS). Refer to cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Medical-Review/FacetoFaceEncounterRequirementforCertainDurableMedicalEquipment.html for a list of impacted DME and DMS.
  • The physician or NPP may document the face-to-face visits with a member for the initial visit for impacted DME and DMS. A physician is required to write the initial prescription for home health services and impacted DME or DMS. 
  • The following NPPs are allowed to provide the face-to-face visit:
    • Clinical nurse specialist
    • Nurse midwife
    • Nurse practitioner
    • Physician assistant
    • Note: Nurse midwives are not an allowable NPP for face-to-face visits for the initial prescription of DME and DMS.
  • Documentation of the face-to-face visit must explain how the individual’s observed health status relates to the primary reason that the member requires home health service or impacted DME or DMS.
  • The documentation of the face-to-face visit must be a clearly titled, separate and distinct section of, or a clearly titled addendum to, the prescription, and include:
    • The date of the face-to-face visit
    • Name and credentials of the physician or NPP who conducted the face-to-face visit
    • The clinical findings that support the member’s need for home health services or impacted DME or DMS
    • The signature of the prescribing physician for home health services
    • The signature of the prescribing physician or NPP who conducted the face-to-face visit for impacted DME or DMS
  • A face-to-face visit is not required for DME or DMS refills, repairs or service of equipment, or rental or purchase of ancillary equipment. The list of DME and DMS items that require a face-to-face visit is developed and maintained by CMS.
  • Timeframe for face-to-face visit:
    • For impacted DME and DMS – no more than six months before the dispense date for initial orders (The written prescription must be received prior to dispensing impacted DME or DMS).
    • For home health services – no more than 90 days before or 30 days after the start of services for initial orders.
  • Prior Authorization (PA): Effective for DOS on and after July 1, 2018, home health, DME, and DMS providers are required to include the initial physician prescription and physician documentation of the face-to-face visit when submitting prior authorization (PA) for those home health services and impacted DME and DMS that require PA.
    • PA requests for impacted DME and DMS received without the face-to-face documentation will be returned to the provider.
  • Second Face-to-face Visit Not Required Due to Medicaid Enrollment: a new face-to-face visit is not required for individuals with documented face-to-face visits for the initial prescription if individual subsequently enrolls in WI Medicaid.
    • Providers are required to maintain the original physician prescription and documentation of a face-to-face visit in the member’s medical record and submit them with the PA request if a PA is applicable.
  • Home health services, DME, and DMS are covered for members in any setting in which normal life activities take place.
  • Homebound Status: Effective for Dates of Service on and after July 1, 2018, Medicaid reimbursement for home health skilled nursing services and home health therapy services are no longer restricted to members who are homebound. A member may receive all of the following home health services without limitations on his or her homebound status:
    • Home health aide services
    • Home health skilled nursing
    • Home health OT, PT, and SLP
    • This policy does not apply to services supplied in facilities specified in 42 C.F.R. $ 440.70(c)1.
  • For Managed Care Policy regarding face-to-face visit requirements, Medicaid HMO network providers should contact their MCO, and agencies that contract with a Family Care MCO should contact their MCO.

Questions for SSM Health at Home may be directed to 800-924-2273.