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Home Care Services

Revised: 01-23-2015

  • Eligible Providers
  • Eligible Recipients
  • Covered Services
  • Home Health Aide
  • Home Care Nurse
  • Rehabilitation Therapies
  • Skilled Nurse Visits
  • Non-Covered Services
  • Authorization Requirements
  • Billing
  • Overview

    MHCP covers the following home care services:

  • • Skilled nurse visits (SNV)
  • • Home Health Aide Visits (HHA)
  • • Home Care Nursing (HCN)
  • • Home Care Therapies
  • Eligible Providers

    Eligible providers must be enrolled with MHCP and categorized as one or more of the following:

  • Medicare Certified, Class A Licensed, Home Health Agencies
  • Class A licensed Home Care Nurse Agency
  • Independent Registered Nurse (RN)
  • Independent Licensed Practical Nurse (LPN) with a class A license from MDH
  • Providers are required to:

  • • Verify eligibility for each MHCP recipient each month
  • • Maintain signed doctor’s orders in each recipient’s file at the provider’s office
  • • Follow additional provider requirements outlined under each covered service
  • • Review additional Providers Requirements
  • Multiple Providers of Services
    Service authorization can be issued to more than one provider agency at the same time. Each provider agency receives a separate service authorization. Each provider agency may be able to bill for the same type of service on the same day. Each agency must have an approved line item on the service agreement:

  • • Services must only be billed in consecutive date spans, to avoid duplicate billing
  • • 15-minute codes may be billed by more than one provider, per date of service
  • Eligible Recipients

    Recipients are eligible under one of the following programs:

  • Medical Assistance
  • MinnesotaCare (Benefit Sets differ depending on the service)
  • Waivered Service Programs
  • Covered Services

    Select the service below to view the policy information about each service:

  • Home Health Aide
  • Home Care Nursing (HCN)
  • Rehabilitation Therapies (physical, occupational, speech and respiratory therapy)
  • Skilled Nurse Visits
  • Services must be:

  • • Provided to an eligible recipient
  • • Medically necessary
  • • Physician ordered
  • • Provided in the recipient’s own residence
  • • Documented in a written care plan
  • Coordination with other MA Services
    with waiver and home care services

    Home Care & Individualized Education Plans (IEP)
    Covered IEP services include nursing services, personal care assistants (PCA), physical therapy, occupational therapy, speech language pathology, mental health services, special transportation, and assistive technology devices.

    The child may also be receiving these services through MA and/or a home and community-based services waiver. When services are provided through the school, they are considered IEP services and billed as such. IEP services are not considered or billed as home care, therapy or waiver services.

    Coordination of IEP services and home care services are assessed on a 24-hour non-school day. A parent/guardian may choose to use authorized home care or waiver services in the school rather than have the school bill for the education plan service:

  • • Services must be listed in the child’s IEP/IFSP/IIIP
  • • Permission must be given by the parent/guardian in the care plan and retained by the provider in their records
  • • The IEP services do not count against the prior authorization cap for home care services, will not be counted against the waiver cap or affect the amount of services available under the waiver and are not counted against DHS service limitations or thresholds for therapies.
  • • The IEP team and the home care provider, or waiver case manager, are responsible to coordinate and not duplicate services
  • For further information and details about IEP, refer to the IEP section.

    Non-Covered Services

  • • Services that are not ordered by the recipient’s physician
  • • Services that are not specified in the recipient’s service plan or care plan
  • • Services provided without authorization when required
  • • Services that have already been paid by Medicare, health plans, health insurance policies, or any other liable third party at more than the MHCP allowable amount
  • • HCN or PCA services provided to Minnesota Care non-pregnant recipients
  • • Services to other members of the recipient’s household
  • • Home care services included in the daily rate of a community-based residential facility where the recipient is residing
  • • Services that are the responsibility of the foster care provider under the terms of the foster care placement agreement and administrative rules
  • • Services provided when the number of foster care residents is greater than four (unless the county responsible for the recipient’s foster placement made prior to April 1,1992, requests that home care service be provided, and county or state case management is provided)
  • • Services provided to GAMC recipients
  • There may be additional non-covered services outlined under each provider-type specific covered service page.

    Authorization Requirements

    Prior authorization for home care services is required for:

  • • All home health aide services
  • • All home care nursing services
  • • Skilled nurse visits above nine visits per recipient, per calendar year for MA
  • • All tele-home-care visits
  • **Authorization is required after 9 skilled nurse visits per recipient, per calendar year, except for AC and waivered service program recipients who always require authorization.

    Submit Authorization Requests
    Submit authorization requests for SNV, HHA, and HCN directly to MHCP following the directions below..

    Before requesting an authorization:

  • • Verify MHCP eligibility online via MN–ITS
  • • Obtain all health insurance coverage information
  • • Use all insurance and Medicare benefits
  • Service Agreements (SA) may be either temporary (45 days), or long-term (up to 365 days or 366 days in a leap year). Approved home care authorization requests can begin the date the request is received unless the request meets an exception. MHCP must receive all the required information before authorization can be approved.

    Exceptions to Prior Authorization
    Authorization may be requested after a home care service is provided to a recipient only under the following conditions:

    Exceptional Condition

    Explanation for requesting authorization after performing service

    Procedure for SNV, HHA and HCN

    Emergency Service Provision

    The home care services were required to treat an emergency medical condition that, if not immediately treated, could cause a recipient serious physical or mental disability, continuation of severe pain, or death. You must be able to substantiate the emergency by documentation such as reports, notes, and admission or discharge history.

    Request retroactive authorization within five working from starting the initial

    Retroactive Eligibility

    Home care services were provided on or after the date on which the recipient’s eligibility began, but before the date the recipient was notified that their case opened.

    Request authorization within 20 working days of the date the recipient was notified that the case was opened.

    Third Party Payer

    A third party payer for home care services denied or adjusted a payment.

    Submit authorization requests to DHS within 20 working days of the notice of denial or adjustment. Include a copy of the third party payer’s notice with the request.

    Administrative Error

    The local county agency or DHS made an error.

    Submit the request within 20 working days and include a statement that specifies:

  • • which agency made the error
  • • what the error was
  • • when it occurred
  • • If a county agency made an error, supporting documentation from that agency must be included.
  • Medical Need

    The professional nurse determines an immediate medical need for up to 40 skilled nursing or home health aide visits per calendar year. Exceptions to prior authorization requests are evaluated according to the same criteria applied to prior authorization requests.

    MHCP cannot authorize Waiver or Alternative Care (AC) services requested by a home care provider. Refer to Elderly Waiver (EW) and Alternative Care (AC) Program chapter for more information about Waiver and AC programs.

    Changes in Medical Status or Primary Caregiver Availability

    Changes in medical status are either temporary for 45 days or less or long term for up to 365 days (366 days in leap years). These include, but are not limited to, a change in health or level of care, service addition, a change in physician orders, recent facility placement, or a change in primary caregiver’s availability. Documentation must support the requested change in service. Temporary authorizations can only be approved for 45 days or less. DHS cannot approve back-to-back temporary requests.

    Upon Receiving Service Authorization

    Review the Service Authorization immediately for content and comments. Line item dates may differ from header dates. If you have questions about this process, contact the Provider Call Center at (651) 431-2700 or 1-800-366-5411.

    Plan of Care

    The Home Care Nurse (HCN) Care Plan is a written description of professional nursing services needed by the recipient as assessed to maintain and/or restore optimal health.

    The orders or plan of care must:

  • • Specify the disciplines providing care
  • • Specify the frequency and duration of all services
  • • Demonstrate the need for the services and be supported by all pertinent diagnoses
  • • Include recipient’s functional level, medications, treatments, and clinical summary
  • • Be individualized based on recipient needs
  • • Have realistic goals
  • • Subsequent plans of care must show recipient response to services and progress since the previous plan was developed; and
  • • Changes to the plan of care are expected if the recipient is not achieving expected care outcomes.
  • Billing

    MHCP pays for services after the recipient has used all other sources of payment. MHCP is the payer of last resort. The order of payers for an MHCP recipient is:

  • • First, third party payers or primary payers to Medicare (e.g., large and small group health plans, private health plans, group health plans covering the beneficiary with End Stage Renal Disease for the first 18 months, workers compensation law or plan, no-fault or liability insurance policy or plan)
  • • Second, Medicare
  • • Third, MHCP Medical Assistance or MinnesotaCare
  • • Last, MHCP Waivered Services programs or Alternative Care (AC) program
  • Providers must bill all third party payers, including Medicare, and receive payment to the fullest extent possible before billing DHS. MHCP becomes the payer only after all other pay options (other than an MA waiver program) have been exhausted. Services that could have been paid by Medicare, an HMO, or insurance plan if applicable rules were followed are not covered by MHCP.

    Providers must be familiar with Medicare coverage for home care recipients. Bill Medicare when Medicare is liable for the service or, if not Medicare certified, refer the recipient to a Medicare certified provider of the recipient’s choice, and notify recipients when Medicare is no longer the liable payer for home care services.

    Medicare Home Health Prospective Payment System (PPS)
    If the service is covered by Medicare, then Medicare guidelines must be followed. This affects all dually eligible recipients (those covered under a Medicare home health plan of care and on Medical Assistance):

  • • Medicare requires consolidated billing of all home health services while a Medicare recipient is under a home health plan of care. All supplies and services listed under PPS are the responsibility of the Home Health Agency that has the recipient under an episode, and are not billable by other providers
  • • During each 60 day episode, the home health agency is responsible to bill Medicare all home health services, including:
  • • A home health agency affiliated or under common control with that hospital
  • • Care for homebound patients involving equipment too cumbersome to take to the home
  • • Home health aide services
  • • Medical services provided by an intern or resident-in-training at a hospital, under an approved teaching program of the hospital
  • • Medical social services
  • • Skilled nursing care
  • • Speech-language pathology
  • • Occupational therapy
  • • Physical therapy
  • • Routine and non-routine medical supplies
  • Home health services are paid on a cost basis. Therefore, the PPS rate assigned to the beneficiary includes all the above services. Home health agencies that do not have these services available need to hire staff and keep supplies on hand or contract services with other agencies.

    Multiple Providers of Services
    Each provider agency may be able to bill for the same type of service on the same day. Each agency must have an approved line item on the service agreement:

    • Services must only be billed in consecutive date spans, to avoid duplicate billing

    • 15-minute codes may be billed by more than one provider, per date of service

    Information about the Waivered Services and the Alternative Care (AC) program can be found in HCBS Waivered Services and Elderly Waiver and Alternative Care.

    Additional billing information and resources are available at the MHCP Provider Website.

    Legal References

    MN Statute 256B.0625
    MN Statute 256B.0651
    MN Statute 256B.0653
    MN Statute 256B.0654

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