OAR 410-127-0060: Reimbursement and Limitations

(1) The Division reimburses home health services on a fee schedule by type of visit (see home health rates on the Authority’s website at: http://www.oregon.gov/OHA/HSD/OHP/Pages/Policy-Home-Health.aspx). (2) The Division recalculates its home health services rates every other year. The Division shall reimburse home health services at a level of 74 percent of Medicare costs reported on the audited, most recently accepted or submitted Medicare Cost Reports prior to the rebase date and pending approval from the Centers for Medicare and Medicaid Services (CMS), and, if indicated, legislative funding authority. (3) The Division shall request the Medicare Cost Reports from home health agencies with a due date and shall recalculate potential rates based on the Medicare Cost Reports received by the requested due date. The home health agency shall submit requested cost reports by the date requested. (4) The Division reimburses only for services that are medically appropriate. (5) Limitations: (a) Limits of covered services: (A) Skilled nursing visits are limited to two visits per day with payment authorization; (B) All therapy services are limited to one visit or evaluation per day for physical therapy, occupational therapy, or speech-language pathology services. Therapy visits require payment authorization; (C) Home health aide services are limited to those ordered by a physician, included in the plan of care, permitted to be performed under state law, consistent with home health aide training, and under the direction of a registered nurse or licensed therapist familiar with the client and the client’s plan of care. These services must not duplicate other Medicaid-paid personal care services. (D) The Division shall authorize home health visits for clients with uterine monitoring only for medical problems that could adversely affect the pregnancy and are not related to the uterine monitoring; (E) Medical supplies must be billed at acquisition cost, and the total of all medical supply revenue codes may not exceed $50 per day. Only supplies that are used during the visit or the specified additional supplies used for current client/caregiver teaching or training purposes as medically appropriate are billable. Client visit notes must include documentation of supplies used during the visit or supplies provided according to the current plan of care; (F) Durable medical equipment must be obtained by the client by prescription through a durable medical equipment provider. (b) Services not covered: (A) Service not medically appropriate; (B) A service for a diagnosis that does not appear on a line of the Prioritized List of Health Services that has been funded by the Oregon Legislature (OAR 410-141-0520); (C) Medical social worker service; (D) Registered dietician counseling or instruction; (E) Drug and biological; (F) Fetal non-stress testing; (G) Respiratory therapist service; (H) Flu shot; (I) Psychiatric nursing service.