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New York Provider Manual
10.4 Durable Medical Equipment (DME), Orthotics & Prosthetics | 10.6 Dental

10.5 Home Healthcare

Healthfirst members are eligible to receive medically necessary  home healthcare services provided by a Certified Home Health Agency (CHHA). Home care providers participating with Healthfirst include CHHAs maintained by member hospitals, and other contracted CHHAs. For a listing of participating CHHAs, see the Provider Directory.

Services and Eligibility

The services listed below comprise the scope of covered home healthcare benefits:

·     Intermittent or part-time nursing visits rendered by a registered nurse
·     Intravenous therapy as ordered by a provider
·     Home health aide services provided under the direction and supervision of a registered nurse. Other services to be delivered in the home setting as requested by the PCP or attending specialist and approved by Medical Management
·     DME, oxygen, respiratory devices, and other equipment and supplies required to care for the member in the home
·     Treatment adherence home assessments for some members on Highly Active Anti-Retroviral Therapy (HAART) treatment adherence home assessments for some members on Highly Active Anti-Retroviral Therapy (HAART)
·     In order to be eligible to receive home healthcare services, members must meet all of the following criteria:
·     be confined to the home
·     be under a plan of treatment established and periodically reviewed by a provider
·     be in need of intermittent skilled nursing care, physical therapy, speech therapy, or, in certain situations, occupational therapy 

Responsibilities of Certified Home Health Agencies

All participating CHHAs must complete the following steps when providing care for Healthfirst members.

·     Verify member eligibility through eMedNY for Medicaid members or by calling Member Services at
·     Develop a treatment plan based on an assessment of the member’s physical, psychological, and social needs
·     Obtain the signature of the provider who initially recommended home healthcare services on the treatment plan
·     Call Medical Management at 1-888-394-4327 for prior authorization of services
·     If changes to the treatment plan are required within the period for which home health services have been approved, the CHHA will notify the PCP or specialist and will contact Medical Management to obtain further authorization
·     If the duration of the home healthcare service period needs to be extended, the CHHA shall notify the treating provider and shall obtain authorization from Healthfirst for the extension. Healthfirst will also notify the PCP or specialist of authorized changes
·     If DME is required as part of the approved treatment plan, the CHHA shall request separate and simultaneous prior authorization of the home healthcare treatment plan and associated DME and/or home infusion therapy from Healthfirst
·     Issue the Healthfirst Notice of Noncoverage to Medicare members two (2) days prior to end of services and retain a signed copy of the notice. CHHA must provide Healthfirst with notice by close of business when requested for QIO appeal. The provider shall be responsible for those services in which the Notice of Noncoverage is not issued to the member with the appropriate signatures within the required time frames.

Prior Authorization Process: General Guidelines

Home healthcare providers are responsible for obtaining authorization from Medical Management before providing services. Home healthcare services must be coordinated with the member’s PCP or attending specialist in accordance with the prescribed plan of care. It is expected that home care providers will inform members under their care about specific healthcare needs requiring follow-up and will teach members appropriate self-care and other measures to promote their own health. Medical necessity guidelines are used to determine the appropriateness of setting for home healthcare. Home healthcare services requested solely for convenience, for activities of daily living, or that are custodial in nature are not a covered benefit.

Please note: If the only service required is venipuncture, it will not qualify for the Healthfirst Medicare Plan home health benefit. Insulin shots for members who are incapable of self-administration are a covered benefit in the home.

Healthfirst members may be referred for home healthcare services by PCPs, specialists, or hospital discharge planners by one of the following methods:

Referrals to Hospital-Owned or Hospital-Operated Home Health Agencies

When a Healthfirst member is referred to a participating hospital-operated home health agency for home care services, the referral must be made by the member’s PCP, the attending specialist, or a hospital discharge planner with approval from the appropriate provider. Referral policies and procedures are based on the current home healthcare referral process of the participating hospital.  Home care services must be pre-authorized by Healthfirst. 

Referrals to Other Contracted Certified Home Health Agencies

When a Healthfirst member in Nassau or Suffolk County is referred for home healthcare or home infusion services to a contracted CHHA other than a hospital-owned or operated agency, the referring provider must contact Medical Management at 1-888-394-4327 to pre-authorize services through a participating home health agency. Medical Management staff will work with the referring provider to confirm the agency’s participation status with Healthfirst and to direct the referral to the appropriate individual responsible for developing a plan of care and initiating services.

Personal Care Services—Medicaid, CompleteCare and AbsoluteCare

Healthfirst Personal Care Services provides qualified members with partial or total assistance with personal hygiene, dressing and feeding, and nutritional and environmental support functions. Such services must be essential to the maintenance of the member’s health and safety within his or her own home, as determined by Healthfirst in accordance with the regulations of DOH; ordered by the attending provider based on an assessment of the beneficiary’s needs; provided by a qualified person in accordance with a plan of care; and supervised by a registered professional nurse.

There are two levels of personal care services:

·     Level I services are limited to the performance of environmental and nutritional functions, including dusting, vacuuming, dishwashing, shopping, laundry, and meal preparation and Healthfirst confidential and proprietary information. Unauthorized use, disclosure or reproduction is strictly prohibited.
·     Level II services include Level I services and personal care functions such as assisting members with bathing, grooming, bathroom and/or bedpan routines, walking, transferring from bed to chair or wheelchair, and assistance with self-administration of medications.