Medicaid Home Health

Any person receiving Health First Colorado (Medicaid) can receive home health care services, provided the individual meets the eligibility requirements. To receive home health services, the individual must need medically necessary services (as defined by a physician) for the treatment of an illness, injury or disability (including mental disorders); the amount, duration and frequency of service must be reasonable; the services must be part of the care plan; care must be provided on an intermittent (not 24-hour) basis, and the only alternative to home care is the hospital or emergency room.

Home care must be provided in the home (including assisted livings and hotels, but not nursing homes or adult day care), and there must be no unpaid caregiver willing and able to provide the services (families cannot be forced to care for someone).

How to get Health First Colorado covered home health care
A physician must order the home care services, and they must be provided by a state certified home health agency accepting and abiding by Health First Colorado rules. Long term home care must also be approved by the Options for Long Term Care agency .

The physician’s order is submitted to the Options for Long Term Care agency, which has ten working days from receipt to complete a face-to-face assessment. Based on that assessment, home care will be approved or denied, in conjunction with the care plan. The care plan must be reviewed every six months, by phone, at the residence, place of service or other appropriate setting.

What services can be received and for how long?
Acute home health care services can be provided for 60 calendar days from the onset of such conditions as infections, stroke, cancer, injury, post-surgical recovery, post hospital care or exacerbated chronic conditions.

Home health aide services can include skilled and unskilled personal care and homemaking. They must be supervised by a registered nurse. Skilled personal care includes those tasks that require a nurse aide, like bathing, shaving, dressing, feeding, ambulation, exercise, transfers, positioning, medication reminding, accompaniment, protective oversight and care for skin, hair, nails, mouth, bladder, bowels, and respiratory systems. Homemaking services may include light housekeeping, meal preparation, dishwashing, bed making, laundry, shopping, and teaching of skills.

Many services will require a prior authorization from the Options for Long Term Care agency. A referral for these services must be part of the care plan, and prior authorizations can be issued for a maximum of one year, though a new plan of care must be submitted every two months.

Services requiring prior authorization include long-term home care (over 61 calendar days unless it is a chronic condition), pre-pouring of medications and two-person transfers.

Limitations on coverage
Home health care services can be provided for a maximum of 60 days, unless approved by the Options for Long Term Care agency for long term care.

Unskilled and homemaking services will not be provided unless the individual is also receiving skilled services as well. Regular homemaker services should be provided by Home and Community Based Services.

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