Home Health Care Attendant Care Respite Care

Home Health, Attendant Care, Respite Care Coverage, Coding and Billing

Federal Medicare Home Health Care PPS Dates to Balanced Budget Act of 1997

The 1997 Balanced Budget Act (BBA), amended by the Omnibus Consolidated and Emergency Supplemental Appropriations Act (OCESAA) of 1999, provided for implementation of a prospective payment system (PPS) for home health services (HHS).

HHS is provided to Medicare patients but is provided to adults, pediatric patients under the Americans with Disabilities Act (ADA) and Medicare, or State Medicaid and state attendant care Standards.Respite Care is an Essential Benefit of the Affordable Care Act, but a New Supreme Court Case is Pending in November 2020 that May Change Certain Essential Health Benefit Limits

Respite care (provided that it is proven to be Medically Necessary) is substitute care. A respite caregiver is a person who takes over when the primary caregiver takes a break.  Habilitative Services: Habilitative services are one of the ten essential health benefits required under the ACA; however, states are allowed to produce their definition of what this means.  Twenty-nine states have not only passed autism insurance mandates requiring private insurers to offer alternative benefit plans, including Applied Behavior Analysis (ABA) therapy in state regulated plans, but they have also opted to mandate the benefit in Affordable Care Act plans sold on the exchange.

These states are Alaska, Arizona, Arkansas, California, Colorado, Connecticut, Delaware, Illinois, Indiana, Kentucky, Louisiana, Maine, Maryland, Massachusetts, Michigan, Missouri, Montana, Nevada, New Hampshire, New Jersey, New Mexico, New York, Ohio, Oregon, Texas, Vermont, West Virginia, Washington, and Wisconsin (from Autism Speaks). Minnesota began to require ABA in its Affordable Care Act plans, but not until 2016.

The Supreme Court will hear a new case and is expected to rule on the constitutionality of the Affordable Care Act (ACA) this November in California v. Texas (known as Texas v. U.S. in the lower courts)

State Medicaid Programs for Home Health and Attendant Care

Each state administers Federal funds in Medicaid programs.  Each state Medicaid program may offer different HHS benefits. For example, in California, Ohio, Texas, and Florida, federal programs and state the programs are available.

Texas Home Health Services Provides:

  1. Institutional / Nursing Home Medicaid
  2. Medicaid Waivers / Home and Community-Based Services
  3. Regular Medicaid / Aged Blind and Disabled

In Texas,

  1. Senate Bill 7 from the 2013 Texas Legislature requires Texas Health and Human Services Commission to put a cost-effective option for attendant care and habilitation services for people with disabilities who have STAR+PLUS Medicaid coverage. STAR+PLUS, which is for people who have disabilities OR who are age 65 or older.  It is designed to provide a choice of care setting at home, rather than in a nursing facility.
  2. Community First Choice, allows states to provide home and community-based attendant services/attendant care and support to Medicaid insureds with disabilities using federal funds. This option provides states with six percent more in federal matching funds. To be eligible for Community First Choice services, one must first qualify for State Medicaid, need help with daily living, and need an institutional level of care.
  3. Primary Home Care or PHC is another form of Long-Term Care for adults with a statement of medical need whose health problems limit their ability to independently complete daily living activities.

Texas Community Attendant Services – Clinical Eligibility in Summary

Texas Community Attendant Services (CAS) is available to eligible adults and children whose health conditions result in functional limitations in performing activities of daily living. An attendant provides services.  Medical necessity is determined by a licensed clinician’s statement of medical need.

Texas Attendant Services – Financial Eligibility in Summary

For 2019 individuals must have ma monthly income less than $27,756 per year, and assets valued at less than $2,000.  For a household of two, the monthly income limit is $54,512 per year and purchases of less than $3,000. Assets such as a home up to a value of $585,000 may be exempt. Financial eligibility changes annually and is calculated as a percentage of the SSI income limit. There are no age restrictions for eligibility.

Texas Respite Care has similar provisions, subject to medical necessity determinations.

Generally, respite care and attendant care are covered at the state level.  Federal Medicare local coverage determinations and national coverage determinations are scant.

Billing for Home Health Care Medical Coding and Medical Billing

Home Healthcare uses HHRGs, and until January 2020, reimbursement was based on the prospective payment system but is now based on PDGMSee this post, which discusses many changes in the PDGM system commencing in 2020.

Attendant Care and Respite Care Medical Coding and Medical Billing

Generally, the HCPCS coding system is used.  Examples:

S9125 – Respite care, in the home, per diem

S5125 – Attendant care services; per 15 minutes

Autism Health Insurance.org http://www.autismhealthinsurance.org/health-plan/affordable-care-act#facts

Behavior Analysis is the scientific study of behavior. Applied Behavior Analysis (ABA) is the application of the principles of learning and motivation from Behavior Analysis, and the procedures and technology derived from those principles, to the solution of problems of social significance. Many decades of research have validated treatments based on ABA. Source: Center for Autism Therapy. http://www.centerforautism.com/aba-therapy.aspx

According to the State of Texas, Section 4000, subpart 4121 Community First Choice Personal Assistance Services, Revision 19-1; Effective June 3, 2019

“Community First Choice (CFC) personal assistance service (PAS) provides assistance with activities of daily living (ADLs) and instrumental activities of daily living (IADLs) through hands-on assistance, supervision and/or cueing. Assistance is provided to a member in performing ADLs and IADLs based on a person-centered service plan. CFC PAS include:

  • Non-skilled assistance with the performance of ADLs and IADLs;
  • Household chores necessary to maintain the home in a clean, sanitary and safe environment;
  • Escort services, which consist of accompanying, but not transporting, and assisting a member to access services or activities in the community; and
  • Assistance with health-related tasks. Health-related tasks, in accordance with state law, include tasks delegated by a registered nurse (RN), health maintenance activities and extension of therapy. An extension of therapy is an activity that a speech therapist, physical therapist or occupational therapist instructs the member to do as follow-up to therapy sessions. If appropriate, the member’s attendant can assist the member in accomplishing such activities with supervision, cueing and hands-on assistance.

In the Consumer Directed Services (CDS) model, the member or legally authorized representative determines health-related tasks without a nurse assessment, in accordance with §531.051(e)  of the Texas Government Code and §225.4 of the Texas Administrative Code.

CFC PAS is the same service (i.e., attendant care) as Personal Care Services (PCS). The only difference is the level of care (LOC) requirement and how the service is billed. Information used to build a plan of care for CFC PAS may be found in the STAR Kids Screening and Assessment Instrument (SK-SAI) Personal Care Assessment Module (PCAM). The PCAM is administered if triggered by certain items on the SK-SAI (see Appendix I, MCO Business Rules for SK-SAI and SK-ISP) or if the member requests CFC services. Although the PCAM may be triggered if the member has an attendant care need, the member may only receive CFC PAS if the member meets CFC level of care criteria.”



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Michael F. Arrigo

Michael is Managing Partner & CEO of No World Borders, a leading healthcare management and IT consulting firm. He serves as an expert witness in Federal and State Court and was recently ruled as an expert by a 9th Circuit Federal Judge. He serves as a patent expert witness on intellectual property disputes, both as a Technical Expert and a Damages expert. His vision for the firm is to continue acquisition of skills and technology that support the intersection of clinical data and administrative health data where the eligibility for medically necessary care is determined. He leads a team that provides litigation consulting as well as advisory regarding medical coding, medical billing, medical bill review and HIPAA Privacy and Security best practices for healthcare clients, Meaningful Use of Electronic Health Records. He advises legal teams as an expert witness in HIPAA Privacy and Security, medical coding and billing and usual and customary cost of care, the Affordable Care Act and benefits enrollment, white collar crime, False Claims Act, Anti-Kickback, Stark Law, physician compensation, Insurance bad faith, payor-provider disputes, ERISA plan-third-party administrator disputes, third-party liability, and the Medicare Secondary Payer Act (MSPA) MMSEA Section 111 reporting. He uses these skills in disputes regarding the valuation of pharmaceuticals and drug costs and in the review and audit of pain management and opioid prescribers under state Standards and the Controlled Substances Act. He consults to venture capital and private equity firms on mHealth, Cloud Computing in Healthcare, and Software as a Service. He advises ERISA self-insured employers on cost of care and regulations. Arrigo was recently retained by the U.S. Department of Justice (DOJ) regarding a significant false claims act investigation. He has provided opinions on over $1 billion in health care claims and due diligence on over $8 billion in healthcare mergers and acquisitions. Education: UC Irvine - Economics and Computer Science, University of Southern California - Business, studies at Stanford Medical School - Biomedical Informatics, studies at Harvard Medical School - Bioethics. Trained in over 10 medical specialties in medical billing and coding. Trained by U.S. Patent and Trademark Office (USPTO) and PTAB Judges on patent statutes, rules and case law (as a non-attorney to better advise clients on Technical and Damages aspects of patent construction and claims). Mr. Arrigo has been interviewed quoted in the Wall Street Journal, New York Times, and National Public Radio, Fortune, KNX 1070 Radio, Kaiser Health News, NBC Television News, The Capitol Forum and other media outlets. See https://www.noworldborders.com/news/ and https://www.noworldborders.com/clients/ for more about the company.

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