Home Health Care Form

Page 1 of 3 Home Health Care Policy Last Reviewed / Revised: 5/30/2025 ALOHACARE Policy Number: MP-35

Policy Name: Home Health Care

Line of Business: QUEST Integration (Medicaid)

Original Effective Date: 10/20/25

Review/Revision Dates: N/A

Attachment(s): No

I. PURPOSE:

The purpose of this policy is to define the medical necessity criteria, coverage guidelines, limitations, and administrative requirements for home health care services.

II. DESCRIPTION

Home health care refers to intermittent skilled health care related services provided by a licensed
home health agency to an individual in his or her place of residence. Skilled health care related
services include skilled nursing care and physical, occupational, and speech therapies.

“Homebound” is defined according to the CMS definition below.

A. Criteria-One:

• The patient must— i. Because of illness or injury, need the aid of supportive devices such as crutches, canes, wheelchairs, and walkers; the use of special transportation; or the assistance of another person in order to leave their place of residence

• OR i. Have a condition such that leaving his or her home is medically contraindicated.

  If the patient meets one of the Criteria-One conditions, then the patient must ALSO meet two additional requirements defined in Criteria-Two below.

Page 2 of 3 Home Health Care Policy Last Reviewed / Revised: 5/30/2025

B. Criteria-Two: i. There must exist a normal inability to leave home;

• AND i. Leaving home must require a considerable and taxing effort.

  III. POLICY CRITERIA:

  Home health care services are covered when ALL the following criteria are met: A. Services are to treat an illness or injury and are prescribed in writing by a physician. B. One of the following conditions is met and documented:

  1. The patient is homebound due to injury or illness, i.e., the patient’s condition is such that there exists an inability to leave home or doing so requires a considerable and taxing effort. The patient is homebound, and the specific service(s) would avoid or delay hospitalization at an acute level of care for the condition being treated. The specific condition being treated must be stated.
  2. The patient is not homebound, but services cannot be performed in a clinic, outpatient setting or a physician’s office. The reason why services cannot be performed in these settings must be documented.
  3. The patient is not homebound but has a history of recurrent hospitalization, which may be prevented by skilled nursing monitoring and timely intervention. Without home health care services, the patient would require inpatient hospital or skilled nursing facility care. Dates and reasons for recurrent hospitalization must be documented. C. The patient requires intermittent skilled health services that are non-custodial in nature. D. The skilled services are reasonable and necessary to the treatment of the patient’s illness or injury. To meet reasonable and necessary criteria: a. The services must be consistent with the nature and severity of the illness or injury, the patient’s particular medical needs, including the requirement that the amount, frequency and duration of the services must be reasonable. b. The services must be provided with the expectation that the condition of the patient will improve materially in a reasonable and generally predictable period of time. E. Services are provided by a licensed home health agency and licensed clinicians. F. For continuation of services, the physician has reviewed the plan of care every 60 days and certified that continued skilled services are necessary. G. For resumption of care following interruption in services (e.g., due to (re)hospitalization), the physician has reviewed the plan of care, certified that continued services are necessary, and updated the plan of care, as applicable. When the necessary services are substantially different from the initial plan of care, AlohaCare will consider resumption of services a new episode of care subject to Administrative Guidelines.

Page 3 of 3 Home Health Care Policy Last Reviewed / Revised: 5/30/2025 IV. LIMITATIONS

A. Home health care services are not covered in the following situations:

1. The patient is no longer homebound, except for situation of III.B.3 and III.B.4.
2. Goals of treatment have been achieved.

3. The patient or willing caregiver is able to perform the necessary care. B. In general, home health services are expected to be short term. C. Unsupervised physical therapy assistant services and unsupervised occupational therapy assistant services are not covered.

   V. ADMINISTRATIVE GUIDELINES

   A. Prior authorization is not required for the initial evaluation for respective skilled disciplines (e.g., physical/occupational therapy, skilled nursing) ordered by a physician. B. Prior authorization for treatment is required every 60 days. Submit a prior authorization request form to AlohaCare via fax, mail or electronic prior authorization (EPA). The following documentation must be submitted:

4. For initial requests: i. Plan of care signed by the treating physician that includes the frequency, duration, and type of home health services (e.g., part-time skilled nursing services, physical, occupational and/or speech therapy); ii. Medical records supporting that criteria III.A – III.F are met.

5. For continuation requests, medical records supporting the need for continuation (e.g., physician’s, nurse’s and/or therapist’s notes). C. For resumption of care following an interruption in services where plan of care is substantially different from the initial plan of care, a separate authorization form with the updated plan of care must be submitted.

   VI. IMPORTANT REMINDER This policy has been developed through consideration of the medical necessity criteria under Hawaii’s Patients’ Bill of Rights and Responsibilities Act (Hawaii Revised Statutes §432E- 1.4) or for QUEST members under Hawaii Administrative Rules (HAR 1700.1-42), generally accepted standards of medical practice and review of medical literature and government approval status.

   VII. RESOURCES AND REFERENCE DOCUMENTS

   A. Centers for Medicare and Medicaid Services, Medicare Benefit Policy Manual. Chapter 7-Home Health Services REV. 258, 03-22-19.