D.C. Mun. Regs. tit. 29, r. 29-906

Current through Register Vol. 71, No. 49, December 6, 2024

Rule 29-906 - STANDARDS FOR MEDICAID REIMBURSEMENT OF PARENTERAL, ENTERAL AND INFUSION THERAPY IN THE HOME

906.1

Parenteral, enteral or infusion therapy shall only be provided by home health agencies certified for participation in the D.C. Medicaid Program.

906.2

Parenteral, enteral or infusion therapy in the home shall only be approved if the following conditions are present:

(a) Parenteral therapy shall be considered medically necessary only for a patient with severe pathology of the alimentary tract which does not allow absorption of sufficient nutrients to maintain weight and strength commensurate with the patient's general condition.

(b) Enteral therapy shall be considered medically necessary only for a patient with a functioning gastrointestinal tract who due to pathology or non-function of the structures that normally permit food to reach the digestive tract cannot maintain weight and strength commensurate with his or her general condition. Enteral therapy may be given by nasogastric, jejunostomy, or gastrostomy tubes; and

(c) Infusion therapy shall be considered medically necessary only for a patient that without the administration of infusible pharmaceuticals in a residential setting, would require the patient to remain in or be admitted to a hospital.

906.3

Prior authorization and reporting requirements shall be as follows:

(a) Providers of parenteral, enteral or infusion therapy shall obtain prior authorization from the Medical Assistance Administration (MAA) before treatment is begun;

(b) To obtain prior authorization, the home health agency shall submit a written plan of treatment that has been prescribed by a physician for each patient;

(c) The home health agency shall include the name and address of the supplier(s) providing the materials, drugs and equipment;

(d) The home health agency shall send monthly reports that detail the status of patients receiving parenteral, enteral or infusion therapy and any revisions in the plan of treatment to the MAA;

(e) Verification of supplies and/or drugs utilized shall also be included in the monthly reports; and

(f) If the therapy period was less than one month, the home health agency shall send written reports, detailing drug and supply utilization, to MAA for those patients receiving the parenteral, enteral or infusion therapy at the completion of therapy.

906.4

MAA shall reimburse for professional services in accordance with the current Medicaid rates of reimbursement for home health visits.

906.5

Reimbursement for drugs and supplies shall not exceed the area prevailing charges and shall be made as follows:

(a) The home health agency shall submit invoices for medical supplies and drugs directly to MAA;

(b) MAA shall determine the appropriate amount to be paid and reimburse the home health agency; and

(c) Unless the medical record establishes that the recipient due to his or her physical or mental state is unable to safely or effectively mix solution and there is no family member or other person who can do so, generally payment shall not be made for pre-mixed solutions.

906.6

Unless prior authorized by MAA, reimbursement to a pharmacy or provider of durable medical equipment for drugs or equipment shall be subject to the following terms and conditions:

(a) Upon notification of the closure of the home health agency providing services to the recipient until a new home health agency has been selected by the recipient for a period not to exceed ninety (90) days; or

(b) If a recipient's physician and home health agency have determined that the professional services associated with enteral feeding by j tube, g tube and ng tube is no longer required and that the caregiver has met the training criteria for enteral feeding.

D.C. Mun. Regs. tit. 29, r. 29-906

Final Rulemaking published at 48 DCR 8192 (August 31, 2001)

AUTHORITY: The authority for this section is D.C. Code, 2001 Ed. § 1-307.02; Reorganization Plan No. 4 of 1996, 3 D.C. Code, 2001 Ed. at 413; and Mayor's Order 97-42 (February 18, 1997).