Medicare and Texas Medicaid home health, explained

Most skilled home health in Texas is paid for by Medicare, Texas Medicaid or a managed care plan that follows their rules. Medicare is the federal program for people 65 and older and some younger people with disabilities. Texas Medicaid is the joint state and federal program run by the Texas Health and Human Services Commission (HHSC) and administered for providers by the Texas Medicaid & Healthcare Partnership (TMHP).

Some patients have both, known as dual eligibility. In that case Medicare usually pays first for covered home health, and Medicaid may cover services Medicare does not. Before the first visit, OceanCare verifies which program and plan applies, so patients and families are not surprised later. Ask our intake team which Medicaid and managed care plans we currently accept.

Under Original Medicare, a patient generally qualifies for home health when all of these are true (Medicare.gov):

• They are under the care of a doctor or allowed practitioner, and services follow a plan of care that is reviewed regularly.
• They need part-time or intermittent skilled nursing, physical therapy, speech-language pathology or continuing occupational therapy.
• They are homebound, meaning leaving home takes a considerable and taxing effort.
• A doctor or allowed practitioner has had a face-to-face encounter with them related to the reason for home health.
• The agency is Medicare-certified.

Covered home health visits have no copay. Durable medical equipment ordered by the physician is usually covered at 80% after the Part B deductible. Medicare Advantage plans cover the same benefit but may require prior authorization and use their own provider networks.

Every Medicare-certified agency follows the federal Conditions of Participation in 42 CFR Part 484: patient rights, a comprehensive assessment, a written plan of care, coordinated services, aide training and supervision, infection control and a quality improvement program.

Medicare protects patients from surprise bills and sudden changes in care through standard written notices. Home health agencies must use the forms published in the CMS Beneficiary Notices Initiative:

• Advance Beneficiary Notice of Noncoverage (ABN, Form CMS-R-131). Given before an agency provides an item or service that Medicare usually covers but is not expected to pay for in this case, so the patient can decide whether to receive it and who will pay.
• Home Health Change of Care Notice (HHCCN, Form CMS-10280). Given before an agency reduces or stops a service in the plan of care because of physician orders or agency limitations (CMS HHCCN).
• Notice of Medicare Non-Coverage (NOMNC, Form CMS-10123). Given before all Medicare-covered home health services end. It explains the right to a fast appeal to the Quality Improvement Organization (QIO) if the patient believes services are ending too soon.

At OceanCare, the clinician explains each notice in plain language, answers questions and makes sure the patient or representative receives a copy. Language assistance is available at no cost.

Texas Medicaid covers skilled nursing by a registered nurse or licensed vocational nurse, home health aide visits, physical and occupational therapy, and medical supplies and equipment when they are medically necessary and provided through an enrolled home health agency (1 Tex. Admin. Code § 354.1039; TMHP).

The rules differ from Medicare in important ways. Under the Texas Medicaid Provider Procedures Manual (TMHP home health handbook):

• Prior authorization is required for skilled nursing and home health aide visits. After the agency's RN completes the home evaluation, the agency must request authorization within three business days of the start of care.
• Authorizations last up to 60 days. Recertifications must be authorized within seven business days of the new start of care date.
• Visits are limited to a combined total of three skilled nursing and aide visits per day, each up to 2.5 hours.
• Care continues during review. The agency delivers the requested services from the agreed start of care date while the request is processed.
• Medicaid managed care plans (such as STAR and STAR+PLUS health plans) handle their own members' authorizations, following the same core rules.

Services furnished without required prior approval are not covered, which is why our intake team confirms the payer and authorization path before scheduling.

Since January 1, 2024, Texas has required Electronic Visit Verification (EVV) for Medicaid home health care services that involve an in-home visit, under the federal 21st Century Cures Act (Texas HHS EVV). EVV records the type of service, the patient, the clinician, the location and the exact start and end time of each visit.

For patients, this means the nurse, aide or therapist will clock in and out at the visit, usually with a mobile app. Claims that do not match a verified visit are denied. EVV protects patients by confirming that authorized care was actually delivered, and it protects the program from billing for visits that did not happen.

Any agency that bills Medicare or Medicaid must not employ or contract with people excluded from federal or state health programs. The Texas HHS Office of Inspector General says providers should check the Texas Exclusions List monthly, and the federal HHS-OIG exclusion list (LEIE) is the primary source for federal exclusions.

OceanCare screens every employee and contractor against the state and federal exclusion lists before hire and every month after, verifies professional licenses, and checks unlicensed staff against the Texas Employee Misconduct Registry and Nurse Aide Registry. We document each check.

Anyone can report suspected Medicaid fraud, waste or abuse, including billing for visits that did not happen, and callers may remain anonymous:

• Texas HHS Office of Inspector General Fraud Hotline: 800-436-6184, or online through the Texas OIG.
• Concerns about care or safety at a licensed agency: Texas HHSC Complaint and Incident Intake, 1-800-458-9858 (Texas HHS).
• Abuse, neglect or exploitation of an adult: call 911 in an emergency.

OceanCare will never retaliate against a patient, family member or employee who raises a concern or makes a report.

For a smooth start of care, send the referral with the physician or allowed practitioner order, face-to-face encounter documentation for Medicare patients, the discharge summary or recent history and physical, the medication list and insurance information, including the Medicaid ID or managed care plan when applicable.

We confirm eligibility, request any required authorization within the program's deadline, and tell you if a payer issue could affect the start date. You get one coordinator and a clear answer, not a guess.