Medicaid waiver billing for home care agencies

The programs behind the claims

Home and community-based services let Medicaid beneficiaries receive support in their own homes and communities rather than in institutions, under waivers and state plan options that each state designs for its own populations: older adults, people with physical or intellectual disabilities, people with behavioral health conditions.¹ For an agency, each program is a separate set of eligible services, codes, rates, authorization rules and payers, and a client can move between them. Waiver claims sit in the non-medical lane of home care billing, next to VA Community Care, long-term care insurance and private pay.

In many states those services are now administered by managed care plans. The authorization comes from the plan, the claim goes to the plan, and the plan's portal, edits and filing window apply. An agency serving three plans is running three billing rule sets whether it knows it or not.

The authorization is the claim's ceiling

• Service, units, period. An authorization names a service code, a number of units, usually in 15-minute blocks, and a start and end date. A visit outside any of the three is not paid.
• Units run down at different rates. A client authorized for personal care and respite uses them unevenly. The biller tracks each line against the schedule every week and flags the one that will run out first.
• Renewals need the plan's paperwork. A reassessment, an updated care plan, a physician signature in some programs. Requested early enough for the plan's turnaround, because a renewal may not be back-dated (North Carolina, for one, does not approve Innovations support plans retroactively).⁶
• Changes in the middle. A hospital stay, a facility placement, a move to another plan. Each one ends or suspends an authorization, and the agency often hears about it from the denial.

Codes, units and the EVV match

Waiver services are billed with HCPCS Level II codes, often from the T series, which CMS created for state Medicaid agencies' program needs, or the S series, which Medicaid programs may also use, with the modifiers and units each state defines.⁷ CMS maintains the code set and each state chooses what it uses.³ The claim for each visit has to match an electronic visit verification record for that visit: the service, the client, the date, the location, the caregiver and the start and end time, inside the state's tolerances.^{2, 8} A visit with an uncleared EVV exception is a frequent reason a waiver claim is held, and clearing exceptions before the batch goes out is the routine that keeps cash on schedule.

IDD agencies: group homes and day programs

Agencies serving people with intellectual and developmental disabilities bill the same way with different services. A 1915(c) waiver can target people with intellectual disabilities, or a diagnosis such as autism, cerebral palsy or traumatic brain injury, and its standard services are case management, homemaker, home health aide, personal care, adult day health, habilitation, both day and residential, and respite, each delivered under a person-centered plan of care.⁴ The claim behind each one is still an authorization, a unit and a record.

• Residential supports bill by the day; day and in-home supports by the quarter hour. Maryland's Developmental Disabilities Administration, for example, pays Community Living, Group Home Support as a daily unit, Day Habilitation and Personal Supports in 15-minute units, and employment services on monthly and milestone units.⁵
• Authorization comes from the plan. Each DDA service is authorized against the participant's Person-Centered Plan before it is billed through LTSSMaryland, and the guide lists the services that cannot be billed in the same unit of time.⁵
• Documentation is per unit. Day habilitation needs an attendance log with in and out times, a service note or activity log, and staff timesheets covering the hours billed.⁵
• EVV reaches in-home IDD services. The federal EVV rule covers Medicaid personal care services under 1915(c) waivers, and Maryland records the start and stop times of supports delivered in the person's own home in the state EVV system.^{2, 5}
• Managed IDD programs add a payer layer. North Carolina's Innovations Waiver is managed, county by county, by four LME/MCOs, and the individual support plan has to carry the signatures Clinical Coverage Policy 8P requires.⁶ One agency in such a state is billing one program under several payers.

Why waiver claims are denied

• No authorization or units exceeded. The visit was delivered after the end date or past the units, and the renewal came in late.
• EVV mismatch. The visit record does not match the claim, or the exception was never cleared.
• Eligibility. The client lost waiver eligibility for the month, moved plans, or was in a facility on the date of service.
• Duplicate. Another agency, or a self-directed caregiver, billed the same hours.
• Timely filing. The plan's window passed while an authorization or an exception was being sorted out.
• Rate or unit edits. Units rounded generously, a code the plan does not pay this provider type for, or a modifier the state requires missing.

The weekly routine

1. Eligibility rechecked for every active client at the start of the month.
2. Units used against units authorized, per client and service, with the next renewal date.
3. Schedule-to-claim reconciliation: every visit delivered has a claim, an EVV record and an authorization, or a documented reason it cannot be billed.
4. Claims to each state program and plan in its own format and window; remittances posted and denials worked to a cause.
5. One page for the owner: visits delivered, billed, paid and held, by payer, with what is stuck and why.