Home care billing in Idaho

Fee-for-service for most members. The only Idaho programs that carry home care are for full dual eligibles: Idaho Medicaid Plus, a 1915(b)/(c) program since November 1, 2018 that is mandatory for full duals in some counties and voluntary in others, and the voluntary Medicare/Medicaid Coordinated Plan, a 1915(a)/(c) program since July 1, 2014. Both cover home health, state plan personal care, HCBS waiver services, private duty nursing and hospice in the CMS 2024 tables.² The CMS 2024 tables named Molina of Idaho and Blue Cross of Idaho as the plans; the Department's current members page names Molina Healthcare of Idaho and UnitedHealthcare Community Plan of Idaho, lists 34 counties where Idaho Medicaid Plus is mandatory for duals who are not in the MMCP, and says developmental disability services stay with Idaho Medicaid outside the MMCP (IDHW Medicare Medicaid Members page, cited below). For everyone else, waiver providers are paid fee-for-service as the Department sets (IDAPA 16.03.10.330, cited below), and Healthy Connections, the statewide primary care case management program, covers only case management.

Provider choice. Since July 1, 2021, agencies delivering personal care, private duty nursing and the Aged and Disabled waiver's attendant care, homemaker and respite must submit claims using a compliant EVV system: one the agency chooses and has certified as compliant with the MMIS aggregator, and the visit data has to reach the aggregator before the claim is billed.³ The Department's long-term care provider page lists the six data elements the system must capture (the type of service, the person receiving it, the date, the location, the person providing it, and the start and end times), extends the Cures Act requirement to home health services that need an in-home visit, and sends alternate vendors to Gainwell Technologies for compatibility testing and technical specifications (IDHW provider resources page, cited below). CMS found Idaho compliant for personal care EVV in a July 30, 2021 letter, which replaced its January 4, 2021 determination, covering the 1905(a)(24) state plan benefit and 1915(c) waivers; Medicaid.gov lists home health care services compliant as of January 1, 2023, the federal deadline.

Services under EVV³

• Personal care services (PCS)
• Private duty nursing services
• Aged and Disabled waiver attendant care
• Aged and Disabled waiver homemaker
• Aged and Disabled waiver respite

By the Department, before the service. Every Aged and Disabled waiver service must be pre-authorized by the Department from the Uniform Assessment Instrument (UAI), the individual service plan and medical information that confirms the need for nursing facility services; the Department administers the UAI itself and writes the initial service plan with the participant, the guardian when appropriate, and the supervising nurse or case manager. The service plan is revised at least annually or when needs change.⁶ Personal care follows the same pattern: every PCS service is prior authorized by the Department from the assessment, the written plan of care or negotiated service agreement that the personal assistance agency prepares with the participant, and medical information, and the plan is updated at least annually (IDAPA 16.03.10.304, cited below). For dual eligibles in Idaho Medicaid Plus or the MMCP, the Department directs questions about the UAI, the service plan and authorizations to the health plan's utilization management team instead (IDHW long-term care provider information page, cited below).

To Idaho Medicaid, whose MMIS claims processing center is run by Gainwell Technologies, within twelve months (365 days) of the date of service. For personal care and the waiver's attendant care, homemaker and respite, the EVV record has to reach the aggregator first, or the claim is not eligible for payment.⁹ Personal care is paid at the Department's uniform rate on claim forms the Department provides or approves, and waiver claims go on forms approved by the Department or its contractor, with mileage built into the waiver fees (IDAPA 16.03.10.307 and 16.03.10.330, cited below). Claim questions go by secure message through the provider's Trading Partner Account at idmedicaid.com (IDHW Medicaid provider information page, cited below). For Idaho Medicaid Plus and MMCP members, the plan covers these services, so the claim follows the member's plan.

National Government Services, the A/B MAC for Jurisdiction 6, processes Medicare home health and hospice claims for Idaho as part of a region of 13 states and five territories that includes Washington, Oregon, Nevada and California; its Part A and Part B work covers Illinois, Minnesota and Wisconsin instead.¹⁵ On the Medicaid side, home health, private duty nursing and hospice are plan benefits for Idaho Medicaid Plus and MMCP members in the CMS 2024 tables, and fee-for-service otherwise. Medicaid.gov lists Idaho compliant with the Cures Act home health EVV requirement as of January 1, 2023, the federal deadline (Medicaid.gov EVV pages, cited below).