Home care billing in West Virginia

Fee-for-service for waiver members and dual eligibles. Under BMS Chapter 527, members enrolled in HCBS waivers other than the Children with Serious Emotional Disorder Waiver are not eligible for Mountain Health Trust, nor are dual eligibles or members in a period of retroactive eligibility, and the MCOs exclude certain home and community-based waiver services, so Aged and Disabled, TBI and IDD waiver services bill the Bureau for Medical Services directly.⁸ For members who are in managed care, the CMS 2024 tables list home health, state plan personal care, private duty nursing and hospice as plan benefits in Mountain Health Trust (Wellpoint West Virginia, The Health Plan of WV and Aetna Better Health of WV) and in Mountain Health Promise (Aetna Better Health of WV), the only one of the two that also carries HCBS waiver services (CMS 2024 tables, cited below).

Open/hybrid. West Virginia chose the open/hybrid model: the state bears the cost of the state-procured EVV system, an agency may select its own system instead at its own cost by providing evidence that the system complies, and the state aggregator links EVV data with the MMIS claims data.³ HHAeXchange was selected as the fee-for-service EVV and aggregation vendor, supplying the free system and collecting all visit data whatever system an agency uses (BMS implementation update, cited below). Since December 1, 2022, home health and private duty nursing claims that require EVV must carry the enrolled rendering provider's individual NPI and be submitted through HHAeXchange (Health PAS-Online notice, cited below). CMS found West Virginia compliant for personal care EVV for services rendered from April 1, 2021, in a May 20, 2021 letter that supplements its December 31, 2020 determination, and Medicaid.gov lists home health care services compliant as of January 1, 2024.

Services under EVV³

• Personal care in the Aged and Disabled Waiver
• Personal care in the Traumatic Brain Injury Waiver
• Personal care in the Intellectual/Developmental Disabilities Waiver
• State plan personal care
• Services involving activities of daily living, instrumental activities of daily living and home health skills

Through the Utilization Management Contractor. For the Aged and Disabled Waiver, the UMC makes the initial medical eligibility determination and each annual re-evaluation with the Pre-Admission Screening (PAS), places the member in one of four service levels from the PAS score, authorizes services based on the assessed needs, and sends service registration information to the claims payer. No Medicaid-paid ADW service can be provided until the member is activated in the UMC web portal.⁶ Actual hours within the level come from the personal attendant agency RN's assessment, and the services must follow the member's person-centered service plan (PCSP), reviewed at six months and annually. A level increase found at re-evaluation can start once the agency notifies the UMC, and a mid-year increase needs a service level change request submitted to the UMC. When an ADW member at level D also needs state plan personal care, the case manager documents the need in the service plan or an addendum and the UMC decides the dual request.

To the Bureau for Medical Services' fiscal agent, received within 12 months of the date of service on a prescribed form or approved electronic transaction, with a valid NPI, member ID and date of service. A denied claim may be corrected, or a paid claim replaced, up to 24 months from the date of service if it was first billed inside the 12 months; Medicare primary claims have 12 months from the Medicare pay date, and a member with a backdated Medicaid card gives 12 months from the card's issue date.⁷ Services not billed within a year of the date of service cannot be added to a claim once it is a year old. ADW claims are billed in full units only: the documented minutes are totaled and divided by the minutes in a unit, and nothing is paid for services outside a valid service plan, beyond service limits, without supporting documentation, or before medical and financial eligibility are established; the agency checks eligibility in the fiscal agent portal before the first visit and monthly after that (Chapter 501, cited below). Gainwell Technologies is the fiscal agent and runs the Health PAS-Online portal, and home health and private duty nursing claims that need EVV go through HHAeXchange instead (Health PAS-Online notice, cited below).

CGS Administrators processes fee-for-service Medicare home health and hospice claims for West Virginia as the A/B MAC for Jurisdiction 15, a region whose home health and hospice states also include Virginia, Maryland, Pennsylvania and Delaware. West Virginia's Medicare Part A and Part B claims go to Palmetto GBA under Jurisdiction M instead (CMS JM page, cited below).¹¹ An ADW member may also receive home health agency services that do not duplicate the waiver, generally skilled nursing or therapy after a hospital stay or for an acute episode of a chronic condition, coordinated by the ADW case manager and documented in the service plan or addendum; the home health agency keeps the physician referral (Chapter 501, cited below). Medicaid.gov lists West Virginia compliant with the Cures Act home health EVV requirement as of January 1, 2024, a year after the federal deadline.