HB 259 – FINAL VERSION
HOUSE BILL 259
This bill codifies existing rules He-W 508, relative to medical assistance for home care of certain children with severe disabilities.
This bill is a request of the commission on medical assistance for home care for children with severe disabilities, 2004, 251:5.
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Explanation: Matter added to current law appears in bold italics.
Matter removed from current law appears [
in brackets and struckthrough.]
Matter which is either (a) all new or (b) repealed and reenacted appears in regular type.
STATE OF NEW HAMPSHIRE
In the Year of Our Lord Two Thousand Five
AN ACT relative to medical assistance for home care for children with severe disabilities.
Be it Enacted by the Senate and House of Representatives in General Court convened:
181:1 Statement of Purpose. The general court recognizes the importance of maintaining the medicaid program that provides home care for children with severe disabilities in a manner that supports the provision of care to those that are most in need and provides for the financial stability and integrity of the program. The general court finds that the program provides essential services to families with children with severe disabilities by offering home-based services to children who would otherwise be cared for in an institution. The general court intends to sustain the program in its present form by codifying existing eligibility rules established by the department of health and human services.
181:2 New Sections; Home Care for Children With Severe Disabilities; Recipient Eligibility; Degree of Care. Amend RSA 167 by inserting after section 3-e the following new sections:
167:3-f Home Care for Children With Severe Disabilities; Recipient Eligibility.
I. In this section:
(a) “Active treatment program” means an aggressive, consistent implementation of specialized and generic training, treatment, health, and related services directed toward:
(1) The acquisition of the behaviors necessary for the child to function with as much self-determination and independence as possible; and
(2) The prevention or slowing of deterioration of the ability to function.
(b) “Family centered community-based home care” means an organized network of integrated and coordinated services delivered at the local level which promotes normal patterns of living and which recognizes the pivotal role of families with respect to the provision of services for their children.
(c) “Cost effective” means the estimated medicaid cost of care outside an institution is no higher than the estimated medicaid cost of appropriate institutional care.
II. The purpose of family centered community-based home care shall be to support but not supplant the child's family as the primary caregiver.
III. To be eligible for medical assistance for home care of certain children with severe disabilities, the child shall, in addition to the eligibility criteria in RSA 167:3-e:
(a) Reside in a place maintained as the child’s home community.
(b) Be able to receive services in the home as defined in 45 CFR 233.90(c)(1)(v)(B).
(c) Meet the program criteria as described in section 1902(e)(3) of the Social Security Act.
(d) Meet the recipient criteria of He-W 641.04, except that, pursuant to the prohibition in section 1614(f)(2)(B) of the Social Security Act, rules requiring the deeming of parental income shall not apply.
(e) Meet the following medical criteria:
(1) Is chronically ill or impaired, whose illness or disability does not require the level of care provided in an inpatient facility, but whose condition requires ongoing and regular medical monitoring and treatment; and
(2) Has a severe disability which includes at least one of the following:
(A) A developmental disability as defined in RSA 171-A:2, V.
(B) A chronic, degenerative, progressive, or life-threatening condition causing impairment of a vital organ function which requires ongoing and regular medical monitoring.
(C) A sensory impairment which is expected to continue indefinitely, including a hearing loss established by audiometry which functionally impacts the child.
(D) A mental illness, emotional disturbance or behavioral disorder which functionally impacts his or her psychosocial adjustment and the diagnosis for which is recognized by the American Psychiatric Association.
(E) An acquired childhood disease which functionally impacts the child.
(F) A genetic disorder or congenital anomaly requiring ongoing medical monitoring.
(f) Require the same degree of care that is typically provided in a hospital, psychiatric hospital, nursing facility, or intermediate care facility for the mentally retarded as specified in RSA 167:3-g.
IV. In addition to the eligibility requirements described in paragraph II, the services proposed for the child shall be:
(a) Medically appropriate, as determined by the joint medical review team in accordance with paragraphs V and VI; and
(b) Cost effective as determined by the department in accordance with RSA 167:3-e, IV.
V. The joint medical review team, upon certification by the child's physician, shall determine if it is medically appropriate, in accordance with paragraph VI, for the child to receive family centered community-based home care as opposed to institutional care.
VI. The joint medical review team shall determine that family centered community-based home care is medically appropriate if each of the following conditions are met:
(a) The care can be provided in the home without jeopardizing the medical needs of the child.
(b) Medical and psychological support services are available in the community.
(c) The child's treating physician recommends home care and certifies the safety of home placement.
(d) The child's family or guardian has expressed a willingness and desire to assume responsibility as the primary caregiver for the child in order to maintain the child at home.
(e) The family and household members have been trained to support the child's needs in the home and have the ability to be primary caregivers.
167:3-g Degree of Care.
I. In this section, “degree of care” means the level of intensity or extent of medical care, treatment, or intervention required by the child as determined by the medical setting in which the child is being evaluated.
II. In order to determine the most appropriate degree of care under which to evaluate the child, the joint medical review team shall review:
(a) The child's medical condition.
(b) The child's community care needs.
III. The joint medical review team shall determine that the degree of care provided by a hospital is appropriate for the child if the following criteria are met:
(a) The child requires hospitalization for an indefinite period of time; and
(b) Either of the following are met:
(1) The child requires a complex care schedule and the use of sophisticated equipment designed to alert caregivers to potential life-threatening problems; or
(2) The child has the constant potential for aspiration, respiratory obstruction or arrest, and/or other life threatening complications requiring the need for prompt, recurrent, skilled interventions to sustain life.
IV. The joint medical review team shall determine that the degree of care provided by a psychiatric hospital is appropriate for the child if all of the following criteria are met:
(a) The child meets the definition of a child with a serious emotional disturbance established by Department of Health and Human Services Notice, dated May 20, 1993, 58 Federal Register 29422 (1993).
(b) The child has specific symptoms and functional impairments that require professional and community interventions.
(c) The child has problems of a chronic and severe nature requiring an intensive amount of professional supervision which are determined by an inability to function in each of the following major life areas:
(1) Family relations.
(2) Interpersonal and/or social skills.
(3) Educational and/or vocational skills.
V. The joint medical review team shall determine that the degree of care provided by a nursing facility is appropriate for the child if any one of the following criteria are met:
(a) The child is dependent on technologically sophisticated medical equipment such as, but not limited to, ventilators, gastrostomy tubes, or central venous lines to sustain life.
(b) The child requires observations or judgments more than once per hour throughout a 24-hour period or continuously, to maintain health status.
(c) The child requires direct interventions from skilled nursing or skilled rehabilitative professionals to maintain health status.
(d) The child is dependent daily on less sophisticated medical equipment such as, but not limited to, catheters, nebulizers, or oxygen to sustain life.
(e) The child requires observations and judgments less often than once per hour and not less often than once every 3 hours throughout the 24-hour period to maintain health status.
(f) The child requires basic nursing and rehabilitative interventions under the direction and supervision of skilled nursing or skilled rehabilitative professionals.
VI. The joint medical review team shall determine that the degree of care provided by an intermediate care facility for the mentally retarded is appropriate for the child if each of the following criteria are met:
(a) The child has a developmental disability as defined in RSA 171-A:2, V.
(b) The child requires a continuous and pervasive active treatment program throughout the child's daily routine.
(c) There is a need for the continuity of treatment to and from all home and community-based settings.
(d) Either of the following are met:
(1) The child requires continuous medical monitoring for a chronic severe health problem; or
(2) The child requires continuous supervision, monitoring, and redirection of behaviors associated with any condition, related to mental retardation, that results in impairment of general intellectual functioning or adaptive behavior.
181:3 Effective Date. This act shall take effect 60 days after its passage.
(Approved: June 30, 2005)
(Effective Date: August 29, 2005)