CHAPTER He-W 500 MEDICAL ASSISTANCE

REVISION NOTE:

Pursuant to RSA 161:4, VI, the Division of Human Services (Division) in December, 1993 and January, 1994 filed with the Office of Legislative Services renumbered and reorganized existing rules under Chapter He-W 500 governing the Division's medical assistance program. The Director of the Office of Legislative Services (OLS) reviewed the changes pursuant to RSA 161:4, VI(b). As certified by the agency, these changes in numbering and organization of existing rules pursuant to RSA 161:4, VI(b) were limited to title, chapter, part, section, and subsection changes and non-substantive changes in the text so as to conform to the renumbering and reorganization.

The renumbered and reorganized Chapter He-W 500 supersedes all previous filings for rules in this chapter. However, these certified changes by the Division do not affect the adoption, effective, or expiration dates of the text of the rules in Chapter He-W 500. Pursuant to RSA 161:4, VI(b), the changes in numbering and organization were effective January 7, 1994 for citation purposes with a notice published in the New Hampshire Rulemaking Register.

The Division with its certification filed a conversion index to relate the new rule numbering to the former rule numbering and section titles, and that index is included below. The index also includes the most recent document numbers for rule filings under the former numbering, with the effective and expiration dates, so that the reader can examine the dates applicable to the respective rules in the renumbered and reorganized Chapter He-W 500.

New Part #	Old Section #	Old Section Title	Doc. #	Eff. Date	Exp. Date

520	501.01	General Program Information	5018	11/30/90	11/30/96
501	502.01	General Medical Eligibility (Int. Rule #93-011)	5749	12/1/93	3/31/94
502	502.02	Aid to the Needy Blind (ANB) Program	5019	11/30/90	11/30/96
502.04	502.02(d)		5272	11/15/91	11/15/97
503	502.03	Aid to the Permanently and Totally Disabled (Int. Rule #93-011)	5749	12/1/93	3/31/94
	502.04	(Reserved)
505	502.05	Aid to Families with Dependent Children Program	5623	5/13/93	5/13/99
	502.06	(Reserved) was: Notice Requirement - Medicaid (EXPIRED)	2918	11/30/84	11/30/90
507	502.07	Medical Assistance for Children with Severe Disabilities	4560-A	1/1/89	1/1/95
508	502.08	Medical Assistance for Home Care of Certain Children with Severe Disabilities	4681	10/4/89	10/4/95
521	503.01	General Payment Information	4488-a	9/13/88	9/13/94
521.01	503.01(a)		4560-B	1/1/89	1/1/95
521.02(c)(1)	503.01(b)(3)a		4560-B	1/1/89	1/1/95
521.02(c)(3)	503.01(b)(3)c		4560-B	1/1/89	1/1/95
521.02(c)(9)	503.01(b)(3)i		4560-B	1/1/89	1/1/95
519	503.02	Payments to Disproportionate Share Psychiatric Hospitals	5194	7/26/91	7/26/97
530	504.01	Service Limits, Non-Covered Services and Co-Payments	4863	7/12/90	7/12/96
530.03(d)	504.01(c)(4)		5714	10/1/93	10/1/99
533	504.02	Chiropractic Services	4817	6/1/90	6/1/96
531	504.03	Physician Services	4629	6/16/89	6/16/95
531.03	504.03(b)		4694	11/9/89	11/9/95
531.05(h)	504.03(d)(8)		4694	11/9/89	11/9/95
531.05(m)	504.03(d)(13)		4779	3/1/90	3/1/96
531.05(s)	504.03(d)(18)		4630	6/16/89	6/16/95
531.05(s)(1) and (2)	504.03(d)(18)a. and b.		4694	11/9/89	11/9/95
531.05(s)(4) through (6)	504.03(d)(18)d. through f.	Physician Services (cont'd)	4694	11/9/89	11/9/95
531.06	504.03(e)		4694	11/9/89	11/9/95
531.06(b)	504.03(e)(2)		4779	3/1/90	3/1/96
531.08(f) through (h)	504.03(g)(5) through (7)		5181	7/22/91	7/22/97
537	504.04	Rural Health Clinics	4884	8/1/90	8/1/96
532	504.05	Podiatrist Services	4818	6/1/90	6/1/96
542	504.06	Abortion Services	4968	11/7/90	11/7/96
536	504.07	Medical Services Clinic	4690	12/1/89	12/1/95
535	504.08	Psychologist Services	4794	3/30/90	3/30/96
535.05	504.08(e)		5182	7/22/91	7/22/97
541	504.09	Family Planning Services	4969	11/7/90	11/7/96
546	504.10	Early and Periodic Screening, Diagnosis and Treatment Services	5532	12/17/92	12/17/98
548	504.11	Extended Services to Pregnant Women	5578	2/11/93	2/11/99
	504.12	(Reserved)	4771	3/1/90
543	504.13	Hospital Services	4488-a	9/13/88	9/13/94
543.01	504.13(a)		4560-B	1/1/89	1/1/95
543.04(i)	504.13(d)(8)		4695	11/9/89	11/9/95
543.07	504.13(g)		4560-B	1/1/89	1/1/95
543.11(a)	504.13(k)(1)		4560-B	1/1/89	1/1/95
543.11(c)	504.13(k)(3)		4560-B	1/1/89	1/1/95
543.11(i)	504.13(k)(9)		4560-B	1/1/89	1/1/95
	504.14	(Reserved)	4773	3/1/90
	504.15	(Reserved)	4774	3/1/90
565	504.16	Vision Care	4819	6/1/90	6/1/96
550	504.17	Adult Medical Day Care	4482	9/1/88	9/1/94
	504.18	(Reserved)	4908	8/17/90
540	504.19	Private Duty Nursing Services	4691	12/1/89	12/1/95
552	504.20	Personal Care Attendant Services	4993	11/30/90	11/30/96
566	504.21	Dental Services	5639	6/17/93	6/17/99
576	504.22	Health Maintenance Organizations	4907	9/1/90	9/1/96
576.06	504.22(f)		5165	6/17/91	6/17/97
576.07	504.22(g)		5165	6/17/91	6/17/97
576.08	504.22(h)		5165	6/17/91	6/17/97
576.09	504.22(i)		5165	6/17/91	6/17/97
553	504.23	Home Health Services	5342	3/3/92	3/3/98
522	504.24	Interpreter Services	5735	11/12/93	11/12/99
568	504.25	Therapy Services	4995	11/30/90	11/30/96
569	504.26	Laboratory and Radiological Services	4886	8/1/90	8/1/96
569.08(f) through (h)	504.26(g)(5) through (7)		5183	7/22/91	7/22/97
	504.27	(Reserved)	4887	8/1/90
570	504.28	Pharmaceutical Services	5742	12/1/93	12/1/99
567	504.29	Hearing Aid Services	4778	3/1/90	3/1/96
567.05(a)(4)	504.29(e)(4)		4888	8/1/90	8/1/96
571	504.30	Durable Medical Equipment, Prosthetic Devices and Medical Supplies	4712	1/1/90	1/1/96
572	504.31	Ambulance Services	5022	11/30/90	11/30/96
573	504.32	Wheelchair Van Services	5023	11/30/90	11/30/96
574	504.33	General Medical Transportation	4696	1/1/90	1/1/96
556	504.34	Supported Residential Care Services	5676	8/1/93	8/1/99
534	504.35	Advanced Registered Nurse Practitioner Services	4793	3/30/90	3/30/96
558	504.36	Home and Community-Based Care for the Elderly and Chronically Ill	4482	9/1/88	9/1/94
558.05(h), except (h) (1)a. and b.	504.36(e)(8), except (e)(8) a. 1. and 2.		4776	3/1/90	3/1/96
	504.37	(Reserved) was: Preadmission Screening Program (EXPIRED)	4062	5/29/86	5/29/92
559	504.38	Case Management Services	4482	9/1/88	9/1/94
590	505.01	Nursing Facility Services	4908	8/17/90	8/17/96
590.01	505.01(a)		5085	3/5/91	3/5/97
590.16	505.01(m)		5085	3/5/91	3/5/97
590.02(d)(3)	505.01(b)(1) d. 3.		5164	6/12/91	6/12/97
593	505.02	Nursing Facility Reimbursement	5058	1/31/91	1/31/97
593.09(g)	505.02(b)(7) a. 7.		5268	11/1/91	11/1/97
593.22	505.02(b)(7) j. 5.		5268	11/1/91	11/1/97
593.27	505.02(b)(7)o.	Nursing Facility Reimbursement (cont'd)	5268	11/1/91	11/1/97
593.28	505.02(b)(7)p.		5268	11/1/91	11/1/97
593.37	505.02(b)(9)b.		5531	12/16/92	12/16/98
593.38	505.02(b)(9)c.		5531	12/16/92	12/16/98
593.39	505.02(b)(9) d. and e.		5531	12/16/92	12/16/98
591	505.03	Nursing Home Enforcement Remedies	4741	1/23/90	1/23/96
592	505.04	Nursing Assistant Training Reimbursement	5618	4/28/93	4/28/99

PART He-W 501 GENERAL MEDICAL ELIGIBILITY - EXPIRED

He-W 501.01 Definitions.

Source. (See Revision Note at chapter heading He-W 500); ss by #5806, eff 3-30-94; amd by #5941, eff 12-22-94, all EXPIRED: 3-30-00, except paragraph (c) EXPIRED: 12-22-02

He-W 501.02

Source. (See Revision Note at chapter heading He-W 500); ss by #5806, eff 3-30-94, EXPIRED: 3-30-00

He-W 501.03

Source. (See Revision Note at chapter heading He-W 500); ss by #5806, eff 3-30-94; amd by #5941, eff 12-22-94, all EXPIRED: 3-30-00, except paragraph (a)(3) EXPIRED: 12-22-02

He-W 501.04 - 501.12

Source. (See Revision Note at chapter heading He-W 500); ss by #5806, eff 3-30-94, EXPIRED: 3-30-00

PART He-W 502 AID TO THE NEEDY BLIND PROGRAM

He-W 502.01 Definitions.

(a) “Aid to the needy blind (ANB)” means a category of assistance for which eligibility is determined by the New Hampshire (NH) department of health and human services, in accordance with RSA 167:6, IV.

(b) “Blindness” means “blindness” as defined in Sections 216(i)(1) and 1614(a)(2) of the Social Security Act, 42 USC 416(i)(1)(B) and 42 USC 1382c(a)(2).

(d) “Medicaid” means the Title XIX and Title XXI programs administered by the department, which makes medical assistance available to eligible individuals.

(e) “Ophthalmologist” means a physician who specializes in the diagnosis and treatment of disorders of the eye.

(f) “Optometrist” means a doctor of optometry (OD), who is a primary health care provider who diagnoses, manages, and treats conditions and diseases of the eye.

(g) “Recipient” means an individual who is eligible for and receiving medical assistance under the medicaid program.

(h) “Title XIX” means the joint federal-state program described in Title XIX of the Social Security Act and administered in NH by the department under the medicaid program.

(i) “Title XXI” means the joint federal-state program described in Title XXI of the Social Security Act and administered in NH by the department under the medicaid program.

Source. (See Revision Note at chapter heading He-W 500); ss by #6112, eff 11-4-95; ss by #7132, eff 11-23-99; ss by #9011, eff 10-25-07; amd by #10139, eff 7-1-12; ss by #11027, eff 1-26-16; ss by #14416, eff 10-28-2025, EXPIRES 10-28-2036

He-W 502.02 Recipient Eligibility. ANB shall be available to recipients who:

(a) Meet the financial, categorical, technical, and other eligibility requirements, pursuant to He-W 800, as applicable; and

(b) Meet the definition of blindness in He-W 502.01.

Source. (See Revision Note at chapter heading He-W 500); amd by #5272, eff 11-15-91; ss by #6112, eff 11-4-95; ss by #7132, eff 11-23-99; ss by #9011, eff 10-25-07; ss by #11027, eff 1-26-16; ss by #14416, eff 10-28-2025, EXPIRES 10-28-2036

He-W 502.03 Blindness Evaluation.

(a) The applicant, recipient, or the recipient’s family member or authorized representative shall complete the “Authorization for Release of Medical Information” section on Form 901, “Report of Eye Examination” (October 2025) acknowledging the following:

“I understand that the Department of Health and Human Services may use the disclosed information to the extent permitted by state and federal law and may no longer be protected by the HIPAA federal privacy rule (45 CFR Part 164.508(c)).

Specific description of information that may be used/disclosed: Information specifying the history of my visual impairment, physical examination of my eyes, diagnosis, prognosis, and recommendations.

The information will be used/disclosed for the following purposes: Information will be used to determine my eligibility for Aid to the Needy Blind (ANB) cash and medical assistance.

I understand that this authorization is voluntary and that I may refuse to sign this authorization. I further understand that my refusal to sign this authorization may result in a determination that I am not eligible for ANB cash or medical assistance. I understand that I may revoke this authorization at any time by notifying DHHS in writing, to the above-noted address, except to the extent that the authorization has already been used to request information prior to my revocation.

This authorization expires: 12-months from the date this form is signed.”

(b) The recipient’s optometrist or ophthalmologist shall complete, sign, and date the applicable sections of Form 901 “Report of Eye Examination” (October 2025) and submit the form to the department accompanied by the recipient’s field chart, if it is determined by the optometrist or ophthalmologist that the recipient’s field measurements are abnormal.

(c) The department shall review the information provided on Form 901 in (a) and (b) above, to determine if the criteria in He-W 502.02 have been met.

Source. (See Revision Note at chapter heading He-W 500); ss by #6112, eff 11-4-95; ss by #7132, eff 11-23-99; ss by #9011, eff 10-25-07; ss by #11027, eff 1-26-16; ss by #14416, eff 10-28-2025, EXPIRES 10-28-2036

PART He-W 503 AID TO THE PERMANENTLY AND TOTALLY DISABLED (APTD) PROGRAM - EXPIRED AND RESERVED

Source. (See Revision Note at chapter heading He-W 500); ss by #5806, eff 3-30-94, EXPIRED: 3-30-00

PART He-W 504 MEDICAID FOR EMPLOYED ADULTS WITH DISABILITIES

He-W 504.01 Definition.

(a) “Medicaid for employed adults with disabilities (MEAD)” means a category of eligibility that allows certain individuals who are working to either retain or obtain medicaid eligibility.

Source. #7644, eff 2-8-02; ss by #8292, eff 2-24-05; ss by #10321, eff 4-25-13

He-W 504.02 Medical Eligibility. To be medically eligible for MEAD:

(a) An individual who is currently a medicaid recipient shall:

(1) Have been determined eligible for aid to the permanently and totally disabled (APTD) according to RSA 167:6, VI, or aid to the needy blind (ANB) according to RSA 167:6, IV, within the 12 months prior to application for MEAD; and

(2) Not have been terminated from APTD or ANB due to medical improvement during the previous 12 months; or

(b) An individual who is not currently an APTD or ANB recipient shall:

(1) Be employed, or self-employed, for pay, pursuant to the provisions of He-W 641.03(b)-(c), on the date of application and during the time eligibility for MEAD is being determined;

(2) Have a medical impairment that meets the Social Security Administration’s Listing of Impairments in accordance with 20 CFR 404, Subpart P, Appendix I; and

(3) Have a medical impairment that has persisted or is expected to persist for a minimum of 48 consecutive months.

Source. #7644, eff 2-8-02; ss by #8292, eff 2-24-05; ss by #10321, eff 4-25-13

PART He-W 505 - RESERVED

He-W 505.01-505.04 - REPEALED

Source. (See Revision Note at chapter heading He-W 500); ss by #5623, eff 5-13-93, EXPIRED: 5-13-99

New. #7134, eff 11-23-99; rpld by #8973, eff 9-11-07

PART He-W 506 MEDICAID CARE MANAGEMENT (MCM)

He-W 506.01 Purpose. The purpose of this part is to prescribe the requirements of the New Hampshire medicaid care management program as they pertain to medicaid recipients, including individuals determined eligible for medicaid coverage through the granite advantage health care program (granite advantage) in accordance with RSA 126-AA:2.

Source. #10410, eff 9-13-13; ss by #10631, eff 7-1-14; ss by #13474, eff 10-24-22

He-W 506.02 Scope. This part shall apply to all medicaid recipients insofar as they are required to enroll in managed care. Those recipients who are not enrolled in managed care shall receive medicaid services on a fee-for-service basis in accordance with applicable rules in He-W 500.

Source. #10410, eff 9-13-13; ss by #10965, eff 11-1-15; ss by #13474, eff 10-24-22

He-W 506.03 Definitions.

(a) “Action” means a managed care organization (MCO) activity including, but not limited to, the following activities identified in the definition of “adverse benefit determination” in 42 CFR 438.400(b):

(1) The denial or limited authorization of a requested service, including the type or level of service, including determinations based on the type or level of service, requirements for medical necessity, appropriateness, setting, or effectiveness of a covered benefit;

(2) The reduction, suspension, or termination of a previously authorized service;

(3) The denial, in whole or in part, of payment for a service except when denial for payment for a service is solely because the claim does not meet the definition of a “clean claim”;

(4) The failure to provide services in a timely manner, as described in the contracts between the department and the MCO;

(5) The failure of an MCO to act within the timeframes required for a service authorization, disposition of a grievance, standard resolution of an appeal, or expedited resolution of an appeal, as described in the contracts between the department and the MCO; or

(6) The denial of a member’s request to dispute a financial liability, including cost sharing, copayments, premiums, deductibles, coinsurance, or other enrollee financial liabilities.

(b) “Alternative Benefit Plan (ABP) services” means the Secretary-approved coverage described in section 1937 of the Social Security Act and which aligns with and includes the traditional medicaid state plan services.

(d) “Clean claim” means a claim that does not have any defect, impropriety, lack of any required substantiating documentation, or particular circumstance requiring special treatment that prevents timely payment.

(e) “Department” means the New Hampshire department of health and human services.

(f) “Fair hearing” means an administrative appeal under He-C 200.

(g) “Fee-for-service” means the reimbursement method used by the department:

(1) For all services to recipients who are not enrolled in managed care; and

(2) For those services excluded from managed care for all recipients.

(h) “Granite Advantage Health Care Program (Granite Advantage)” means the granite advantage health care program established under RSA 126-AA, which authorizes medical assistance for individuals described in 42 U.S.C §1396a(a)(10)(A)(i)(VIII).

(i) “Grievance” means an expression of dissatisfaction about any matter other than an action that is communicated to the MCO, such as with regard to the quality of care or services provided, and aspects of interpersonal interactions with the MCO employees.

(j) “Managed care organization (MCO)” means an entity that has a comprehensive risk-based contract with the department to provide managed medicaid health care services.

(k) “MCO grievance system” means the system through which members can complain, express dissatisfaction, or challenge an action made by the MCO, including:

(1) An MCO grievance process;

(2) An MCO appeal process; and

(3) Access to the department’s fair hearing process after (k)(2) above has been exhausted.

(l) “Medicaid” means the Title XIX and Title XXI programs administered by the department which makes medical assistance available to eligible individuals.

(m) “Member” means a recipient who has selected or who has been passively enrolled into an MCO.

(n) “Recipient” means any individual who is eligible for and is receiving medical assistance under the New Hampshire medicaid program.

(o) “Title XIX” means the joint federal-state program described in Title XIX of the Social Security Act and administered in New Hampshire by the department under the medicaid program.

(p) “Title XXI” means the joint federal-state program described in Title XXI of the Social Security Act and administered in New Hampshire by the department under the medicaid program.

Source. #10410, eff 9-13-13; amd by #10631, eff 7-1-14; amd by #10965, eff 11-1-15; ss by #12537, eff 5-24-18; ss by #13474, eff 10-24-22

He-W 506.04 Covered Services.

(a) Covered services provided through an MCO shall include all covered state plan and ABP services except the following:

(1) Dental services provided in the dental setting;

(2) Intermediate care facility for individuals with intellectual disabilities;

(3) Medicaid to schools program;

(4) Skilled nursing facility;

(5) Skilled nursing facility atypical care;

(6) Inpatient hospital swing beds, intermediate care facility;

(7) Inpatient hospital swing beds, skilled nursing facility;

(8) Intermediate care facility nursing home;

(9) Intermediate care facility atypical care;

(10) Glencliff Home;

(11) Early supports and services;

(12) The following services which are only offered to children involved with the division for children, youth, and families:

a. Home based therapy;

b. Child health support service;

c. Placement services;

d. Intensive home and community services;

e. Private non-medical institutional care for children; and

f. Crisis intervention; and

(13) Section 1915(i) of the Social Security Act, state plan home and community based services for high risk children with severe emotional disturbances.

(b) The services excluded in (a) above shall be covered by medicaid on a fee-for-service basis except the dental services which are covered under He-W 566.

(c) Covered services shall be provided by the MCO starting the same business day as a member’s selection of or passive enrollment in an MCO.

(d) Covered state plan and ABP services provided through an MCO shall be furnished in an amount, duration, and scope that is no less than the amount, duration, and scope for the same services furnished to recipients under fee-for-service.

(e) Covered services provided through a DO shall include all covered state plan, Section 1915(b) of the Social Security Act, Section 1915(c) of the Social Security Act, and Section 1115 of the Social Security Act, and ABP dental services.

Source. #10410, eff 9-13-13; ss by #10631, eff 7-1-14; amd by #11107, eff 7-1-16; amd by #12016, eff 10-25-16; ss by #13474, eff 10-24-22; ss by #13879, eff 2-21-24; ss by #14240, eff 4-22-25, EXPIRES: 4-22-35

He-W 506.05 Enrollment in Managed Care.

(a) All medicaid recipients shall be enrolled in managed care unless the recipient is excluded from managed care as described in (b) below.

(b) The following individuals shall not be allowed to enroll in managed care:

(1) Recipients receiving certain financial benefits from the U.S. Department of Veterans Affairs;

(2) Recipients receiving in and out medically needy assistance in accordance with 42 CFR 435.301 and He-W 878.01;

(3) Recipients who are eligible under the qualified medicare beneficiary (QMB), specified low-income medicare beneficiary (SLMB), or qualified disabled working individual (QDWI) benefits only, and are not eligible for full medicaid coverage;

(4) Recipients who are eligible under the family planning expansion category (FPEC) in accordance with 1902(a)(10)(A)(ii) of the Social Security Act, 42 U.S.C. 1396a(a)(10)(A)(ii) and He-W 509;

(5) Individuals during a presumptive eligibility period; and

(6) Individuals in a retroactive eligibility period.

Source. #10410, eff 9-13-13; ss by #10631, eff 7-1-14; ss by #10965, eff 11-1-15; ss by #13474, eff 10-24-22

He-W 506.06 Selection of a Managed Care Organization.

(a) Recipients shall be passively enrolled in an MCO if they do not select a plan at application.

(b) Recipients shall select an MCO at application by:

(1) Utilizing the on-line NH Electronic Application System (NH EASY);

(2) A personal interview, as required in He-W 636.01 and He-W 644.01;

(3) A telephone application pursuant to He-W 802.03; or

(4) Calling the medicaid service center.

(c) The department shall send a notice to all recipients not excluded from managed care per He-W 506.05(b) specifying which MCO the recipient has been enrolled into.

(d) Passive enrollment shall be based on the following criteria:

(1) MCO participation of a primary care provider with whom the recipient has a pre-existing relationship as demonstrated by past claims history;

(2) MCO participation of a specialty care provider with whom the enrollee has a pre-existing relationship as demonstrated by past claims history;

(3) Family affiliation to an MCO;

(4) Previous enrollment with an MCO prior to a loss of medicaid eligibility;

(5) Provider-member relationship, to the extent obtainable; or

(6) If enrollment cannot be made utilizing (1)-(5) above, enrollment shall be based on the terms of the contract agreed to by the department and the MCO.

(e) A member may request to change his or her MCO selection without cause, by making a written or oral request to the department at any of the following times:

(1) Once during the 90 days following the date of the member’s initial medicaid eligibility;

(2) During the first 12 months of enrollment, if the member has an established relationship with a primary care provider that is only in-network of a non-assigned MCO;

(3) During annual open enrollment periods and enrollments related to renegotiation and re-procurement; and

(4) When the department imposes an intermediate sanction specified in 42 CFR 438.702(a)(3).

(f) A member may request to change his or her MCO with cause after seeking redress through the MCO’s grievance system, by making a written or oral request to the department at any time for any of the following reasons:

(1) The member requires related services simultaneously that are not available in the MCO’s network and bifurcation of the care creates unnecessary risk to the member as determined by the member’s treating provider;

(2) Due to moral or religious objections of the MCO, the MCO does not provide the covered service the member needs;

(3) Poor quality of care;

(4) Lack of access to covered services;

(5) The member has experienced a violation of his or her member rights, as established in 42 CFR 438.100; or

(6) The MCO’s network providers are not experienced in the member’s unique healthcare needs.

(g) If a request made pursuant to (e) or (f) above does not include the selection of a different MCO, the department shall not act on the request unless there are only 2 MCOs.

(h) A member may request a department fair hearing of a denial of (e) or (f) above in accordance with He-C 200 without first exhausting the MCO appeal process.

(i) A member shall be locked into an MCO for a period of 12 months or until the next open enrollment period, whichever comes first, unless the member changes his or her MCO selection in accordance with (e)(1)-(3) or (f) above.

(j) A member shall disenroll from an MCO when the member has moved out of state and is no longer NH medicaid eligible or becomes exempt as described in He-W 506.05(b).

(k) An MCO may request the department to disenroll a member who is threatening or abusive such that the health or safety of other members, MCO staff, or providers is jeopardized.

(l) The department shall approve a request for disenrollment in (j) above when no other option is available that would ensure the health and safety of other members, MCO staff, or providers.

(m) If the department approves an MCO request for involuntary disenrollment, the member may request a department fair hearing of the disenrollment in accordance with He-C 200 without first exhausting the MCO appeal process.

(n) Members appealing involuntary disenrollment may request a continuation of services pending appeal as outlined in 42 CFR 431.230.

Source. #10410, eff 9-13-13; ss by #10965, eff 11-1-15; ss by #13474, eff 10-24-22

He-W 506.07 MCO Grievance Process.

(a) A member who is dissatisfied with any matter other than an action, as defined in He-W 506.03(a), shall utilize the MCO grievance process exclusively.

(b) The MCO grievance process shall address members’ expression of dissatisfaction about any matter other than an action including, but not limited to:

(1) The quality of care or services provided;

(2) Aspects of interpersonal interactions with providers or MCO employees; or

(3) Failure to respect the member’s rights.

(c) Actions, as defined in He-W 506.03(a), shall be subject to the MCO appeal process but not subject to the MCO grievance process.

(d) A member, or the member’s authorized representative, appointed in accordance with He-W 803.01, shall file a grievance with the MCO either orally or in writing.

(e) Members shall be notified of the disposition of grievances as follows:

(1) Either orally or in writing for grievances not involving clinical issues; and

(2) In writing for grievances involving clinical issues.

(f) Members shall not have the right to a department fair hearing in regard to the disposition of a grievance.

(g) The MCO grievance process shall not preclude a member’s ability to pursue client rights protection under He-M 204.

Source. #10410, eff 9-13-13; ss by #13474, eff 10-24-22

He-W 506.08 MCO Appeal Process.

(a) The MCO appeal process shall address members’ requests for the appeal of any adverse benefit determination or action taken by the MCO.

(b) A member who wants to appeal an action taken by the MCO shall utilize the MCO appeal process.

(c) A member, the member’s authorized representative, the member’s legal guardian appointed in accordance with He-W 803.01, or the member’s provider acting on behalf of the member and with the member’s written consent may file an appeal with the MCO. However, a provider acting as an authorized representative shall not request continuation of benefits pending the appeal even with written consent.

(d) All requests for appeals shall be made within 60 calendar days of the date on the MCO’s notice of action.

(e) All requests for appeals shall be made either orally or in writing. An oral request for an appeal shall be followed by a written request, unless the request is for expedited resolution as described in (g) below.

(f) The MCO shall resolve standard appeals within 30 calendar days from the day the MCO receives the appeal.

(g) A person in (c) above may request an expedited resolution of an appeal when taking the time needed for a standard resolution could seriously jeopardize the member’s life, physical or mental health, or ability to attain, maintain, or regain maximum function.

(h) The MCO shall resolve an expedited appeal within 72 hours of receiving the appeal.

(i) The MCO may extend the timeframes to resolve standard and expedited appeals up to 14 calendar days if:

(1) The member requests the extension; or

(2) The MCO demonstrates that there is a need for additional information in order to resolve the appeal and the extension is in the member’s interest.

(j) If the MCO extends the timeframes not at the request of the member in accordance with (i)(2) above, then the MCO shall:

(1) Make reasonable efforts to give the member prompt oral notice of the delay by providing a minimum of 3 oral attempts to contact the member at various times of the day, on different days within 2 calendar days of the MCO’s decision to extend the timeframe;

(2) Within 2 calendar days of the MCO’s decision to extend, give the member written notice of the reason for the decision to extend the timeframe and inform the member of the right to file a grievance if he or she disagrees with that decision; and

(3) Resolve the appeal as expeditiously as the member’s health condition requires and no later than the date the extension expires.

(k) A member’s benefits shall be continued during an appeal if:

(1) The member requests a continuation of benefits on or before the later of the following:

a. Within 10 calendar days of the date the MCO mails the notice of action; or

b. The intended effective date of the MCO’s proposed action;

(2) The appeal involves the termination, suspension, or reduction of previously authorized services;

(3) The services were ordered by an authorized provider; and

(4) The period covered by the original authorization has not expired.

(l) If the MCO’s action is upheld in a hearing, the MCO may institute recovery procedures against the member to recoup the cost of any continued benefits furnished to the member.

(m) The MCO grievance process shall not preclude a member’s ability to pursue client rights protection under He-M 204.

Source. #10410, eff 9-13-13; ss by #12537, eff 5-24-18; ss by #13474, eff 10-24-22

He-W 506.09 Department Fair Hearing Process.

(a) A member shall exhaust the MCO appeal process prior to filing a request for a fair hearing with the department, subject to the following:

(1) Grievances shall not be the subject of a department fair hearing; and

(2) The MCO shall have resolved an appeal under He-W 506.08 and provided notice of that resolution prior to the member requesting a fair hearing with the department, except that a member shall be deemed to have exhausted the MCO’s appeal process if the MCO fails to adhere to the notice and timing for expedited and standard appeals as described in He-W 506.08(f), (h), and (j).

(b) If the member does not agree with the MCO’s resolution of an appeal, the member may file a request, in accordance with He-C 200, for a department fair hearing.

(c) Requests for a department fair hearing shall be made in writing within 120 calendar days of the date of the MCO’s notice of the resolution of the appeal.

(d) A member in (b) above may request an expedited resolution of a department fair hearing if the department determines that the time otherwise permitted for a hearing could seriously jeopardize the member’s life, physical or mental health, or ability to attain, maintain, or regain maximum function, and:

(1) The MCO adversely resolved the member’s appeal, wholly or partially; or

(2) The MCO failed to resolve the appeal within 72 hours and failed to extend the 72-hour deadline in accordance with 42 CFR 438.408(c) and He-W 506.08(i).

(e) The department shall notify the member as expeditiously as possible as to whether the request for an expedited department fair hearing is granted or denied. If oral notice is provided, the department shall follow up with written notice, which might be made through electronic means.

(f) If the department denies the member’s request for an expedited department fair hearing, the department shall schedule a department fair hearing within 90 days from the date the member filed an MCO appeal not including the number of days the member took to subsequently file for a department fair hearing.

(g) If the department grants the member’s request for an expedited department fair hearing, then the department shall resolve the appeal within 3 business days after the department receives from the MCO the case file and any other necessary information. The MCO shall have no more than 3 days from the date the department notifies the MCO that it has granted the member’s expedited appeal, to provide the case file to the department.

(h) A member’s benefits shall be continued during a department fair hearing if:

(1) The member received benefits pending the MCO appeal; and

(2) The member requests a department fair hearing and continuation of benefits within 10 calendar days of the date the MCO sends the notice of adverse decision of an MCO appeal to the member.

(i) If the member did not receive benefits pending the MCO appeal, then a member’s benefits shall be continued during a department fair hearing if:

(1) The member requests a department fair hearing within 10 calendar days of the date the MCO mails the notice of decision adverse to the member;

(2) The member requests continuation of benefits pending the department fair hearing;

(3) The department fair hearing involves the termination, suspension, or reduction of a previously authorized service;

(4) The service was ordered by an authorized provider; and

(5) The original authorization period for the service has not expired.

(j) Only the member, the member’s authorized representative, or the member’s legal guardian may request benefits pending a department fair hearing of a MCO decision.

(k) Providers acting as an authorized representative shall not request continuation of benefits pending the appeal even with written consent.

(l) If the MCO’s adverse decision is upheld in a department fair hearing, the MCO may institute recovery procedures against the member to recoup the cost of any continued benefits furnished to the member.

Source. #10410, eff 9-13-13; ss by #12537, eff 5-24-18; ss by #13474, eff 10-24-22

PART He-W 507 MEDICAL ASSISTANCE FOR CHILDREN WITH SEVERE DISABILITIES

He-W 507.01 Definitions.

(a) “Department” means the New Hampshire department of health and human services.

(b) “Medical review team (MRT)” means a team of medical professionals, comprised of physicians and registered nurses with expertise in the care of children with special health care needs, developmental disabilities and behavioral issues, who determine medical eligibility for healthy kids-gold medical assistance in accordance with the criteria set forth in He-W 507 and He-W 508.

(c) “Medicaid” means the Title XIX and Title XXI programs administered by the department which makes medical assistance available to eligible individuals.

(d) “Recipient” means any individual who is eligible for and receiving medical assistance under the medicaid program.

(e) “Title XIX” means the joint federal-state program described in Title XIX of the Social Security Act and administered in New Hampshire by the department under the medicaid program.

(f) “Title XXI” means the joint federal-state program described in Title XXI of the Social Security Act and administered in New Hampshire by the department under the medicaid program.

Source. (See Revision Note at chapter heading He-W 500); ss by #5941, eff 12-22-94, EXPIRED: 12-22-02

New. #7867, eff 4-10-03; ss by #9866, eff 2-11-11; amd by #10139, eff 7-1-12

He-W 507.02 Recipient Eligibility. Title XIX services shall be available to children with disabilities who:

(a) Are under the age of 19;

(b) Meet the requirements of He-W 641.04;

(c) Are 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

(d) Have a severe disability which includes at least one of the following:

(1) A developmental disability as defined in RSA 171-A:2,V;

(2) A chronic, degenerative, progressive, or life-threatening condition causing impairment of a vital organ function which requires ongoing and regular medical monitoring;

(3) A sensory impairment which is expected to continue indefinitely, including a hearing loss established by audiometry which functionally impacts the child;

(4) 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;

(5) An acquired childhood disease which functionally impacts the child; or

(6) A genetic disorder or congenital anomaly requiring ongoing medical monitoring.

Source. (See Revision Note at chapter heading He-W 500); ss by #5941, eff 12-22-94, EXPIRED: 12-22-02

New. #7867, eff 4-10-03; ss by #9866, eff 2-11-11

He-W 507.03 Continued Eligibility.

(a) The MRT shall conduct periodic redeterminations of medical eligibility for Title XIX benefits based on current evidence of the child’s disability.

(b) At the time of redetermination, the MRT shall first determine whether the recipient meets the eligibility criteria in accordance with He-W 507.02.

(d) If an adverse eligibility determination is made, the written notice to the recipient shall include the following information:

(1) The recipient’s identifying information;

(2) A listing of the medical and non-medical reports considered during the disability determination process;

(3) A statement of the department’s action;

(4) The reasons for the department’s action;

(5) Citations from federal and state statutes and regulations supporting the department’s actions; and

(6) An explanation of the individual’s rights to appeal the department’s disability determination and to reapply for medical assistance.

(e) The department shall continue the recipient’s medical eligibility after an adverse medical eligibility determination is made when the recipient:

(1) Submits a hearing request to the local district office within 30 days from the date on the written notice of adverse decision; and

(2) Submits a request to the local district office for a continuation of benefits during the appeal process within 10 days of the date on the written notice of adverse decision.

Source. (See Revision Note at chapter heading He-W 500); ss by #5941, eff 12-22-94, EXPIRED: 12-22-02

New. #7867, eff 4-10-03; ss by #9866, eff 2-11-11

He-W 507.04 Termination of Medical Eligibility. The department shall terminate medical eligibility after an adverse medical eligibility determination is made when:

(a) The MRT determines that the recipient no longer meets the eligibility criteria specified in He-W 507.02; and

(b) The recipient fails to submit a continuation of benefits request to the local district office within 10 days from the date of written notice of adverse decision.

Source. #7867, eff 4-10-03; ss by #9866, eff 2-11-11

He-W 507.05 Appeals.

(a) Individuals may appeal an adverse disability determination, pursuant to RSA 541-A:31, III and He-C 200.

(b) Individuals must submit the written request for a hearing to the local district office pursuant to RSA 541-A:31, III and He-C 200 within 30 days from the date of the notice of decision.

Source. #7867, eff 4-10-03; ss by #9866, eff 2-11-11

PART He-W 508 MEDICAL ASSISTANCE FOR HOME CARE OF CERTAIN CHILDREN WITH SEVERE DISABILITIES

He-W 508.01 Purpose. The purpose of family centered community-based home care shall be to support, but not supplant, the recipient’s family as the primary caregiver.

Source. (See Revision Note at chapter heading He-W 500); ss by #5941, eff 12-22-94, EXPIRED: 12-22-02

New. #8196, INTERIM, eff 10-29-04, EXIRED: 7-1-05

New. #9291, eff 7-1-09

He-W 508.02 Definitions.

(a) “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.

(b) “Department” means the New Hampshire department of health and human services.

(c) “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.

(d) “Joint medical review team (MRT)” means a team of medical professionals, comprised of physicians and registered nurses with expertise in the care of children with special health care needs, developmental disabilities, and behavioral issues, that determines if home care services are medically appropriate in accordance with RSA 167:3-f, VI, and the most appropriate level of care under which to evaluate the child in accordance with RSA 167:3-g, III–VI.

(e) “Medicaid” means the Title XIX and Title XXI programs administered by the department which makes medical assistance available to eligible individuals.

(f) “Recipient” means any individual who is eligible for and receiving medical assistance under the medicaid program.

(g) “Title XIX” means the joint federal-state program described in Title XIX of the Social Security Act and administered in New Hampshire by the department under the medicaid program.

(h) “Title XXI” means the joint federal-state program described in Title XXI of the Social Security Act and administered in New Hampshire by the department under the medicaid program.

Source. (See Revision Note at chapter heading He-W 500); ss by #5941, eff 12-22-94; amd by #6198, eff 2-28-96, all EXPIRED: 12-22-02 except (b)(3) EXPIRED: 2-28-04

New. #8196, INTERIM, eff 10-29-04, EXIRED: 7-1-05

New. #9291, eff 7-1-09 (from He-W 508.01); amd by #10139, eff 7-1-12

He-W 508.03 Recipient Eligibility.

(a) In accordance with RSA 167:3-e, III, and RSA 167:3-f, III (a)–(f), recipients shall be eligible for medical assistance for home care of children with severe disabilities (HC-CSD), if the recipient:

(1) Resides in a place maintained as the recipient’s home community;

(2) Is able to receive services in the home as defined in 45 CFR 233.90(c)(1)(v)(B);

(3) Meets the program criteria described in Section 1902(e)(3) of the Social Security Act;

(4) Meets the criteria described in He-W 641.04, except that, pursuant to the prohibition in Section 1614(f)(2)(B) of the Social Security Act, the criteria described in He-W 641.04(b)-(e) on the deeming of parental income shall not apply;

(5) Has an impairment, or combination of impairments, that meets, medically equals, or functionally equals the criteria for an impairment as described in 20 CFR, Part 404, Subpart P, App. 1;

(6) Meets the medical criteria pursuant to RSA 167:3-f, III(e); and

(7) Requires the same degree of care that is typically provided in a hospital, psychiatric hospital, nursing facility, or intermediate care facility for the mentally retarded (ICF-MR), in accordance with He-W 508.04.

(b) In addition to (a) above, recipients shall be eligible only if the services proposed for the recipient are:

(1) Medically appropriate in accordance with He-W 508.05; and

(2) Cost effective in accordance with He-W 508.06.

Source. (See Revision Note at chapter heading He-W 500); ss by #5941, eff 12-22-94, EXPIRED: 12-22-02

New. #8196, INTERIM, eff 10-29-04, EXIRED 7-1-05

New. #9291, eff 7-1-09 (from He-W 508.02)

He-W 508.04 Degree of Care. The most appropriate degree of care under which to evaluate the recipient’s eligibility per He-W 508.03(a)(7) above shall be determined as follows:

(a) The MRT shall review, in accordance with RSA 167:3-g, II, the recipient’s medical condition and community care needs; and

(b) Based upon the review in (a) above, the MRT shall:

(1) Determine that the degree of care provided by a hospital is appropriate for the recipient, if all of the criteria in RSA 167:3-g, III, are met;

(2) Determine that the degree of care provided by a psychiatric hospital is appropriate for the recipient, if all of the criteria in RSA 167:3-g, IV, are met;

(3) Determine that the degree of care provided by a nursing facility is appropriate for the recipient, if any one of the criteria in RSA 167:3-g, V, is met; or

(4) Determine that the degree of care provided by an ICF-MR is appropriate for the recipient, if all of the criteria in RSA 167:3-g, VI, are met.

Source. #9291, eff 7-1-09 (from He-W 508.03)

He-W 508.05 Medically Appropriate Services.

(a) The medical services proposed for a recipient shall be medically appropriate if the MRT, upon certification by the recipient’s physician, determines in accordance with (b) below, that it is medically appropriate for the recipient to receive family centered, community-based home care as opposed to institutional care.

(b) In accordance with RSA 167:3-f, VI, family centered, community-based home care shall be medically appropriate if each of the following conditions is met:

(1) The care can be provided in the home without jeopardizing the medical needs of the recipient;

(2) Medical and psychological support services are available in the community;

(3) The recipient’s treating physician recommends home care and certifies the safety of home placement in accordance with (c) below;

(4) The recipient’s family or guardian has expressed a willingness and desire to assume responsibility as the primary caregiver for the recipient in order to maintain the recipient at home; and

(5) The family and household members have been trained to support the recipient’s needs in the home and have the ability to be primary caregivers.

(c) The treating physician’s recommendation of home care and certification of the safety of home placement shall be submitted in writing by mail, electronic mail, or facsimile to the department or via direct telephone conversation with the MRT.

(d) The written certification in (c) above, or MRT documentation of direct telephone conversation with the treating physician as per (c) above, shall be maintained in the recipient’s case file at the department.

Source. #9291, eff 7-1-09

He-W 508.06 Monitoring and Determination of Cost Effectiveness.

(a) In accordance with RSA 167:3-e, IV, the medical services proposed for a recipient shall be cost effective if the estimated cost of care outside an institution is no higher than the estimated medicaid cost of appropriate institutional care.

(b) For each recipient, cost effectiveness shall be monitored monthly and determined annually by the department as follows:

(1) The department shall obtain Title XIX payment data on the costs paid by Title XIX for the recipient’s home care from the department’s cost reports generated for each recipient from the Medicaid Management Information System (MMIS);

(2) For each recipient, the items or services included in the home care cost data in (1) above shall include only those items or services listed in (c) below;

(3) The items or services included in (d) below shall not be included in home care cost data for (1) above, or in institutional cost of care data in (c) below;

(4) The department shall utilize, as institutional cost of care data, the most recently published inpatient per diem Title XIX rates for hospitals, psychiatric hospitals, nursing facilities, or ICF-MR;

(5) The department shall determine the per diem rate to use as the recipient’s institutional cost of care by selecting the rate for the facility in (4) above that most closely corresponds to the degree of care determined and utilized for the recipient’s eligibility determination pursuant to He-W 508.04; and

(6) The department shall compare the costs of the recipient’s home care to the recipient’s institutional cost of care, as determined in He-W 508.06(b)(1)–(b)(5).

(c) The costs associated with the following categories of service, which are included in an institution’s per diem rate, shall be the only costs utilized in determining the costs incurred for the recipient’s home care in accordance with He-W 508.06(b)(1) and (2) above:

(1) Mental health services, including psychotherapy and community mental health center services;

(2) Family planning services;

(3) Drugs which are included in the per diem of the institution in (b)(4) above that is utilized in the calculation in (b)(6) above;

(4) Durable medical equipment;

(5) Medical supplies;

(6) Dental services;

(7) Private duty nursing services;

(8) Physical therapy;

(9) Occupational therapy;

(10) Speech therapy;

(11) Care provided through the Home and Community Based Care for the Developmentally Disabled waiver in accordance with He-M 517, with the exception of assistive technology support services, environmental modifications, employment services, respite and specialty services that would not otherwise be included in the institutional per diem rate;

(12) Home and community-based care provided through the In Home Supports Waiver for Children with Developmental Disabilities in accordance with He-M 524, with the exception of environmental modifications, respite, and consultative services not otherwise included in the institutional per diem rate;

(13) Case management services;

(14) Home health; and

(15) Early supports and services.

(d) Costs associated with the following categories of service, which are not included in an institution’s per diem rate, shall not be included in home care cost data in (b)(1) above or in institutional cost of care data in (c) above:

(1) Inpatient services, including acute psychiatric admissions;

(2) Outpatient services;

(3) Laboratory services;

(4) X-ray services;

(5) Medical assistance services provided by education agencies in accordance with He-M 1301;

(6) Ambulance services;

(7) Wheelchair van services;

(8) Audiology services;

(9) Ophthalmology services;

(10) Podiatry services;

(11) Chiropractic services;

(12) Physician services, including services of a psychiatrist;

(13) Advanced registered nurse practitioner services;

(14) DCYF/DJSS medicaid funded services to include private non-medical institutional placement services (PNMI) and residential placement;

(15) Youth development center or other youth detention center placements;

(16) Rural health clinics and federally qualified health centers;

(17) Short term stays of 30 days or less in an intermediate care facility for the mentally retarded or in a nursing facility;

(18) Services provided on an acute or short-term basis, in response to an illness or injury, rather than care for the chronic condition which is the basis for the home care;

(19) Mileage reimbursement; and

(20) Medicaid health insurance premium payments.

Source. #9291, eff 7-1-09

He-W 508.07 Recipient Notification of Cost Effectiveness Monitoring and Determination Results.

(a) When the department’s monthly monitoring of cost effectiveness results in an estimated, projected annual home care cost for a recipient which is higher than the appropriate type of institutional care cost, the department shall notify the recipient in writing.

(b) The notification in (a) above shall include:

(1) A reminder of the requirement to maintain annual home care costs at or below the cost of care for the appropriate type of institution pursuant to state and federal law in order to maintain HC-CSD eligibility;

(2) Medicaid payment data showing the recipient’s monitored home care costs and estimated, projected annual home care costs, including a copy of the report used;

(3) The calculated cost of care in an appropriate type of institution for the same time period as in (2) above and the projected annual institutional costs, including identification of the appropriate type of institution; and

(4) Contact information for the department’s care coordination services unit.

(1) For an explanation of the information included in the notification pursuant to (b) above;

(2) To report costs they believe the department should not include in the home care costs; and

(3) To request assistance with reducing the costs of home care or achieving cost effectiveness pursuant to He-W 508.06(a).

(d) For each state fiscal year ending June 30, the department shall complete an annual determination of cost effectiveness for each recipient pursuant to He-W 508.06(b).

(e) If the department’s annual determination of cost effectiveness indicates that home care costs are higher than the costs of the appropriate type of institutional care, the department shall provide written notice to the recipient within 30 days of the determination.

(f) The written notice pursuant to (e) above shall include:

(1) A statement that annual cost effectiveness has not been demonstrated;

(2) A statement that the recipient is required to reduce and maintain annual home care costs at or below the cost of care for the appropriate type of institution pursuant to state and federal law in order to maintain HC-CSD eligibility;

(3) Medicaid payment data showing the recipient’s annual home care costs and a copy of the report used;

(4) The calculated annual cost of care in an appropriate type of institution, including identification of the appropriate type of institution;

(5) A statement that the recipient’s family or guardian shall submit and implement a written plan for reducing costs in accordance with (f)(2) within 3 months of the date of the notice in (e) above;

(6) Contact information for the department’s care coordination services unit which the recipient’s family or guardian may use for assistance in identifying any billing errors and in developing the cost reduction plan in (5) above; and

(7) Information that a fair hearing on the requirement to reduce costs may be requested within 30 calendar days of the date on the cost effectiveness annual determination notice, in accordance with He-C 200.

(g) If the recipient’s family or guardian requests assistance in accordance with (f)(6) above, the department shall assign a care coordination manager to assist the recipient’s family or guardian.

Source. #9291, eff 7-1-09

He-W 508.08 Cost Reduction Plans.

(a) The department shall continue to monitor cost effectiveness monthly and determine it annually in accordance with He-W 508.06, for recipients who submit and implement a cost reduction plan in accordance with He-W 508.07(f)(5).

(b) The department shall terminate a recipient’s medical eligibility for HC-CSD if:

(1) The recipient submits a cost reduction plan that does not demonstrate cost effectiveness in accordance with He-W 508.07(f)(2);

(2) The recipient submits a cost reduction plan that demonstrates cost effectiveness, but does not implement the cost effectiveness plan in accordance with He-W 508.07(f)(5); or

(3) The recipient does not submit a cost reduction plan in accordance with He-W 508.07(f)(5).

(c) A recipient’s termination of medical eligibility for HC-CSD, in accordance with (b) above, shall be effective 30 days after the due date of the written plan in He-W 508.07(f)(5).

(d) The recipient shall receive a written notice of termination of medical eligibility on department Form 272hc, “Termination of Medical Eligibility for HC-CSD,” including:

(1) The reason for, and legal basis of, the termination;

(2) Information that a fair hearing on the termination may be requested within 30 calendar days of the date on the notice of termination, in accordance with He-C 200.

(e) The department shall continue the recipient’s medical eligibility after the termination date of medical eligibility in accordance with (b) above when the recipient submits to the local district office both a request for a fair hearing and for a continuation of benefits during the appeal process not later than 10 calendar days from the date on the written notice of termination.

Source. #9291, eff 7-1-09

He-W 508.09 Continued Medical Eligibility for HC-CSD.

(a) The MRT shall conduct reviews of continued medical eligibility for Title XIX benefits based on current evidence of the recipient’s disability or based upon changes in eligibility.

(b) At the time of medical eligibility review, the MRT shall determine whether the recipient meets the eligibility standards in accordance with He-W 508.03 and He-W 508.04.

(c) The department shall issue a written notice to the recipient when a denial of continued medical eligibility is made following a medical eligibility review.

(d) The written notice in (c) above shall include:

(1) The recipient’s identifying information:

(2) A listing of the medical and non-medical reports used for consideration during the medical eligibility review process;

(3) A description of the impairments used for consideration during the medical eligibility review process;

(4) The reasons for the department’s decision;

(5) The legal basis supporting the department’s decision(s);

(6) Information that a fair hearing on the denial of continued medical eligibility may be requested within 30 calendar days of the date on the notice of denial, in accordance with He-C 200; and

(7) Information on how to reapply for medical assistance.

(e) The department shall continue the recipient’s medical eligibility after a denial of continued medical eligibility in accordance with (c) above when the recipient submits to the local district office both a request for a fair hearing and for a continuation of benefits during the appeal process not later than 10 calendar days from the date on the written notice of denial.

Source. #9291, eff 7-1-09

He-W 508.10 Denial or Termination of Medical Eligibility for HC-CSD. The department shall deny or terminate medical eligibility for HC-CSD if:

(a) The MRT, in accordance with He-W 508.09(b), determines that the recipient does not meet the eligibility criteria specified in He-W 508.03 and 508.04; or

(b) Both the following occur:

(1) A cost reduction plan is not acceptable in accordance with He-W 508.08(b); and

(2) The recipient fails to submit a request for a fair hearing and for a continuation of benefits during the appeals process to the local district office within 10 calendar days from the date of written notice of adverse decision or termination.

Source. #9291, eff 7-1-09

PART He-W 509 FAMILY PLANNING EXPANSION CATEGORY (FPEC)

He-W 509.01 Purpose. The purpose of this part is to describe the family planning and family planning-related services and supplies available to individuals who are determined eligible, in accordance with He-W 626, for this expanded Title XIX eligibility category. In accordance with Section 1902(a)(10)(A)(ii) of the Social Security Act, 42 U.S.C. 1396a(a)(10)(A)(ii), FPEC recipients shall not be eligible for any other Title XIX services, except as provided for in this part.

Source. #10357, eff 7-1-13

He-W 509.02 Definitions.

(a) “Department” means the New Hampshire department of health and human services.

(b) “Family planning expansion category” means a category of recipients who meet the technical eligibility requirements established by the department for the family planning services and/or family planning-related services specified in this part, but who are not eligible for any other Title XIX services not specified in He-W 509.

(c) “Family planning-related services” means certain medical diagnosis and treatment services and pharmaceutical supplies that are provided pursuant to a family planning service in a family planning setting and that do not receive an enhanced rate of 90% federal match.

(d) “Family planning services” means family planning services and supplies described in section 1905(a)(4)(c) of the Social Security Act, 42 U.S.C. 1396d(a)(4)(c), including medical services, medical procedures, and pharmaceutical supplies and devices provided by or under the supervision of a physician or other health professional that allow an individual to prevent or delay pregnancy or to otherwise control family size, and which receive an enhanced match rate of 90% federal match.

(e) “Hysterectomy” means a surgical procedure for the purpose of removing the uterus.

(f) “Institutionalized individual” means “institutionalized individual” as defined in 42 CFR 441.251.

(g) “Mentally incompetent individual” means “mentally incompetent individual” as defined in 42 CFR 441.251.

(h) “Sterilization” means any medical procedure, treatment, or surgical procedure which is intended to render an individual permanently incapable of reproducing.

(i) “Title XIX program” means the joint federal-state program described in Title XIX of the Social Security Act.

Source. #10357, eff 7-1-13

He-W 509.03 Eligibility.

(a) Individuals shall be eligible for family planning services and family planning-related services, as described in He-W 509.06(b) and (c) below, respectively, and in accordance with He-W 509 if the individual:

(1) Meets the division of family assistance eligibility requirements specified in He-W 626;

(2) Once determined eligible in accordance with (1) above, the FPEC recipient has reached reproductive maturity; and

(3) If female, is not known to be pregnant.

(b) Acceptance of any family planning services shall be voluntary on the part of the individual.

(c) FPEC recipients shall not be considered to be Title XIX recipients for the purposes of receipt of services other than those as described in He-W 509.

Source. #10357, eff 7-1-13

He-W 509.04 Provider Participation. All participating family planning providers shall be:

(a) Licensed by the state in which s/he practices or be a NH certified midwife; and

(b) A New Hampshire enrolled Title XIX provider.

Source. #10357, eff 7-1-13

He-W 509.05 Service Limits. Family planning services and family planning-related services for FPEC recipients shall be subject to the limits described in He-W 530.

Source. #10357, eff 7-1-13

He-W 509.06 Covered Services.

(a) The services in (b) and (c) below shall be covered as family planning services and family planning-related services, respectively, only if the services, supplies, and procedures are clearly provided or performed for family planning purposes.

(b) The following services shall be covered as family planning services:

(1) Those physician services in accordance with He-W 531, certified midwife services in accordance with He-W 538, and advanced registered nurse practitioner services in accordance with He-W 534, provided for family planning purposes;

(2) Contraceptive devices or drugs, both prescription and non-prescription, in accordance with He-W 570;

(3) Pregnancy tests and screening for a sexually transmitted disease (STD) only when performed routinely as part of an initial, regular, or follow-up family planning visit; and

(4) Sterilization, in accordance with 42 CFR 441.253 and 42 CFR 441.254, as follows:

a. The FPEC recipient shall be at least 21 years old at the time consent is obtained;

b. The FPEC recipient shall not be a mentally incompetent individual;

c. The FPEC recipient shall not be an institutionalized individual;

d. The FPEC recipient shall voluntarily give informed consent in accordance with the requirements at 42 CFR 441.257 through 42 CFR 441.258;

e. The provider shall submit a sterilization consent form meeting the requirements of 42 CFR 441, Subpart F, to the department prior to the department’s payment for the sterilization claim;

f. At least 30 days, but not more than 180 days, shall have passed between the date of informed consent and the date of sterilization, with the exception of cases of premature delivery or emergency abdominal surgery as described in g. below;

g. A FPEC recipient may consent to be sterilized at the time of an emergency abdominal surgery if at least 72 hours have passed since he or she gave informed consent for the sterilization; and

h. Treatment of surgical or anesthesia-related complications resulting from or during a covered sterilization procedure shall be covered; and

(5) Family planning-related services that were provided as part of, or as follow-up to, a family planning visit in which a sterilization procedure took place.

(1) Services to treat adverse reactions to, or medical complications of, family planning procedures, services, treatments, or therapies including, but not limited to:

a. Treatment of perforated uterus due to an intrauterine device insertion; and

b. Treatment of severe menstrual bleeding caused by Depo-Provera injection;

(2) Drugs, in accordance with the following:

a. Drugs shall be for the treatment of STDs, except for HIV/AIDS and hepatitis, when the STD is identified or diagnosed during a routine or periodic family planning visit; and

b. Title XIX providers shall comply with the provisions of He-W 570 regarding pharmaceutical services when prescribing or dispensing drugs covered in a. above;

(3) A follow-up visit after prescribing drugs for the treatment of an STD, including a re-screen for the STD;

(4) Drugs and other treatment for lower genital tract and genital skin infections/disorders, and urinary tract infections, when the infection/disorder is identified/diagnosed during a routine/periodic family planning visit;

(5) A follow-up visit for drugs and other treatment of the lower genital tract and genital skin infections or disorders where the infections or disorder is identified during a family planning visit; and

(6) Vaccinations to prevent cervical cancer that are routinely provided pursuant to a family planning service in a family planning setting.

Source. #10357, eff 7-1-13

He-W 509.07 Non-Covered Services. The following services shall not be covered as family planning or family planning-related services:

(a) Sterilizations which do not meet the requirements of He-W 509.06(b)(4) above;

(b) Hysterectomies;

(d) Medical, surgical, or pharmaceutical treatment for the purpose of enhancing, promoting, or restoring fertility;

(e) Diagnostic examination of the cervix or vagina by means of a special microscope, colposcopy, biopsy, or cryotherapy of the cervix or vagina; and

(f) Any medical service, procedure, or pharmaceutical supply or device provided to a FPEC recipient who is known to be pregnant.

Source. #10357, eff 7-1-13

He-W 509.08 Transportation.

(a) FPEC recipients shall be ensured assistance with locating or being reimbursed for transportation to Title XIX providers in order to access necessary family planning and family planning-related services described in He-W 509.

(b) FPEC recipients who wish to be reimbursed for transportation shall:

(1) Enroll in the transportation provider system in accordance with He-W 574.10(b)–(e); and

(2) Be known as a recipient driver only for enrollment and payment purposes.

(1) Transportation shall be to in-state or border Title XIX enrolled providers, except as described in (2) below;

(2) Transportation to out-of-area providers shall be authorized in advance in accordance with He-W 574.08;

(3) There is no transportation available free of charge or payable by any other agency;

(4) Only one trip per day, whether one-way or round-trip, shall be covered;

(5) Only the actual number of miles driven from the individual’s residence to the Title XIX provider and return to individual’s residence shall be reimbursed; and

(6) Transportation shall be to the nearest available provider of the necessary covered family planning services or family planning-related services via the shortest, most economical route, as described in He-W 574.14(b).

(d) FPEC recipients shall submit transportation claims in accordance with He-W 574.06.

(e) The above transportation claims shall be paid in accordance with He-W 574.07.

(f) The provisions of He-W 574.12 and He-W 574.14 regarding hearings and utilization review and control shall apply to FPEC recipients.

(g) FPEC recipients who request transportation assistance via wheelchair van in order to access family planning services or family planning-related services shall qualify for wheelchair van transportation if they meet the requirements in He-W 573.02(a)(1) and (2), except that eligibility as an FPEC recipient shall be substituted for the requirements in He-W 573.02(a) to be a Title XIX recipient.

(h) FPEC recipients utilizing wheelchair van transportation shall be subject to the provisions of He-W 573.04, He-W 573.10, He-W 573.11, and He-W 573.12 regarding service limits, prior authorization to exceed service limits, utilization review and control, and third party liability.

(i) FPEC recipient shall utilize Title XIX enrolled wheelchair van providers who meet the requirements of He-W 573.

(j) FPEC recipients shall be eligible to be transported by volunteer drivers in accordance with He-W 574 only for the purpose of accessing family planning services or family planning-related services.

Source. #10357, eff 7-1-13

He-W 509.09 Co-Payments. Co-payments for family planning pharmaceutical products shall not be required.

Source. #10357, eff 7-1-13

He-W 509.10 Utilization Review and Control. The department’s surveillance and utilization review of subsystems unit (SURS) shall monitor utilization of family planning services in accordance with 42 CFR 455 and 42 CFR 456.

Source. #10357, eff 7-1-13

He-W 509.11 Third Party Liability. All third party obligations shall be exhausted before Title XIX shall be billed, in accordance with 42 CFR 433.139.

Source. #10357, eff 7-1-13

He-W 509.12 Payment for Services.

(a) Rates of payment for family planning and family planning-related services shall be established by the department in accordance with RSA 161:4, VI(a).

(b) The provider shall submit claims for payment to the department’s fiscal agent.

Source. #10357, eff 7-1-13

PART He-W 510 - RESERVED

PART He-W 511 HEALTH INSURANCE PREMIUM PAYMENT PROGRAM (HIPP)

He-W 511.01 Purpose. The purpose of this part is to describe the requirements for enrollment in the health insurance premium payment program (HIPP), which uses medicaid funds to purchase employer group health plan coverage on behalf of a medicaid recipient, as allowed by 42 USC §1396e.

Source. #10632, eff 7-1-14; ss by #14075, eff 9-20-24, EXPIRES: 9-20-34

He-W 511.02 Scope. This part shall apply to all medicaid and children’s health insurance program (CHIP) members. Enrollment in HIPP shall be voluntary for all medicaid recipients.

Source. #10632, eff 7-1-14; ss by #14075, eff 9-20-24, EXPIRES: 9-20-34

He-W 511.03 Definitions.

(a) “Cost effective” means that the cost to enroll an individual in an employer group health plan is likely to be less than the average medicaid expenditures for medicaid recipients with the same category of assistance, age, and sex.

(b) “Cost effectiveness test” means the method by which the department determines if a recipient’s employer group health plan costs less than the expected medicaid expenditure.

(d) “Employer group health plan” means any plan of, or contributed to by, an employer, including a self-insured plan, to provide health care to the employer’s employees, former employees, or the families of employees or former employees, and which meets section 5000(b)(1) of the Internal Revenue Code of 1986, and includes continuation coverage pursuant to Title XXII of the Public Health Services Act, section 4980B of the Internal Revenue Code of 1986, or Title VI of the Employee Retirement Income Security Act of 1974.

(e) “Health insurance premium payment program (HIPP)” means a state and federal cost savings program administered by the department consistent with 42 U.S.C 1396e , which permits the use of medicaid funds to purchase employer group health plan coverage on behalf of eligible medicaid recipients if deemed cost effective.

(f) “Medicaid” means the Title XIX and Title XXI programs administered by the department, which makes medical assistance available to eligible individuals.

(g) “Policyholder” means the family member who owns the employer group health plan policy and is responsible for premium payment.

(h) “Wrap-around services” means to the extent that an employer group health plan does not cover a benefit contained in the NH state medicaid benefit package, the service is covered by traditional medicaid so that the individual has access to the same services to which they are entitled if they were only covered by the state’s medicaid program.

Source. #10632, eff 7-1-14; ss by #14075, eff 9-20-24, EXPIRES: 9-20-34

He-W 511.04 Recipient Participation.

(a) Participation in HIPP shall be voluntary and determined to be cost effective for the state medicaid program.

(b) Pending the determination of cost effectiveness, the medicaid recipient shall be eligible to receive medicaid covered services through the medicaid fee-for-service program, or through the managed care program.

(1) The insurance plan is an indemnity plan that pays only a predetermined amount for covered services, such as dental or vision only plans, or long-term care plans;

(2) The insurance plan is a school-based plan offered based on attendance or school enrollment;

(3) The individual is only eligible for medicaid through in and out medical assistance in accordance with He-W 878.01;

(4) The insurance plan is only offered for a temporary time period;

(5) The eligible individual does not qualify for full medicaid benefits;

(6) The insurance plan is through New Hampshire’s high-risk pool;

(7) The insurance plan is a medicare supplemental policy, if the HIPP application was filed after March 1, 1996;

(8) The insurance plan is COBRA;

(9) The medicaid recipient is or becomes eligible for medicare;

(10) No portion of the insurance plan premiums is paid for by the employer; or

(11) The employer benefit package is a cafeteria plan and the employer does not contribute a percentage of the benefit package to the employer group health plan premium that the employee contributes.

(d) Premiums for dental plans shall not be covered by HIPP unless the employer plan premium does not separate the dental portion.

(e) The policyholder of the insurance plan shall provide information necessary to establish the cost effectiveness of the employer group health plan including but not limited to the following:

(1) Health plan information, such as the plan name and policy number;

(2) Premium liability, which is the portions of the premium that is paid by the policyholder and employer;

(3) Co-insurance, which is the policyholder’s share of the cost of a covered health care services, and is generally calculated as a percentage of the total charge for the service;

(4) Deductible, which is the amount the policyholder must pay for health care services before the employer group health plan begins to pay;

(5) Co-pay liability, which is a fixed amount the policyholder pays for a health care service, and generally paid for at the time the services are rendered;

(6) Covered benefits and services;

(7) Any service limits applied to the benefit and service use by the health plan; and

(8) Demographic information relative to other individuals on the policyholder’s plan, including name, gender, and age.

(f) In addition to the information listed in (e)(1)-(8) above, the policyholder shall also provide employer and employment information to the department to include:

(1) The employer’s business name; and

(2) Contact information for the employer's human resource department.

(g) A HIPP application shall not be processed until all information in (e) and (f) above are submitted.

(h) If the department or the department’s vendor determines that the employer group health plan is cost effective, the medicaid recipient shall:

(1) Enroll in the health plan within 15 days of receiving notification from the department or the department’s vendor that the plan is cost effective, if not already enrolled; and

(2) Upon enrollment, provide the department or the department’s vendor with confirmation of the start date of coverage.

(i) In the event that the mediciad recipient is already enrolled in cost effective group health plan prior to applying for HIPP, then the HIPP premium payments shall begin the month following HIPP approval notification.

(j) If the department or the department’s vendor determines that the group health plan is not cost effective, the medicaid recipient shall remain enrolled in their medicaid care management program or fee for service program in accordance with He-W 506.

(k) The department shall not pay premiums when the department determines the employer group health plan is not cost effective, even if the non-medicaid members are not able to change the employer group health plan.

(l) Enrollment in an employer group health plan shall not change the individual’s eligibility for medicaid benefits.

Source. #10632, eff 7-1-14; ss by #14075, eff 9-20-24, EXPIRES: 9-20-34

He-W 511.05 Cost Effectiveness Determination.

(a) Cost effectiveness shall be determined by the department utilizing managed care rates.

(b) The cost effectiveness calculation shall be determined as follows:

(1) The average medicaid cost which is the managed care capitation payment at the time a completed HIPP application is received for the category of assistance, age, and gender of the medicaid recipient in the employer group health plan; and

(2) Any additional cost added for the conditions in a. through d. below, paid for under fee for service or additional managed care rates:

a. Blood disorders;

b. Hepatitis C;

c. Disorder of urea cycle metabolism; and

d. Maternity and newborn.

(d) The medicaid cost for included services shall be the percent of the managed care capitation payment, as determined by the actuarial vendor and noted in (b)(1) above, for medicaid only covered services included in the employer group health plan.

(e) Adjustment of coinsurance and deductible shall be 30% of the managed care capitation payment after the reduction for the medicaid only covered services in (b)(2) above.

(f) An employer group health plan shall be considered cost effective when the cost of the employer group health plan is lower than the cost under the medicaid managed care program.

(g) The employer group health plan cost shall be the employee’s share of the premium plus the coinsurance and deductible amount calculated in (e) above.

(h) The medicaid cost shall be determined by the managed care capitation payment in (b)(2) above.

Source. #10632, eff 7-1-14; ss by #14075, eff 9-20-24, EXPIRES: 9-20-34

He-W 511.06 Cost Effectiveness Redetermination.

(a) Cost effectiveness shall be redetermined annually concurrent with the policyholder’s annual open enrollment in the employer group health plan, or any time there is a change in the group health plan.

(b) It shall be the responsibility of the policyholder to submit the current employer group health plan, as described in He-W 511.04(e) and (f) above, when employer open enrollment starts, there is a change in the employer group health plan, or there is a change in the family status on the employer group health plan.

Source. #10632, eff 7-1-14; ss by #14075, eff 9-20-24, EXPIRES: 9-20-34

He-W 511.07 Wrap Around Coverage.

(a) If the employer group health plan does not cover the full range of medicaid services, the medicaid recipient shall receive wrap-around services through fee-for-service medicaid.

(b) Non-medicaid eligible family members, covered by the employer group health plan, shall not be eligible to receive wrap around services.

Source. #10632, eff 7-1-14; ss by #14075, eff 9-20-24, EXPIRES: 9-20-34

He-W 511.08 Payment of Cost Sharing, Co-Pays, and Deductibles.

(a) Recipient cost sharing, co-pays, and deductible obligations shall be either paid directly by medicaid to the providers or reimbursed to the recipient or person who paid, if the recipient is a minor.

(b) If the provider is a NH medicaid provider, then the provider shall be required to directly bill NH medicaid for any recipient obligation after the employer group health plan processes the claim in accordance with 42 CFR 433.139.

(c) The recipient, or person who paid, if recipient is a minor, shall be directly reimbursed by the department for services provided by providers not enrolled in medicaid, but in network with the employer group health plan, in which the recipient was unable to obtain the service from a medicaid provider or prescriptions obtained from a mail order pharmacy required by the employer group health plan.

(d) The recipient, or person who paid, if recipient is a minor, shall not be reimbursed for services:

(1) Not covered by NH medicaid; and

(2) If the provider is not in either the medicaid network or employer group health plan network.

(e) The HIPP program shall pay the premium for the minimum coverage group option that allows the medicaid-eligible recipient to be covered.

(f) If a non-medicaid family member is enrolled in the employer group health plan, then medicaid funds shall be expended for payment of premiums, but not for any other cost sharing expenses attributable to the non-medicaid family members.

(g) When more than one cost effective employer group health plan is available, the department shall pay the premium for only one plan, but the policyholder may choose the cost effective plan in which to enroll.

(h) If the medicaid recipient’s health plan offers more services than what is covered under medicaid, the medicaid recipient shall be responsible for any deductibles, coinsurance, and other cost sharing obligations attributable to those services not covered by medicaid.

(i) The medicaid recipient shall be responsible for payment of any nominal medicaid cost sharing amounts permitted under section 1916 of the Social Security Act (SSA).

Source. #10632, eff 7-1-14; ss by #14075, eff 9-20-24, EXPIRES: 9-20-34

He-W 511.09 Loss of Eligibility and Discontinuation of Premium Payments.

(a) When the medicaid recipient loses medicaid eligibility, premium payments shall be discontinued as of the month of medicaid ineligibility.

(b) Coverage of any medicaid benefits provided outside the employer group health plan, including any wrap around services, shall end on the date the medicaid recipient loses medicaid eligibility.

(c) If the department determines that the employer group health plan is no longer cost effective, HIPP premium payment shall be discontinued the month following the date of the termination letter or for redeterminations on the renewal date of the employer group health plan.

(d) If the policyholder fails to provide the information necessary to establish ongoing HIPP eligibility within 30 calendar days prior to employer group health plan renewal date, the policyholder shall be terminated from the HIPP program on the date when the insurance plan annually ends.

(e) If the policyholder does not have the employer group health plan renewal information 30 days prior, then the medicaid recipient or policyholder shall notify the department and submit the information within 2 business days of receiving the renewal information.

(f) If the policyholder disenrolls from their cost effective employer group health plan, the premium payments shall be discontinued as of the date of disenrollment.

(g) If the employer group health plan is no longer available or the policy has lapsed, premium payments shall be discontinued as of the effective date of the termination of the coverage.

(h) If the policyholder does not inform the department of the loss of the employer group health plan for any reason or any change in the employer group health plan and received premiums beyond the termination or change of the employer group health plan, the policyholder shall be required to refund to the department any premium and cost sharing over payments.

Source. #10632, eff 7-1-14; ss by #14075, eff 9-20-24, EXPIRES: 9-20-34

He-W 511.10 Third Party Liability. All third party obligations shall be exhausted before claims shall be submitted to the department’s fiscal agent in accordance with 42 CFR 433.139.

Source. #10632, eff 7-1-14; ss by #14075, eff 9-20-24

He-W 511.11 Utilization Review & Control. The department’s provider program integrity unit shall monitor utilization of services to identify, prevent, and correct potential occurrences of fraud, waste, and abuse in accordance with He-W 520, He-W 521, 42 CFR 455, and 42 CFR 456.

Source. #10632, eff 7-1-14; ss by #14075, eff 9-20-24, EXPIRES: 9-20-34

He-W 511.12 Appeals. Notice and appeal rights under 42 CFR 431 subpart E, shall not apply to the HIPP program.

Source. #14075, eff 9-20-24, EXPIRES: 9-20-34

PART He-W 512 ALTERNATIVE BENEFIT PLAN (ABP) AND PREMIUM ASSISTANCE PROGRAM

He-W 512.01 Purpose. The purpose of this part is to describe the alternative benefit plan (ABP) services and the premium assistance program (PAP) available through the medicaid program to the newly eligible population in accordance with the New Hampshire Health Protection Program, RSA 126-A:5, XXIV.

Source. #10656, eff 8-15-14; ss by #11012, INTERIM, eff 1-1-16, EXPIRES: 6-29-16; ss by #11119, eff 6-29-16

He-W 512.02 Definitions.

(a) “Alternative benefit plan (ABP)” means the medicaid benchmark or benchmark equivalent coverage described in section 1937 of the Social Security Act.

(b) “Department” means the New Hampshire department of health and human services.

(c) “Medicaid” means the Title XIX and Title XXI programs administered by the department, which makes medical assistance available to eligible individuals.

(d) “Medically frail” means a newly eligible individual who is exempt from mandatory enrollment in the ABP or PAP in accordance with the conditions set forth in 42 CFR § 440.315(f).

(e) “Newly eligible adult” means adults who are eligible for medicaid under the New Hampshire health protection program and the provision of section 1902(a)(10)(A)(i)(VIII) of the Social Security Act of 1935 as amended, 42 USC §1396a(a)(10)(A)(i)(VIII).

(f) “Premium Assistance Program (PAP)” means the Marketplace Premium Assistance Program, established by RSA 126-A:5 which requires that adults eligible for medical assistance under 42 USC § 1396a(a)(10)(A)(i)(VIII) enroll in a cost-effective Qualified Health Plan offered on New Hampshire’s federally facilitated Marketplace, authorized through the Section 1115(a) research and demonstration waiver, # 11-W-00298/1 by the Centers for Medicare and Medicaid Services on March 4, 2015.

(g) “Premium Assistance Program participants (PAP participants)” means those newly eligible adults who are mandatorily required to enroll in a qualified health plan, and those who voluntarily enroll in a qualified health plan.

(h) “Qualified Health Plan (QHP)” means an individual health insurance policy certified by the Centers for Medicare and Medicaid Services (CMS) for sale through New Hampshire’s individual health insurance Marketplace.

(i) “Subluxation” means an incomplete dislocation, off centering, misalignment, fixation, or abnormal spacing of the vertebrae.

(j) “Title XIX” means the joint federal-state program described in Title XIX of the Social Security Act and administered in New Hampshire by the department.

(k) “Title XXI” means the joint federal-state program described in Title XXI of the Social Security Act and administered in New Hampshire by the department.

(l) “Wrap benefits” means:

(1) Non-emergency medical transportation;

(2) Early Periodic Screening Diagnosis and Treatment (EPSDT) services as described in He-W 546, for individuals who are under the age of 21; and

(3) Family planning services and supplies from a medicaid enrolled provider, and adult dental in accordance with He-W 566.04(e) and adult vision services in accordance with He-W 530.03(g).

Source. #10656, eff 8-15-14; ss by #11012, INTERIM, eff 1-1-16, EXPIRES: 6-29-16; ss by #11119, eff 6-29-16

He-W 512.03 Eligibility.

(a) All newly eligible individuals shall receive services under the ABP, unless they are medically frail or identify as pregnant after application and opt to receive Medicaid state plan services.

(b) Individuals who are eligible for medicaid through the New Hampshire Health Protection Program (NHHPP) shall be in the PAP unless the individual is exempt or voluntary as described in He-W 512.04(b) and (c) below.

Source. #10656, eff 8-15-14; ss by #11012, INTERIM, eff 1-1-16, EXPIRES: 6-29-16; ss by #11119, eff 6-29-16

He-W 512.04 Enrollment.

(a) For individuals who are eligible for PAP, enrollment in a QHP shall be mandatory unless the individual is determined to be exempt as described in (b) below or voluntary as described in (c) and (d) below.

(b) Individuals who are determined to be medically frail as defined in 42 CFR § 440.315(f) shall be exempt from mandatory enrollment with a QHP.

(1) Individuals who are members of a federally recognized Indian tribe or Alaskan natives; and

(2) Individuals who are enrolled in PAP who identify as pregnant after the point of application for medicaid.

(d) The following shall apply to voluntary individuals described in (c) above:

(1) Voluntary individuals shall be enrolled in a QHP unless the individual identifies to the department that he or she is in a voluntary eligibility group as noted in (c) above; and

(2) If, after identifying as being in a voluntary eligibility group, a voluntary individual chooses not to enroll in a QHP, the individual shall be notified by the department and required to choose a medicaid managed care organization (MCO) as described in He-W 506.

(e) The department shall send a notice of QHP plan selection to all individuals eligible for PAP enrollment as indicated in (a) above except those who are exempted from enrollment.

(f) PAP participants shall have 30 days from the date of the QHP plan selection notice in (e) above to select a QHP and to respond to the department’s notice by using the on-line portal NH Electronic Application System (NH EASY) at www.nheasy.nh.gov, calling via telephone at 1-888-901-4999, or contacting the department in person.

(g) Except for voluntary individuals described in (c) and (d) above, PAP participants who fail to select a QHP within 30 days from the date of the notice in (f) above shall be auto-assigned to a QHP.

(h) Auto-assignments with a QHP shall be based on the following criteria:

(1) Personal or family affiliation to a QHP or MCO, if the MCO offers a complementary QHP;

(2) Primary care provider affiliation with a QHP; or

(3) If no assignment can be made utilizing (1)-(2) above, assignment shall be equally distributed among the available QHPs.

(i) PAP participants may request to change the QHP selection without cause, by making a written or oral request to the department at any of the following times:

(1) During the first 30 days following the date of the member’s initial selection of or the auto-assignment to the QHP, or the date the department sends the member confirmation of the individual’s selection or auto-assignment, whichever is later; and

(2) During annual open enrollment.

(j) PAP participants may request to change the QHP selection for cause, by making a written or oral request to the department within 60 days of the occurrence of one of the following events:

(1) PAP participant loses access to the QHP he or she is currently enrolled in because of a permanent move to a county where that QHP is not available;

(2) PAP participant gains or becomes a dependent through marriage, birth, adoption, foster care, child support order, or court order;

(3) PAP participant loses a dependent or is no longer considered a dependent through divorce or legal separation as defined by state law in the state in which the divorce or legal separation occurs, or if the enrollee’s dependent dies;

(4) The department confirms based on a PAP participant’s complaint that the QHP in which the PAP participant is enrolled violated a material provision of its contract in relation to the PAP participant; or

(5) PAP participant’s enrollment or non-enrollment in a QHP is unintentional, inadvertent, or erroneous and is the result of the error, misrepresentation, misconduct, or inaction of an officer, employee, or agent of the department, its instrumentalities, or a non-departmental entity providing enrollment assistance or conducting enrollment activities.

(k) PAP participants shall be dis-enrolled from the PAP program if they identify as medically frail after they were previously determined eligible.

(l) Medically frail individuals shall have the option to enroll with a medicaid MCO to receive the ABP benefit or the state plan medicaid benefit.

(m) Individuals who are voluntary as described in (c) and (d) above shall be enrolled as follows:

(1) Individuals who are enrolled in PAP and identify as pregnant after the point of application for medicaid shall elect to receive either state plan medicaid benefits delivered through a medicaid MCO or remain enrolled in the PAP with a QHP; and

(2) Individuals who are members of a federally recognized Indian tribe or Alaskan natives who elect to dis-enroll from their QHP shall receive ABP benefits delivered through a medicaid MCO.

(n) For PAP participants eligible for medicaid after October 1, 2015, the PAP participant shall receive coverage through fee-for-service medicaid from the date of the eligibility determination until the individual’s enrollment in the QHP becomes effective.

(o) If a PAP participant selects or is auto-assigned to a QHP on or before the 15^th of the month, coverage in the QHP shall be begin the first day of the month following the month in which the selection or auto-assignment was made.

(p) If a PAP participant selects or is auto-assigned to a QHP any time after the 15^th of the month, coverage in the QHP shall be begin the first day of the second month following the month in which the selection or auto-assignment was made.

Source. #10656, eff 8-15-14; ss by #11012, INTERIM, eff 1-1-16, EXPIRES: 6-29-16; ss by #11119, eff 6-29-16

He-W 512.05 Covered Services.

(a) ABP services for NHHPP participants who are medically frail or identify as members of federally recognized Indian tribes or Alaskan natives who choose to opt-out of the PAP shall include the following:

(1) Services described in He-W 506.04(a) and (b);

(2) Substance use disorder (SUD) services as described in He-W 513; and

(3) Chiropractor services, which shall be provided as follows:

a. Chiropractic services shall consist of spinal manipulation and manual medical intervention services, including:

1. Office visits for:

(i) Assessment;

(ii) Evaluation;

(iii) Spinal adjustments;

(iv) Manipulation; and

(v) Physiological therapy before or in conjunction with spinal adjustments; and

2. Medically necessary diagnostic laboratory and x-ray tests;

b. Chiropractic services shall not include wellness care; and

c. Chiropractic services shall be limited to 12 visits per recipient, per state fiscal year.

(b) Covered services for PAP participants enrolled with a QHP shall include the following categories of services from a QHP:

(1) Ambulatory patient services;

(2) Emergency services;

(3) Hospitalization;

(4) Maternity and newborn care;

(5) Mental health and substance use disorder services, including behavioral health treatment;

(6) Prescription drugs;

(7) Rehabilitative and habilitate services and devices;

(8) Laboratory services;

(9) Preventive and wellness services and chronic disease management; and

(10) Pediatric services including oral and vision care.

(c) PAP participants shall receive benefits described in (b) above from a QHP, and shall be restricted to using the QHP provider networks except that PAP participants shall not be restricted in their choice of family planning providers if the family planning provider is enrolled with medicaid.

(d) PAP participants shall receive fee for service wrap benefits as defined in He-W 512.02(l) above.

Source. #10656, eff 8-15-14; ss by #11012, INTERIM, eff 1-1-16, EXPIRES: 6-29-16; ss by #11119, eff 6-29-16

He-W 512.06 Co-payments.

(a) Except as prohibited by 42 USC § 1396o-1(b)(3)(B), newly eligible individuals who have an income greater than 100 percent of the FPL and are PAP participants shall be subject to the following co-payments:

(1) A co-payment in the amount of $8.00 for each non-preferred drug prescription and refill dispensed;

(2) A co-payment in the amount of $4.00 for each preferred drug prescription and refill dispensed;

(3) A co-payment in the amount of $5.00 for each primary care provider visit to treat illness or injury;

(4) A co-payment in the amount of $125.00 for each inpatient mental health admission, inpatient substance use disorder treatment admission or hospital admission, excluding maternity admissions;

(5) A co-payment in the amount of $50.00 for high-cost imaging such as CT/PET scans, and MRIs;

(6) A co-payment in the amount of $5.00 for each mental health outpatient visit;

(7) A copayment in the amount of $5.00 for each substance use disorder outpatient visit;

(8) A co-payment in the amount of $8.00 for each physical therapy visit;

(9) A co-payment in the amount of $8.00 for each occupational therapy visit;

(10) A co-payment in the amount of $8.00 for each speech therapy visit;

(11) A co-payment in the amount of $5.00 for each chiropractor visit;

(12) A co-payment in the amount of $8.00 for each specialty physician visit;

(13) A co-payment in the amount of $5.00 for each visit to other medical professionals such as an advanced practice registered nurse or a physician’s assistant; and

(14) A co-payment in the amount of $5.00 for each laboratory outpatient visit.

(b) Co-payment obligations shall be suspended for the remainder of the calendar year quarter when the total co-payments made out of pocket by the newly eligible individual reach 5 percent of the individual’s household income for that quarter. Co-payment obligations shall resume at the beginning of the next quarter. “Quarter” means one of 4 calendar periods ending March 31, June 30, September 30, and December 31.

Source. #10656, eff 8-15-14; ss by #11012, INTERIM, eff 1-1-16, EXPIRES: 6-29-16 (from He-W 512.05); ss by #11119, eff 6-29-16; ss by #12438, eff 1-1-18

He-W 512.07 Appeals Process for the Premium Assistance Program.

(a) The appeals process for the PAP shall address PAP participants’ requests for the appeal of any adverse decisions made by the QHP related to a PAP participant’s QHP covered benefits and decisions made by the department related to eligibility or wrap benefits related to the PAP.

(b) PAP participants who want to appeal a decision made by the QHP regarding a QHP’s covered benefits shall exhaust all private market appeals processes applicable under RSA 420-J:5 and RSA 420-J:5-a through 5-e prior to requesting a state fair hearing with the department. The private market appeals processes include internal review conducted by the QHP under RSA 420-J:5 with respect to both medical necessity and coverage issues, and an independent external review conducted by an independent review organization (IRO) under RSA 420-J:5-a through 5-e with respect to medical necessity issues only.

(c) PAP participants shall have the right to a state fair hearing in accordance with (d) and (e) below when the enrollee has exhausted the private market appeals processes without having the issue under appeal resolved in his or her favor. PAP enrollees shall file a request for a fair hearing in accordance with He-C 200.

(d) PAP participants shall have the right to a state fair hearing for the following issues:

(1) For medical necessity issues, at the conclusion of the external review process as provided in RSA 420-J:5-a-5-e;

(2) For issues not related to medical necessity, at the conclusion of a QHP internal review process as provided in RSA 420-J:5; and

(3) For decisions related to eligibility for medicaid or decisions made regarding wrap benefits made by the department, without first exhausting any private market appeals processes.

(e) Requests for a department fair hearing shall be made in writing within 30 calendar days of the date of the notice of the resolution of the appeal through the private market appeals process.

(f) A PAP participant’s benefits shall be continued during a department fair hearing if:

(1) The individual requests a department fair hearing within 10 calendar days of the notice of the disposition of the private market appeals process or the notice of the department’s decision on eligibility or wrap benefits;

(2) The individual requests continuation of benefits; and

(3) The individual identifies a medicaid enrolled provider to provide the benefit requested.

(g) If the QHP’s adverse decision is upheld in a department fair hearing, the member shall be liable for the cost of continued benefits.

Source. #10656, eff 8-15-14; ss by #11012, INTERIM, eff 1-1-16, EXPIRES: 6-29-16; ss by #11119, eff 6-29-16

He-W 512.08 Utilization Review and Control. The department’s provider program integrity unit shall monitor utilization of ABP services to identify, prevent, and correct potential occurrences of fraud, waste and abuse in accordance with in accordance with He-W 520, 42 CFR 455, and 42 CFR 456.

Source. #11012, INTERIM, eff 1-1-16, EXPIRES: 6-29-16 (from He-W 512.06); ss by #11119, eff 6-29-16

He-W 512.09 Third Party Liability. All third party obligations shall be exhausted before claims shall be submitted to the department’s fiscal agent in accordance with 42 CFR 433.139.

Source. #11012, INTERIM, eff 1-1-16, EXPIRES: 6-29-16 (from He-W 512.07); ss by #11119, eff 6-29-16

PART He-W 513 SUBSTANCE USE DISORDER (SUD) TREATMENT AND RECOVERY SUPPORT SERVICES

He-W 513.01 Purpose. The purpose of this part is to establish the procedures and requirements for age and clinically appropriate substance use disorders (SUDs) treatment and recovery support services that are provided to the individuals who are eligible for medicaid.

Source. #10655, INTERIM, eff 8-15-14, EXPIRES: 2-11-15; ss by #10779, eff 2-11-15; ss by #10922, eff 9-1-15; ss by #11107, eff 7-1-16; ss by #12681, eff 11-27-18

He-W 513.02 Definitions.

(a) “Collaborative service model” means a model whereby SUD treatment and recovery support services, health care services, and mental health services are provided by practitioners from different programs who work together via formalized relationships.

(b) “Comprehensive SUD program” means:

(1) An agency under contract with or agreement with the department which provides specialty SUD treatment and recovery support services on a residential and outpatient basis and whose facility is:

a. Licensed as a residential treatment and rehabilitation facility in accordance with He-P 807; or

b. A state-owned SUD residential treatment and rehabilitation facility which is exempt from licensure in accordance with RSA 151:2, II (i)and He-P 807;

(2) A hospital enrolled in medicaid both as a hospital in accordance with He-W 543 and as a comprehensive SUD program in accordance with He-W 513, which provides specialty SUD treatment and recovery support services on a residential and outpatient basis; or

(3) Providers enrolled in medicaid in the state in which they practice to provide residential services consistent with criteria as set forth in the American Society of Addiction Medicine (ASAM) Criteria: Treatment Criteria for Substance-Related, Addictive, and Co-Occurring Conditions, Third Edition (2013), henceforth referred to as “ASAM Criteria (2013)” available as noted in Appendix A, and who are also enrolled in NH medicaid.

(c) “Crisis intervention” means a response to a crisis or emergency situation experienced by an individual, family member, or significant other(s) related to a recipient’s SUD.

(d) “Department” means the New Hampshire department of health and human services.

(e) “Direct supervision” means that the supervisor meets with the individual to review his or her clinical practice in order to evaluate his or her performance.

(f) “Evaluation” means a clinical interview conducted by a qualified individual using one or more standardized, evidence based evaluation tools to determine the existence and severity of substance use and specific problem areas.

(g) “Family treatment” means outpatient individual or group treatment services provided by a clinician to assist recipients and their families to achieve treatment objectives through the exploration of SUDs and their ramifications, including an examination of attitudes and feelings, and consideration of alternative solutions and decision making with regard to substance misuse.

(h) “Integrated service model” means a model whereby SUD treatment and recovery support services, health care services, and mental health services are provided by a team of practitioners within a single program.

(i) “Intensive outpatient SUD services” means intensive and structured individual and group alcohol or other drug treatment services and activities that are provided at least 9 hours a week for recipients age 21 and over, and at least 6 hours a week for recipients under age 21, according to an individualized treatment plan that include a range of outpatient treatment services and other ancillary alcohol or other drug services.

(j) “Licensed mental health provider” means a psychotherapist licensed by the NH board of mental health practice or the NH board of psychologists, or an advanced practice registered nurse (APRN) with a psychiatric specialty.

(k) “Lived Experience” means that an individual has direct, personal experience with either their own recovery from a substance use disorder or that of a family member.

(l) “Medicaid” means the Title XIX and Title XXI programs administered by the department, which makes medical assistance available to eligible individuals.

(m) “Office-based medication assisted substance use disorder treatment” means medication prescription and monitoring by a licensed prescriber for the purpose of treating a SUD, including clinically appropriate referral to, and coordination with, SUD treatment providers within the prescriber’s practice or externally.

(n) “Opioid treatment services” means treatment for opioid use disorders using a combination of approved medications, limited to methadone and buprenorphine, and behavioral health services which is delivered by an agency certified as an opioid treatment program in accordance with He-A 304.03.

(o) “Outpatient, group treatment” means services provided by a clinician to assist 2 or more individuals to achieve treatment objectives through the exploration of substance use disorders and their ramifications, including an examination of attitudes and feelings, and consideration of alternative solutions and decision making with regard to substance misuse.

(p) “Outpatient, individual treatment” means services provided by a clinician to assist an individual to achieve treatment objectives through the exploration of substance use disorders and their ramifications, including an examination of attitudes and feelings, and consideration of alternative solutions and decision making with regard to substance misuse.

(q) “Outpatient SUD program” means an agency which provides specialty SUD treatment and recovery support services on an outpatient basis and which is:

(1) Under contract with or agreement with the department;

(2) A hospital enrolled in medicaid both as a hospital in accordance with He-W 543 and as an outpatient SUD program in accordance with He-W 513;

(3) A provider enrolled in medicaid in the state in which they practice to provide intensive outpatient services consistent with Level 2.1, as set forth in ASAM Criteria (2013), available as noted in Appendix A, or partial hospitalization consistent with Level 2.5, as set forth in ASAM Criteria (2013), available as noted in Appendix A, and who is also enrolled in NH Medicaid;

(4) Under current primary care services contract obligation with the maternal and child health section of the NH division of public health services;

(5) A medicaid enrolled community mental health center;

(6) A medicaid enrolled Federally Qualified Health Center (FQHC), as defined in section 1905(l)(2)(B) of the Social Security Act, or a medicaid enrolled Rural Health Clinic (RHC), as defined in section 1905(l)(1) of the Social Security Act; or

(7) An opioid treatment program which is certified as such in accordance with He-A 304.03.

(r) “Partial hospitalization services” means intensive and structured individual and group treatment of moderate to severe co-occurring substance use and other mental health disorder(s) that are provided at least 20 hours per week.

(s) “Peer recovery coach” means an individual who meets the requirements set out in He-W 513.05(r)(4).

(t) “Peer recovery program” means a recovery community organization or program that is accredited by the Council on Accreditation of Peer Recovery Support Services (CAPRSS), is accredited by Clubhouse International, is under contract with the department’s contracted facilitating organization, or is under contract with the department’s BDAS to provide peer recovery support services.

(u) “Peer recovery support services” means non-clinical recovery support services which are recipient directed and delivered by peers who have common life experiences with the recipients they are serving.

(v) “Recipient” means any individual who is eligible for and receiving medical assistance under the medicaid program.

(w) “Recovery support services” means non-clinical services that are provided to recipients to support their recovery from substance use disorders and prevent relapse.

(x) “Rehabilitative services” means 24-hour per day non-acute care in a non-hospital, residential treatment program where a planned program of professionally directed evaluation, care, and treatment for the restoration of functioning for persons with substance use disorders occurs.

(y) “Screening” means a brief process designed to identify an individual who is misusing substances, or is at risk for developing a substance use disorder, by using a screening instrument and evaluating responses to questions about alcohol and other drug use.

(z) “Screening, brief intervention, and referral to treatment (SBIRT)” means a comprehensive, integrated public health approach for early identification and intervention with patients whose alcohol or drug use may put their health at risk.

(aa) “Substance use disorder (SUD)” means a cluster of symptoms meeting the criteria for SUD as set forth in the Diagnostic and Statistical Manual of Mental Disorders, 5^th edition (DSM-5) (2013), available as noted in Appendix A.

(ab) “Title XIX” means the joint federal-state program described in Title XIX of the Social Security Act and administered in New Hampshire by the department under the medicaid program.

(ac) “Title XXI” means the joint federal-state program described in Title XXI of the Social Security Act and administered in New Hampshire by the department under the medicaid program.

(ad) “Treatment plan” means an action plan, written in behavioral terms, which:

(1) Is consistent with the competencies described in Section 2: Practice Dimensions, II. Treatment Planning of the “Addiction Counseling Competencies, TAP 21” (2017 revision), available as noted in Appendix A;

(2) Is based on evaluation data;

(3) Identifies the recipient’s clinical needs, treatment goals, and objectives;

(4) Defines the strategy for providing services to meet those needs, goals, and objectives;

(5) Provides the criteria for terminating specific interventions; and

(6) Includes specification and description of the indicators to be used to assess the individual’s progress.

Source. #10655, INTERIM, eff 8-15-14, EXPIRES: 2-11-15; ss by #10779, eff 2-11-15; ss by #10922, eff 9-1-15; ss by #11107, eff 7-1-16; amd by #12012, INTERIM, eff 10-25-16, EXPIRES: 4-23-17; amd by #12131, eff 3-10-17; ss by #12681, eff 11-27-18

He-W 513.03 Recipient Eligibility.

(a) All recipients shall be eligible for SUD treatment and recovery support services in accordance with this part and He-W 506.

(b) In order to receive SUD treatment and recovery support services, other than SBIRT pursuant to He-W 513.05(c), substance use screenings pursuant to He-W 513.05(d), crisis intervention pursuant to He-W 513.05(q), peer recovery support pursuant to He-W 513.05(r), non-peer recovery support pursuant to He-W 513.05(s), continuous recovery monitoring pursuant to He-W 513.05(t), and evaluations pursuant to He-W 513.05(u), the recipient shall have been determined to have a SUD by undergoing a clinical evaluation in accordance with He-W 513.05(u) to determine the level of care and ensuing treatment plan to be followed.

Source. #10655, INTERIM, eff 8-15-14, EXPIRES: 2-11-15; ss by #10779, eff 2-11-15; ss by #10922, eff 9-1-15; ss by #11107, eff 7-1-16; ss by #12681, eff 11-27-18

He-W 513.04 Provider Participation.

(a) All SUD treatment and recovery support service providers shall be enrolled as a New Hampshire medicaid provider.

(b) SUD treatment and recovery support service practitioners shall meet the provider requirements in He-W 531.05 for the services they are enrolling to provide.

(c) Individual practitioners delivering services as part of a medicaid enrolled outpatient SUD program or medicaid enrolled comprehensive SUD program shall be allowed to delegate, in accordance with scope of law and practice, the performance of SUD treatment and recovery support services to individuals under their supervision in such program, and subject to the following restrictions:

(1) With the exception of those licensed alcohol and drug counselors (LADCs) who are permitted to engage in independent practice in accordance with Chapter Law 189:2, II, Laws of 2008, and Chapter Law 249:24, V, Laws of 2010, LADCs shall only provide SUD treatment and recovery support services under the supervision of:

a. A master licensed alcohol and drug counselor (MLADC) who is on the staff of a medicaid enrolled outpatient SUD program or comprehensive SUD program;

b. A LADC who is permitted to engage in independent practice in accordance with Chapter Law 189:2, II, Laws of 2008, and Chapter Law 249:24, V, Laws of 2010, who also is a licensed clinical supervisor (LCS), and who is on the staff of a medicaid enrolled outpatient SUD program or comprehensive SUD program; or

c. A licensed mental health provider who is on the staff of a medicaid enrolled outpatient SUD program or comprehensive SUD program;

(2) Supervision requirements for SUD recovery support services shall be as follows:

a. A certified recovery support worker (CRSW) shall be supervised by one of the following:

1. An MLADC who is on the staff of or under contract with a medicaid enrolled outpatient SUD program, comprehensive SUD program, or peer recovery program;

2 A LADC who is permitted to engage in independent practice in accordance with Chapter Law 189:2, II, Laws of 2008, and Chapter Law 249:24, V, Laws of 2010, who also is an LCS and who is on the staff of or under contract with a medicaid enrolled outpatient SUD program, comprehensive SUD program, or peer recovery program;

3. A LADC who is on the staff of or under contract with a medicaid enrolled outpatient SUD program, comprehensive SUD program, or peer recovery program;

4. A CRSW who has been certified for one year and has taken 6 hours of supervisory training and 6 hours of practical training which has been approved by the board pursuant to Alc 409.01; or

5. A licensed mental health provider who is on the staff of or under contract with a medicaid enrolled outpatient SUD program, comprehensive SUD program, or peer recovery program;

b. A LADC delivering recovery support services shall be supervised by an MLADC who is on the staff of or under contract with a medicaid enrolled outpatient SUD program, comprehensive SUD program, or peer recovery program; and

c An MLADC delivering recovery support services shall not require supervision;

(3) Individuals who meet the following criteria shall only provide services under the supervision of an MLADC or licensed mental health provider who is on the staff of a medicaid enrolled outpatient SUD program or comprehensive SUD program:

a. The individual shall be enrolled in a formal internship for at least a master’s degree in a clinical discipline that meets the requirements for initial licensing as an MLADC pursuant to RSA 330-C:16, I, or

b. The individual shall:

1. Have completed at least one year of work in the field of substance use disorders treatment under the supervision of an MLADC or licensed mental health provider;

2. Have at least a master’s degree in a clinical discipline that meets the requirements for initial licensing as an MLADC pursuant to RSA 330-C:16, I; and

3. Be working to accumulate the work experience required for licensure;

(4) Individuals who meet the criteria below shall only provide services under the supervision of a psychologist who is on the staff of a medicaid enrolled outpatient SUD program or comprehensive SUD program:

a. The individual shall be enrolled in a formal internship for at least a master’s program that meets the requirements for initial licensure by the NH board of psychologists pursuant to RSA 329-B; or

b. The individual shall:

1. Have completed at least one year of work in the field of substance use disorders treatment under the supervision of a person licensed by the NH board of psychologists;

2. Have at least a master’s degree that meets the requirements for initial licensure by the NH board of psychologists pursuant to RSA 329-B; and

3. Be working to accumulate the work experience required for licensure;

(5) Individuals who meet the criteria below shall only provide services under the supervision of a psychotherapist who is on the staff of a medicaid enrolled outpatient SUD program or comprehensive SUD program:

a. The individual shall be enrolled in a formal internship for at least a master’s program that meets the requirements for initial licensure by the NH board of mental health practice pursuant to RSA 330-A; or

b. The individual shall:

1. Have completed at least one year of work in the field of substance use disorders treatment under the supervision of a psychotherapist;

2. Have at least a master’s degree that meets the requirements for initial licensure by the NH board of mental health practice pursuant to RSA 330-A; and

3. Be working to accumulate the work experience required for licensure;

(6) Individuals who qualify to provide services pursuant to He-W 513.04(c)(3) – (5) above and who hold at least a master’s degree shall have ongoing supervision of at least 2 hours per month as follows:

a. There shall be direct, individual, or group supervision of at least one hour per month by the supervising practitioner noted in (3) -(5) above; and

b. The second hour of supervision may be peer review or case review, such as client-centered conferences;

(7) Individuals who qualify to provide services pursuant to He-W 513.04(c)(3) – (5) above and who are enrolled in a formal internship shall receive direct supervision as follows:

a. There shall be direct supervision of at least one hour per week;

b. The supervisor shall write and sign a weekly note in the intern’s supervisory record stating his or her observations and recommendations relative to the intern’s performance; and

c. The supervisor shall write and sign a monthly note in the intern’s supervisory record summarizing his or her evaluation;

(8) The medicaid program shall reimburse the outpatient or comprehensive SUD program only if the supervision required in accordance with He-W 513.04(c)(3) - (7) occurs and is documented;

(9) The delegated services shall be billed by the outpatient or comprehensive SUD program; and

(10) A LADC who is permitted to engage in independent practice in accordance with Chapter Law 189:2, II, Laws of 2008, and Chapter Law 249:24, V, Laws of 2010, shall not provide supervision to an MLADC for the purposes of providing services under He-W 513.

(d) SUD treatment and recovery support service providers shall ensure that the recipient has undergone a clinical evaluation, as required by He-W 513.03(b) above, prior to the provider’s delivery of other SUD treatment and recovery support services.

(e) SUD treatment and recovery support service providers shall ensure that all SUD treatment and recovery support services are provided and documented in accordance with the Health Insurance Portability and Accountability Act (HIPAA) of 1996, 45 CFR 160, 45 CFR 164, Subparts A and E, and 42 CFR, Part II.

(f) SUD treatment and recovery support service providers shall ensure that any SUD group treatment and recovery support services described in He-W 513.05 below are delivered in accordance with the following:

(1) Services shall only be covered when 2 or more individuals are present for a group service;

(2) SUD treatment groups shall include no more than 12 individuals with one licensed practitioner present or no more than 16 individuals when that licensed practitioner is joined by a CRSW or a second licensed practitioner;

(3) Recovery support groups shall include no more than 8 individuals with one CRSW present or no more than 12 individuals when that CRSW is joined by a second CRSW; and

(4) Peer recovery support groups shall include no more than 8 individuals with one peer recovery coach present or no more than 12 individuals when that peer recovery coach is joined by a second peer recovery coach.

(g) SUD treatment service providers shall ensure that all covered services are provided in accordance with criteria as set forth in ASAM Criteria (2013), available as noted in Appendix A, except for SBIRT services provided in accordance with He-W 513.05(c), substance use screening provided in accordance with He-W 513.05(d), crisis intervention provided in accordance with He-W 513.05(q), and evaluations provided in accordance with He-W 513.05(u).

(h) All SUD treatment and recovery support service providers shall treat co-occurring disorders in accordance with scope of law and practice.

(i) Except as in (j) below, LADCs, and MLADCs who are delivering or supervising SUD treatment and recovery support services shall be licensed by the NH board of licensing for alcohol and other drug use professionals.

(j) Providers who hold a reciprocal international certification and reciprocity consortium/alcohol and other drug abuse (IC&RC) license shall be considered to have met the requirement in (i) above for the purpose of He-W 513.

(k) New Hampshire enrolled out of state providers whose license or certification allows them to provide SUD services in the state in which they practice shall be considered to have met the requirements in (i) above.

(l) Hospitals enrolled in medicaid as a hospital in accordance with He-W 543 shall also be enrolled in medicaid as an outpatient or comprehensive SUD program in order to provide outpatient or comprehensive SUD services in accordance with He-W 513.05.

(m) Providers who are enrolled in other states and who meet the definition of outpatient or comprehensive SUD programs in accordance with He-W 513.02 (b) or (q) shall also be enrolled in NH medicaid in order to provide outpatient or comprehensive SUD services in accordance with He-W 513.05.

(n) Providers who are employed by, or under contract with, a comprehensive or outpatient SUD program shall be considered to be on the staff of that program.

Source. #10655, INTERIM, eff 8-15-14, EXPIRES: 2-11-15; ss by #10779, eff 2-11-15; ss by #10922, eff 9-1-15; ss by #11107, eff 7-1-16; amd by #12131, eff 3-10-17; ss by #12681, eff 11-27-18

He-W 513.05 Covered Services.

(a) SUD treatment and recovery support services shall be covered in accordance with this section.

(b) In order for the services described in this section to be covered, they shall:

(1) Be delivered in accordance with appropriate guidelines that are consistent with generally accepted standards of care in the ASAM Criteria (2013), available as noted in Appendix A;

(2) Include continuing care, transfer, and discharge plans that address all domains in ASAM Criteria (2013), available as noted in Appendix A, as follows:

a. Plans shall include the process of transfer and discharge planning at the time of the recipient’s intake to the program;

b. Plans for continuing care shall include at least one of the 3 following criteria for continuing services:

1. The recipient is making progress but has not yet achieved the goals articulated in the individualized treatment plan, and continued treatment at the present level of care is assessed as necessary to permit the recipient to continue to work toward his or her treatment goals;

2. The recipient is not yet making progress, but has the capacity to resolve his or her problems, is actively working toward the goals articulated in the individualized treatment plan, and continued treatment at the present level of care is assessed as necessary to permit the recipient to continue to work toward his or her treatment goals; or

3. New problems have been identified that are appropriately treated at the present level of care and that requires services at a frequency and intensity that can only safely be delivered by the recipient’s continued stay in the current level of care; and

c. Plans for transfer or discharge planning shall include at least one of the 4 following criteria:

1. The recipient has achieved the goals articulated in the individualized treatment plan thus resolving the problem or problems that justified admission to the present level of care and continuing chronic disease management of the recipient’s condition at a less intensive level of care is indicated;

2. The recipient has been unable to resolve the problem or problems that justified the admission to the present level of care despite amendments to the treatment plan and has been determined to have met the maximum possible benefit from engagement in services at the current level of care, so transfer or discharge from treatment is indicated;

3. The recipient has demonstrated a lack of capacity due to diagnostic or co-occurring conditions that limit his or her ability to resolve his or her problem, so treatment at a qualitatively different level of care or type of service, or discharge from treatment is indicated; or

4. The recipient has experienced an intensification of his or her problem or problems or has developed a new problem or problems and can be treated effectively at a more intensive level of care;

(3) Be evidence based, as demonstrated by meeting one of the following criteria:

a. The service shall be included as an evidence-based mental health and substance abuse intervention on the SAMHSA Evidence-Based Practices Resource Center available at https://www.samhsa.gov/ebp-resource-center;

b. The services shall be published in a peer-reviewed journal and found to have positive effects; or

c. The SUD treatment and recovery support service provider shall be able to document the services’ effectiveness based on the following:

1. The service is based on a theoretical perspective that has validated research; or

2. The service is supported by a documented body of knowledge generated from similar or related services that indicate effectiveness;

(4) When clinically appropriate, include referral to, and assistance in accessing, medication assisted SUD treatment either on site or off site;

(5) Include an assessment of all recipients for risk of self-harm at all phases of treatment, such as at initial contact, during screening, intake, admission, on-going treatment services, and at discharge;

(6) With the exception of peer and non-peer recovery and continuous recovery monitoring, be consistent with the “Addiction Counseling Competencies, TAP 21” (2017 revision), available as noted in Appendix A;

(7) Be provided in accordance with the ASAM Level of Care service descriptions, as applicable, noted in He-W 513.11; and

(8) Be provided at a length of time and frequency of care based on individual client need in accordance with ASAM Criteria (2013), available as noted in Appendix A, and not on predetermined time or frequency limits.

(c) Screening, brief intervention, and referral to treatment (SBIRT) shall be a covered service when provided as follows:

(1) The screening shall be provided for the purpose of identifying individuals who have an alcohol or drug use problem or who are at risk for developing one;

(2) The screening shall be conducted by evaluating responses to questions as described in (3) below about the context, frequency, and amount of alcohol and other drug use;

(3) The screening shall be performed using a screening instrument listed in Appendix E of “Systems-Level Implementation of Screening, Brief Intervention, and Referral to Treatment, TAP 33” (2013 edition), available as noted in Appendix A;

(4) SBIRT shall be provided with and billed with another medical service;

(5) SBIRT shall be conducted by a provider who has been trained in the SBIRT model and is either:

a. A medicaid enrolled physician or APRN;

b. A medicaid enrolled physician assistant, or other practitioner under a physician’s supervision; or

c. A practitioner working in an outpatient SUD program as defined in He-W 513.02(q)(4) or He-W 513.02(q)(6) who is either:

1. A physician or APRN; or

2. A physician assistant or other practitioner under a physician’s supervision;

(6) SBIRT shall be performed in the primary care practitioner’s office or other health care settings not specific to the delivery of SUD treatment and recovery support services;

(7) The services provided by the providers described in (5)a. above shall be billed by the medicaid enrolled practitioner; and

(8) The services provided by the providers described in (5)b. above shall be billed by the supervising physician.

(d) SUD screening shall be a covered service when provided as follows:

(1) The screening shall be provided for the purpose of identifying individuals who have an alcohol or drug use problem or who are at risk for developing one;

(2) The screening shall be conducted by evaluating responses to questions as described in (3) below about the context, frequency, and amount of alcohol and other drug use;

(4) Except as allowed in (5) and (6) below, the screening shall be performed by medicaid enrolled psychotherapy providers licensed by the NH board of mental health practice, medicaid enrolled psychotherapy providers licensed by the NH board of psychology, medicaid enrolled MLADCs licensed by the NH board of licensing for alcohol and other drug use professionals, LADCs who are permitted to engage in independent practice in accordance with Chapter Law 189:2, II, Laws of 2008, and Chapter Law 249:24, V, Laws of 2010, medicaid enrolled outpatient SUD programs, or medicaid enrolled comprehensive SUD programs; and

(5) The screening may be performed by individuals who are allowed to do such screenings under the supervision of the providers in (4) above in accordance with RSA 329-B, RSA 330-A, or RSA 330-C as follows:

a. The restrictions described in He-W 513.04(c) shall not apply; and

b. Such screenings shall be billed by the supervising practitioner or the outpatient or comprehensive SUD program.

(e) Opioid treatment services shall be a covered service when provided as follows:

(1) Opioid treatment services shall be provided by medicaid enrolled providers who meet the medical services clinic requirements in He-W 536 and are certified as an opioid treatment program in accordance with He-A 304.03;

(2) Opioid treatment providers shall operate and provide services in accordance with He-A 304;

(3) Opioid treatment services shall be delivered in accordance with a treatment plan;

(4) Opioid treatment services shall be limited to treatment with methadone or buprenorphine;

(5) Opioid treatment services shall be inclusive of the necessary components of the daily opioid treatment services, such as intake services, medication counseling, administration, medical supervision of vitals, observation afterwards, urine testing, and blood and lab work;

(6) SUD treatment and recovery support services may be provided in conjunction with the opioid treatment services and may be billed separately from the opioid treatment service; and

(7) Except as specified in (5) above, opioid treatment services shall be billed in accordance with He-W 536.

(f) Pharmaceuticals prescribed for SUD treatment services shall be covered in accordance with He-W 570.

(g) Office-based medication assisted SUD treatment shall be a covered service when provided as follows:

(1) Office-based medication assisted SUD treatment via buprenorphine shall be provided by medicaid enrolled providers who:

a. Have obtained a waiver in accordance with the Drug Addiction Treatment Act of 2000 (DATA 2000), Title XXXV, Section 3502 of the Children’s Health Act of 2000, to treat opioid addiction with Schedule III, IV, and V narcotic medications; and

b. Provide services in accordance with TIP 63: Medications for Opioid Use Disorder (2018), available at https://store.samhsa.gov/product/tip-63-medications-opioid-use-disorder-%E2%80%93-full-document-including-executive-summary-parts-1-5 and as noted in Appendix A;

(2) Office-based medication assisted SUD treatment shall be provided by medicaid enrolled providers who meet the physician requirements in He-W 531 or the advanced practice registered nurse requirements in He-W 534;

(3) Office-based medication assisted SUD treatment shall be delivered in accordance with a treatment plan;

(4) The writing of the prescription shall be a component of an office visit;

(5) The provider shall:

a. Refer the recipient to clinically appropriate SUD treatment and recovery services as described in He-W 513; and

b. Coordinate care with the SUD treatment and recovery provider within or external to the office based practice;

(6) Office-based medication assisted SUD shall be billed by the prescribing provider, outpatient SUD program, or comprehensive SUD program; and

(7) The prescribing provider shall be listed as the rendering provider on the claim.

(h) Outpatient, individual treatment consistent with Level 1, as set forth in ASAM Criteria (2013), available as noted in Appendix A, shall be a covered service when provided as follows:

(1) Outpatient, individual treatment shall be delivered in accordance with a treatment plan;

(2) Outpatient, individual treatment shall be covered when provided by medicaid enrolled psychotherapists licensed by the NH board of mental health practice or the NH board of psychologists, medicaid enrolled MLADCs licensed by the NH board of licensing for alcohol and other drug use professionals, LADCs who are permitted to engage in independent practice in accordance with Chapter Law 189:2, II, Laws of 2008, and Chapter Law 249:24, V, Laws of 2010, medicaid enrolled physicians or advanced practice registered nurses (APRNs), medicaid enrolled outpatient SUD programs, or medicaid enrolled comprehensive SUD programs; and

(3) Outpatient, individual treatment shall be billed by the medicaid enrolled individual or group practitioner or by the outpatient or comprehensive SUD program.

(i) Group treatment consistent with Level 1, as set forth in ASAM Criteria (2013), available as noted in Appendix A, shall be a covered service when provided as follows:

(1) Group treatment shall meet the requirements in He-W 513.04(f);

(2) Group treatment shall be delivered in accordance with a treatment plan;

(3) Group treatment shall be covered when provided by medicaid enrolled psychotherapists licensed by the NH board of mental health practice or the NH board of psychologists, medicaid enrolled MLADCs licensed by the NH board of licensing for alcohol and other drug use professionals, LADCs who are permitted to engage in independent practice in accordance with Chapter Law 189:2, II, Laws of 2008, and Chapter Law 249:24, V, Laws of 2010, medicaid enrolled physicians or APRNs, medicaid enrolled outpatient SUD programs, or medicaid enrolled comprehensive SUD programs; and

(4) Group treatment shall be billed by the medicaid enrolled individual or group practitioner or by the outpatient or comprehensive SUD program.

(j) Family treatment consistent with Level 1, as set forth in ASAM Criteria (2013), available as noted in Appendix A, shall be a covered service when provided as follows:

(1) Family treatment shall be provided to either:

a. The recipient; or

b. The recipient’s family members or significant others, either with or without the recipient present, if treatment is related to the recipient’s SUD;

(2) Family treatment shall be delivered in accordance with a treatment plan;

(3) Family treatment shall be covered when provided by medicaid enrolled psychotherapists licensed by the NH board of mental health practice or the NH board of psychologists, medicaid enrolled MLADCs licensed by the NH board of licensing for alcohol and other drug use professionals, LADCs who are permitted to engage in independent practice in accordance with Chapter Law 189:2, II, Laws of 2008, and Chapter Law 249:24, V, Laws of 2010, medicaid enrolled physicians or APRNs, medicaid enrolled outpatient SUD programs, or medicaid enrolled comprehensive SUD programs; and

(4) Family treatment shall be billed by the medicaid enrolled individual or group practitioner or by the outpatient or comprehensive SUD program.

(k) Intensive outpatient SUD services consistent with Level 2.1, as set forth in ASAM Criteria (2013), available as noted in Appendix A, shall be a covered service when provided as follows:

(1) Intensive outpatient SUD services shall be covered when they are:

a. Provided by medicaid enrolled outpatient or comprehensive SUD programs; and

b. Delivered by the following practitioners:

1. Psychotherapists licensed by the NH board of mental health practice or the NH board of psychologists; or

2. MLADCs licensed by the NH board of licensing for alcohol and other drug use professionals;

(2) Intensive outpatient SUD services shall be comprised of a combination of individual and group treatment services at least 9 hours per week for recipients age 21 and over and at least 6 hours per week for recipients under age 21;

(3) Group treatment shall meet the requirements in He-W 513.04(f);

(4) Intensive outpatient SUD services shall be delivered in accordance with a treatment plan;

(5) Intensive outpatient SUD services shall be comprised of a range of outpatient treatment services and other ancillary alcohol or drug treatment services to include all of the following:

a. Evaluation;

b. Individual, group, or family treatment;

c. Crisis intervention;

d. Activity therapies; and

e. Substance use prevention education; and

(6) Intensive outpatient SUD services shall be billed by the outpatient or comprehensive SUD program.

(l) Partial hospitalization services consistent with Level 2.5, as set forth in ASAM Criteria (2013), available as noted in Appendix A, shall be a covered service when provided as follows:

(1) Partial hospitalization services shall be:

a. Provided to recipients with moderate to severe co-occurring SUD and mental health disorders as described in DSM-5 (2013), available as noted in Appendix A;

b. Provided by a medicaid enrolled outpatient or comprehensive SUD treatment program; and

c. Delivered by the following practitioners:

1. For all partial hospitalization services, except medication management:

(i) Psychotherapists licensed by the NH board of mental health practice or the NH board of psychologists; or

(ii) MLADCs licensed by the NH board of licensing for alcohol and other drug use professionals; and

2. For medication management services:

(i) Psychiatrists licensed by the NH board of medicine; or

(ii) APRNs with a psychiatric specialty;

(2) Partial hospitalization shall address both disorders and be comprised of a range of outpatient treatment services and other ancillary mental health and alcohol or drug treatment services to include all of the following:

a. Evaluation;

b. Individual, group, or family treatment;

c. Crisis intervention;

d. Activities therapies;

e. Medication management, which shall include psychiatric services, including psychotropic medication management services as applicable; and

f. Substance use prevention education;

(3) Services shall be provided at least 20 hours per week;

(4) Group sessions shall meet the requirements in He-W 513.04(f); and

(5) Services shall be billed by the outpatient or comprehensive SUD program.

(m) Rehabilitative services shall be a covered service when provided as follows:

(1) Rehabilitative services shall be:

a. Provided by a medicaid enrolled comprehensive SUD program;

b. Delivered by the following practitioners:

1. Psychotherapists licensed by the NH board of mental health practice or the NH board of psychologists;

2. MLADCs licensed by the NH board of licensing for alcohol and other drug use professionals;

3. Physicians; or

4. Advanced practice registered nurses (APRN); and

c. Provided as a planned program of professionally directed evaluation, care, and treatment for the restoration of functioning for persons with SUDs;

(2) Recipients who are being treated at an ASAM 3.5 level of care shall be present in the facility at least 22 hours per day; and

(3) Recipients who are being treated at an ASAM 3.1 level of care shall receive at least 5 hours of clinical service per week..

(n) Medically monitored outpatient withdrawal management (WM) consistent with Level 1-WM, as set forth in ASAM Criteria (2013), available as noted in Appendix A, shall be a covered service when provided as follows:

(1) Medically monitored outpatient withdrawal management services shall be provided by a medicaid enrolled outpatient or comprehensive SUD program and supervised by a licensed physician or APRN who is on the staff of, or under contract with, the outpatient or comprehensive SUD program;

(2) Medically monitored outpatient withdrawal management services shall be organized and delivered by SUD treatment and mental health personnel and other health care providers who provide a planned regimen of care in the outpatient setting;

(3) Personnel required in (2) above shall be:

a. Psychotherapists licensed by the NH board of mental health practice or the NH board of psychologists on the staff of, or under contract with, the outpatient or comprehensive SUD program;

b. MLADCs licensed by the NH board of licensing for alcohol and other drug use professionals on the staff of, or under contract with, the outpatient or comprehensive SUD program;

c. Licensed physicians on the staff of, or under contract with, the outpatient or comprehensive SUD program; or

d. Licensed APRNs on the staff of, or under contract with, the outpatient or comprehensive SUD program;

(4) Medically monitored outpatient withdrawal management services shall be delivered in accordance with a treatment plan;

(5) Medically monitored outpatient withdrawal management services shall be provided in regularly scheduled sessions in accordance with defined policies and procedures consistent with ASAM Criteria (2013) standards, available as noted in Appendix A;

(6) Medically monitored outpatient withdrawal management services shall be provided under an integrated or collaborative service model; and

(7) Medically monitored outpatient withdrawal management services shall be billed by the outpatient or comprehensive SUD program.

(o) Medically monitored residential withdrawal management consistent with Level 3.7-WM, as set forth in ASAM Criteria (2013), available as noted in Appendix A, shall be a covered service when provided as follows:

(1) Medically monitored residential withdrawal management services shall be provided by a medicaid enrolled comprehensive SUD program;

(2) Medically monitored residential withdrawal management services shall be organized and delivered by SUD treatment and mental health personnel and other health care providers who provide a planned regimen of care in a 24-hour live-in setting;

(3) Personnel required in (2) above shall be:

a. Psychotherapists licensed by the NH board of mental health practice or the NH board of psychologists on the staff of, or under contract with, the comprehensive SUD program;

b. MLADCs licensed by the NH board of licensing for alcohol and other drug use professionals on the staff of, or under contract with, the comprehensive SUD program;

c. Licensed physicians on the staff of, or under contract with, the comprehensive SUD program; or

d. Licensed APRNs on the staff of, or under contract with, the comprehensive SUD program; and

(4) Medically monitored residential withdrawal management services shall be billed by the comprehensive SUD program.

(p) Medically managed withdrawal in an acute care setting shall be covered for recipients in accordance with the provisions of He-W 543.

(q) Crisis intervention shall be a covered service when provided as follows:

(1) Crisis intervention shall be covered when a recipient, family member, or significant other is facing a crisis or emergency situation and the crisis intervention is related to the recipient’s SUD;

(2) Crisis intervention shall be covered when provided by medicaid enrolled psychotherapists licensed by the NH board of mental health practice or the NH board of psychologists, medicaid enrolled MLADCs licensed by the NH board of licensing for alcohol and other drug use professionals, LADCs who are permitted to engage in independent practice in accordance with Chapter Law 189:2, II, Laws of 2008 and Chapter Law 249:24, V, Laws of 2010, medicaid enrolled physicians or APRNs, medicaid enrolled outpatient SUD programs, or medicaid enrolled comprehensive SUD programs; and

(3) Crisis intervention shall be billed by the medicaid enrolled individual or group practitioner or by the outpatient or comprehensive SUD program.

(r) Peer recovery support shall be a covered service when provided as follows:

(1) Peer recovery support services shall include non-clinical services delivered by peers who self-identify as having lived experience to help recipients age 12 and above and families identify and work toward strategies and goals around stabilizing and sustaining recovery and, as applicable, providing links to professional treatment and community supports;

(2) Peer recovery support services shall include:

a. Skill restoration therapy intended to reduce or remove barriers to achieving and maintaining recovery;

b. Emergency or crisis services available by telephone;

c. Assistance in accessing transportation services for individuals who lack safe transportation;

d. Individual skills development and restoration to prevent continuation or recurrence of substance misuse;

e. Psychoeducation interventions to support recovery;

f. Development and periodic revision of a specific recovery plan based on the information collected through the assessment that shall specify the goals and actions to address the recovery goals and other services needed by the individual; and

g. Working with the individual to develop and refine recovery goals;

(3) Peer recovery support services shall be provided by a medicaid enrolled peer recovery program;

(4) Peer recovery support services shall be delivered by a peer recovery coach who shall have:

a. Completed 30 contact hours of recovery coach training approved by:

1. NH Training Institute on Addictive Disorders;

2. The NH Board of Licensing for Alcohol and Other Drug Use Professionals;

3. NAADAC, the Association for Addiction Professionals;

4. AdCare Education Institute, Inc., of New England;

5. Addiction Technology Transfer Center; or

6. Connecticut Communities for Addiction Recovery (CCAR) Recovery Coach Academy (RCA);

b. Completed a minimum of sixteen contact hours of training in ethics approved by any of the providers in (r)(4)a.1.-6.;

c. Completed a minimum of 6 contact hours of training in suicide prevention approved by any of the providers in (r)(4)a.1.-6.; and

d. Completed a minimum of 3 contact hours of training on co-occurring mental health and substance use disorders approved by any of the providers in (r)(4)a.1.-6.;

(5) The individual providing the services shall be supervised by a practitioner in accordance with He-W 513.04 (c)(2) who is on the staff of, or under contract with, the peer recovery program who shall have:

a. Completed the training described in He-W 513.05(r)(4); and

b. Completed 6 contact hours of training in the supervision of individuals delivering peer recovery support services approved by:

1. NH Training Institute on Addictive Disorders;

2. The NH Board of Licensing for Alcohol and Other Drug Use Professionals;

3. NAADAC, the Association for Addiction Professionals;

4. AdCare Education Institute, Inc., of New England;

5. Addiction Technology Transfer Center; or

6. Connecticut Communities for Addiction Recovery (CCAR) Recovery Coach Academy (RCA);

(6) Peer recovery support services shall be billed by the peer recovery program; and

(7) The supervising practitioner in (5) above shall be listed as the rendering provider when billing for services.

(s) Recovery support services shall be a covered service when provided as follows:

(1) Recovery support services shall include non-clinical group or individual services consistent with a recipient’s treatment plan that help to prevent relapse and promote recovery and community integration for the individual being served;

(2) Recovery support services shall include:

a. Skill restoration therapy intended to reduce or remove barriers to achieving and maintaining recovery;

b. Emergency and crisis services available by telephone;

c. Assistance in accessing transportation services for individuals who lack safe transportation;

d. Individual skills development and restoration to prevent continuation or recurrence of substance misuse;

e. Psychoeducation interventions to support recovery;

g. Working with the individual to develop and refine recovery goals;

(3) Recovery support services shall be provided by a medicaid enrolled outpatient, comprehensive SUD treatment program, or peer recovery program;

(4) Recovery support services shall be provided by a CRSW certified by the NH board of licensing for alcohol and other drug use professionals, by a LADC or MLADC licensed by the board of licensing for alcohol and other drug use professionals, or by a psychotherapist licensed by the NH board of mental health practice or the NH board of psychologists;

(5) The individual providing the services shall be supervised by a practitioner in accordance with He-W 513.04(c)(2);

(6) Recovery support shall be billed by the outpatient, comprehensive SUD program, or peer recovery program; and

(7) The supervising practitioner in (5) above shall be listed as the rendering provider when billing for services.

(t) Continuous recovery monitoring shall be a covered service when provided as follows:

(1) Continuous recovery monitoring shall include recovery check-ups with recipients on a regular basis, evaluations of the status of the recipient’s recovery, consideration of a broad array of recipient needs, and provision of active referral to community resources as applicable;

(2) Continuous recovery monitoring shall be provided by a medicaid enrolled outpatient or comprehensive SUD treatment program or a peer recovery program;

(3) When provided in a peer recovery program, continuous recovery monitoring shall be provided by an individual described in He-W 513.05(r)(4) above who is supervised in accordance with He-W 513.04(c)(2) above;

(4) When provided in an outpatient or comprehensive SUD program, continuous recovery monitoring shall be provided by an individual described in He-W 513.05(s)(4) who is supervised in accordance with He-W 513.04(c)(2) above;

(5) Continuous recovery monitoring shall be billed by the outpatient or comprehensive SUD program or peer recovery program; and

(6) The supervising practitioner in (3) above shall be listed as the rendering provider when billing for services.

(u) Evaluations to determine the existence and severity of the SUD and appropriate level of care for the recipient shall be a covered service when provided as follows:

(1) An evaluation shall be covered when provided by a medicaid enrolled psychotherapist licensed by the NH board of mental health practice or the NH board of psychologists, medicaid enrolled MLADCs licensed by the NH board of licensing for alcohol and other drug use professionals, LADCs who are permitted to engage in independent practice in accordance with Chapter Law 189:2, II, Laws of 2008 and Chapter Law 249:24, V, Laws of 2010, or medicaid enrolled outpatient or comprehensive SUD programs;

(2) The results of the evaluation, which shall include the following, shall be maintained in the recipient’s file:

a. Client identified problem(s);

b. Summary of data gathered;

c. Diagnostic evaluation interpretive summary, including signs, symptoms, and progression of the recipient’s involvement with alcohol and other drugs;

d. Statement regarding provision of an HIV/AIDS screening and referrals made; and

e. Documentation of the level of care recommended in accordance with ASAM Criteria (2013), available as noted in Appendix A;

(3) Evaluations shall be billed by the medicaid enrolled individual or group practitioner or by the outpatient or comprehensive SUD program; and

(4) Evaluations shall be completed within 3 sessions or within 3 days of client admission to services, whichever is longer.

He-W 513.06 Non-Covered Services.

(a) Services that are delivered at a higher level than the recipient’s level of care, as described in ASAM Criteria (2013), available as noted in Appendix A, shall not be covered.

(b) Services that are non-evidence based in accordance with He-W 513.05(b) shall not be covered.

Source. #10655, INTERIM, eff 8-15-14, EXPIRES: 2-11-15; ss by #10779, eff 2-11-15; ss by #10922, eff 9-1-15; ss by #11107, eff 7-1-16; ss by #12681, eff 11-27-18

He-W 513.07 Utilization Review and Control.

(a) The department’s provider program integrity unit shall monitor utilization of SUD treatment services to identify, prevent, and correct potential occurrences of fraud, waste, and abuse, in accordance with 42 CFR 455, 42 CFR 456, and He-W 520.

(b) Failure to maintain records in accordance with He-W 520 and He-W 513 shall entitle the department to recoupment of state and federal medicaid payments made as permitted by 42 CFR 455, 42 CFR 447, and 42 CFR 456.

Source. #10655, INTERIM, eff 8-15-14, EXPIRES: 2-11-15; ss by #10779, eff 2-11-15; ss by #10922, eff 9-1-15; ss by #11107, eff 7-1-16; ss by #12681, eff 11-27-18; ss by #12681, eff 11-27-18

He-W 513.08 Third Party Liability. All third party obligations shall be exhausted before medicaid may be billed, in accordance with 42 CFR 433.139.

Source. #10655, INTERIM, eff 8-15-14, EXPIRES: 2-11-15; ss by #10779, eff 2-11-15; ss by #10922, eff 9-1-15; ss by #11107, eff 7-1-16; ss by #12681, eff 11-27-18

He-W 513.09 Payment for Services.

(a) Payment for SUD treatment and recovery support services shall be made in accordance with rates of reimbursement established by the department in accordance with RSA 161:4, VI(a).

(b) The rate of reimbursement for rehabilitative services in a comprehensive SUD program shall:

(1) Be on a per diem basis that takes into account the ASAM level of care and is inclusive of all component services rendered;

(2) Not include room and board; and

(3) Be established by the department in accordance with RSA 161:4, VI(a).

(c) The rate of reimbursement established by the department in accordance with RSA 161:4, VI(a) for partial hospitalization, medical monitored residential withdrawal management, and intensive outpatient SUD services shall be on a per diem basis inclusive of all component services rendered.

(d) The rate of reimbursement established by the department in accordance with RSA 161:4, VI(a), for medically monitored outpatient withdrawal management shall be on a per visit basis inclusive of all component services rendered.

(e) SUD providers may bill separately for drug testing utilizing rapid read tests, except when in conjunction with opioid treatment services in accordance with He-W 513.05(e).

(f) The SUD treatment and recovery support services provider shall submit claims for payment to the department’s fiscal agent.

Source. #10655, INTERIM, eff 8-15-14, EXPIRES: 2-11-15; ss by #10779, eff 2-11-15; ss by #10922, eff 9-1-15; ss by #11107, eff 7-1-16; ss by #12681, eff 11-27-18

He-W 513.10 Documentation.

(a) With the exception of peer recovery programs, SUD treatment and recovery support services providers shall maintain supporting records, in accordance with He-W 520 and (b) - (f) below.

(b) Supporting documentation shall include:

(1) A complete record of all physical examinations, laboratory tests, and treatments including drug and counseling therapies, whether provided directly or by referral;

(2) A progress note for each treatment session, including:

a. The treatment modality and duration;

b. The signature of the primary therapist for each entry;

c. The primary therapist’s professional discipline; and

d. The date of each treatment session; and

(3) A copy of the treatment plan that is:

a. Updated at least every 4 sessions or 4 weeks, whichever is less frequent;

b. Signed by the provider and the recipient prior to treatment being rendered; and

c. Signed by the clinical supervisor, prior to treatment being rendered, if the service is an outpatient or comprehensive SUD program.

(1) The recipient’s name, date of birth, address, and phone number; and

(2) A copy of the evaluation described in He-W 513.05(u)(2).

(d) SUD providers that close their treatment and recovery support programs shall arrange for continued management of all medicaid recipient records as follows:

(1) The provider shall notify the department in writing of the address where records will be stored;

(2) The provider shall specify to the department the person who will be managing the records and the person’s contact information; and

(3) The provider shall arrange for storage of each record through one or more of the following measures:

a. The provider shall continue to manage the records and give written assurance to the department that it will respond to authorized requests for copies of client records within 10 working days;

b. The provider shall transfer records of clients who have given written consent to another medicaid enrolled provider; or

c. The provider shall enter into an agreement with a medicaid enrolled provider to store and manage records.

(e) All electronic or written documentation shall be legible and written in English.

(f) The SUD treatment and recovery support services provider shall provide documentation to the department upon request.

(g) Peer recovery programs shall maintain supporting records in accordance with He-W 520 and(d), (e), and (f) above, and shall include the following supporting documentation:

(1). Progress on goals for each recovery contact including:

a. The type of support received and duration;

b. The topics addressed with the recipient;

c. The signature of the person delivering services; and

d. The date of each recovery contact;

(2) Where applicable, a copy of the recovery plan that is:

a. Updated a every session; and

b. Signed by the provider and the recipient prior to services being rendered; and

(3) The recipient’s name, date of birth, address, and phone number.

Source. #10655, INTERIM, eff 8-15-14, EXPIRES: 2-11-15; ss by #10779, eff 2-11-15; ss by #10922, eff 9-1-15; ss by #11107, eff 7-1-16; ss by #12681, eff 11-27-18

He-W 513.11 ASAM Level of Care Service Descriptions. The covered services in He-W 513.05 above that are required to be provided in accordance with the levels of care in ASAM Criteria (2013), available as noted in Appendix A, shall include the following:

(a) Services required to be provided consistent with Level 1, ASAM Criteria (2013), shall include:

(1) Affiliation with other levels of care, including:

a. Other levels of specialty substance use disorder treatment for additional problems identified through a comprehensive biophysical assessment; and

b. Coordination of services and service planning within a provider agency, with other providers, and with other human service agencies and systems such as local health and social services departments;

(2) Continued treatment planning individualized to the recipient’s needs;

(3) Medical, psychiatric, psychological, laboratory, and toxicology services on-site or through consultation or referral, and in accordance with He-W 513.11(h);

(4) Coordinating discharge or transfer planning an referrals for counseling and community recovery support groups;

(5) Random drug screening to monitor and reinforce treatment gains as appropriate to the recipient’s treatment plan;

(6) Stabilization of imminent risk;

(7) Services in an amount, frequency, and intensity appropriate to the objectives of the treatment plan;

(8) For recipients with mental health conditions, the addressing of the issues of psychotropic medication, mental health treatment, and their relationship to substance use and addictive disorders as the need arises;

(9) Skill restoration therapy to reduce or remove barriers to recipients who are achieving and maintaining recovery;

(10) Emergency services by telephone 24 hours a day, 7 days a week;

(11) Assistance in accessing transportation services for recipients who lack transportation;

(12) Motivational enhancement and engagement strategies appropriate to the recipient’s stage of readiness and desire to change;

(13) Family therapy for the direct benefit of the recipient in accordance with the recipient’s needs and treatment goals identified in the treatment plan and for the purpose of assisting in the recipient’s recovery; and

(14) Skilled treatment services which may include evaluation, individual and group counseling, motivational enhancement, family therapy with recipient present, psychoeducational groups, psychotherapy, addiction pharmacotherapy, medication management, or other skilled therapies;

(b) Services required to be provided consistent with Level 2.1, ASAM Criteria (2013), shall include:

(1) The services in (a)(1) - (13) above;

(2) A planned format of therapies delivered on an individual and group basis and adapted to the recipient’s developmental stage and comprehension level; and

(3) Skilled treatment services which:

a. May include evaluation, individual and group counseling, motivational enhancement, family therapy with individual present, psychoeducational groups, psychotherapy, addiction pharmacotherapy, medication management, or other skilled therapies; and

b. Shall be provided a minimum of 9 hours per week for individuals age 21 and over and a minimum of 6 hours per week for individuals under age 21;

(1) The services in (a)(1) - (13) above;

(2) A planned format of therapies delivered on an individual and group basis and adapted to the patient’s developmental stage and comprehension level; and

(3) Skilled treatment services which:

b. Shall be provided a minimum of 20 hours per week;

(d) Services required to be provided consistent with Level 3.1, ASAM Criteria (2013), shall include:

(1) The services in (a)(1) - (9) and (a)(12) - (13) above;

(2) A planned format of therapies delivered on an individual and group basis and adapted to the patient’s developmental stage and comprehension level;

(3) Daily clinical services to improve the individual’s ability to structure and organize tasks of daily living and recovery to include individual skills development and restoration to prevent continuation or recurrence of substance misuse;

(4) Planned clinical program activities which:

a. Shall be adapted to the individual’s developmental stage, level of comprehension, level of understanding, and physical abilities for the purpose of stabilizing and maintaining the stability of the individual’s substance use disorder symptoms and to help him or her develop and apply recovery skills;

b. May include relapse prevention, exploring interpersonal choices, medication education and management, addiction pharmacotherapy, psychoeducational groups, skill development services, health education, family reintegration, recovery support services, or development of a social network supportive of recovery; and

c. Consist of at least 5 hours per week of professionally directed treatment; and

(5) Monitoring of the individual’s adherence to taking any prescribed medications or permitted over the counter medications or supplements;

(e) Services required to be provided consistent with Level 3.5, ASAM Criteria (2013), available as noted in Appendix A, shall include:

(1) The services in (a)(1) - (9) and (a)(12) - (13) above;

(2) A planned format of therapies delivered on an individual and group basis and adapted to the patient’s developmental stage and comprehension level;

(4) Planned clinical program activities which:

(5) Monitoring of the individual’s adherence to taking any prescribed medications or permitted over the counter medications or supplements;

(f) Services required to be provided consistent with Level 1-WM, ASAM Criteria (2013), available as noted in Appendix A, shall include:

(1) The services in (a)(1) - (8) and (a)(10) - (11) above;

(2) A comprehensive medical history and physical examination of the individual at admission;

(3) A range of cognitive, behavioral, medical, mental health, and other skilled therapies administered to the individual on a group or individual basis which:

a. Shall be designed to enhance the individual’s understanding of addiction, the completion of the withdrawal management process, and referral to an appropriate level of care for continuing treatment;

b. Shall be clinically necessary based on the individual’s progress through withdrawal management and the assessed needs in ASAM Dimensions 2 through 6; and

c. May include multidisciplinary individualized assessment and treatment, health education services, and medical nursing care and observation;

(4) Family involvement in the withdrawal management process for the direct benefit of the individual in accordance with the individual’s needs and treatment goals identified in the individual’s treatment plan and for the purpose of assisting in the individual’s recovery;

(5) Individual assessment, medication or non-medication methods of withdrawal management, patient education, non-pharmacological clinical support, and involvement of family members or significant others in the withdrawal management process with the individual present; and

(6) Inclusion in therapies of physician or nurse monitoring, assessment, and management of signs and symptoms of intoxication and withdrawal;

(g) Services required to be provided consistent with Level 3.7-WM, ASAM Criteria (2013), available as noted in Appendix A, shall include:

(1) The services in (a)(1) - (8) above;

(2) A comprehensive medical history and physical examination of the individual at admission;

(3) A range of cognitive, behavioral, medical, mental health, and other skilled therapies administered to the individual on a group or individual basis which:

b. Shall be clinically necessary based on the individual’s progress through withdrawal management and the assessed needs in ASAM Dimensions 2 through 6; and

c. May include multidisciplinary individualized assessment and treatment, health education services, and medical nursing care and observation;

(5) Daily clinical services to assess and address the needs of each individual which may include:

a. Appropriate medical services;

b. Individual and group therapies; and

c. Withdrawal support; and

(6) Hourly nurse monitoring of the individual’s progress and medication administration as needed; and

(h) Services described in He-W 513.11(a)(3) shall be provided in accordance with the following:

(1) Medical and psychiatric consultation shall be available within 24 hours by telephone or, if in person, within a time frame appropriate to the severity and urgency of the consultation requested for services provided at Level 1, ASAM Criteria (2013), available as noted in Appendix A;

(2) Psychiatric and other medical consultation shall be available within 24 hours by telephone and within 72 hours in person for services provided at Level 2.1, ASAM Criteria (2013), available as noted in Appendix A;

(3) Psychiatric and other medical consultation shall be available within 8 hours by telephone and within 48 hours in person for services provided at Level 2.5, ASAM Criteria (2013), available as noted in Appendix A; and

(4) Telephone or in-person consultation with a physician or any other practitioner licensed to perform the duties designated for a physician shall be available 24 hours a day, 7 days a week for emergency services provided at Level l-WM and Level 3.7-WM, ASAM Criteria (2013), available as noted in Appendix A.

Source. #12681, eff 11-27-18

He-W 513.12 Waivers.

(a) Medicaid providers or the director of the bureau of drug and alcohol services (BDAS) seeking waivers of specific rules in He-W 513 shall submit a written request for a waiver to the commissioner that shall include:

(1) The specific reference to the rule for which a waiver is being sought;

(2) A full explanation of why a waiver is necessary;

(3) The time period for which the waiver is requested and a full explanation of why this time period is being requested; and

(4) A full explanation of alternatives proposed which shall detail how the intent of the rule will be satisfied if the waiver is granted.

(b) A request for waiver shall be granted if the commissioner determines that the waiver would:

(1) Meet the objective or intent of the rule;

(2) Rectify problems unforeseen by the rule;

(3) Meet the provider requirements of the federal regulations and the medicaid state plan; and

(4) Not waive or modify any state statute or federal requirement unless such statute or requirement allows for such waiver.

(d) The medicaid provider’s or BDAS’ subsequent compliance with the alternatives approved in the waiver shall be considered equivalent to complying with the rule from which the waiver was sought.

(e) Waivers shall not be transferable.

(f) When a medicaid provider or BDAS wishes to renew a non-permanent waiver beyond the approved period of time, they shall apply for a new waiver at least 60 days prior to the expiration of the existing waiver by submitting the information required by (a) above.

(g) The request to renew a waiver shall be subject to (b) through (f) above.

Source. #12681, eff 11-27-18

PARTS He-W 514 THROUGH 518 RESERVED

PART He-W 519 PAYMENTS TO DISPROPORTIONATE SHARE PSYCHIATRIC HOSPITALS

Source. (See Revision Note at chapter heading He-W 500); ss by #6642, eff 11-27-97; moved by #8432, eff 11-27-05 (see He-M 601)

PART He-W 520 GENERAL PROGRAM INFORMATION

He-W 520.01 Definitions.

(a) “Department” means the New Hampshire (NH) department of health and human services.

(b) “Direct ownership interest” means the possession of equity of 5% or greater in capital, stock, or profits of the provider or provider applicant.

(c) “Early and periodic screening, diagnosis, and treatment (EPSDT)” means a program pursuant to 42 CFR 440.40(b), designed to provide medical care to recipients under the age of 21.

(d) “High risk provider or high risk provider applicant” means an individual or entity which meets one of the criteria in He-W 520.06(i).

(e) “Indirect ownership interest” means an ownership interest of 5% or greater in an entity that has a direct ownership interest in the provider or provider applicant.

(f) “Medicaid” means the Title XIX and Title XXI programs administered by the department, which makes medical assistance available to eligible individuals.

(g) “Medicaid management information system (MMIS)” means the general system for mechanized claims processing and information retrieval recommended by the Centers for Medicare and Medicaid Services (CMS) for the implementation of the requirements of state fiscal administration pursuant to 42 CFR 433, Subpart C.

(h) “Presumptive eligibility” means an eligibility period as described in Sections 1920 through 1920C of the Social Security Act during which eligibility for an individual is determined for the medicaid program.

(i) “Provider” means an entity or individual who furnishes health care services or supplies to medicaid recipients under an agreement with the department.

(j) “Provider applicant” means an individual or entity who is undergoing the provider enrollment or re-enrollment process to become a NH medicaid provider.

(k) “Qualified entity” means an entity authorized and trained by the department to determine presumptive eligibility pursuant to the provisions of Sections 1920 through 1920C of the Social Security Act, including providers that are:

(1) Title V-funded family and community health agencies;

(2) Title X family planning agencies;

(3) Hospitals;

(4) Agencies authorized to determine eligibility for the head start program;

(5) Agencies authorized to determine eligibility for child care services provided under the child care and development block grant;

(6) Agencies participating in the early intervention program; and

(7) Agencies participating in the special supplemental nutrition program for women, infants, and children (WIC).

(l) “Recipient” means an individual who is eligible for and receiving medical assistance under the medicaid program.

(m) “Revalidation” means the process through which the provider verifies the accuracy of, and updates if necessary, its current provider enrollment information.

(n) “Termination” means that the department revoked a provider’s medicaid billing privileges.

(o) “Title XIX” means the joint federal-state program described in Title XIX of the Social Security Act and administered in NH by the department under the medicaid program.

(p) “Title XXI” means the joint federal-state program described in Title XXI of the Social Security Act and administered in NH by the department under the medicaid program.

(q) “Utilization review and control” means the monitoring of medicaid program services pursuant to 42 CFR 455 and 42 CFR 456.

Source. (See Revision Note at chapter heading He-W 500); ss by #6574, eff 9-12-97; ss by #6745, eff 5-1-98, EXPIRED: 12-31-98; ss by #6925, eff 1-1-99; amd by #7666, eff 4-1-02; ss by #8781, eff 1-1-07; amd by #10139, eff 7-1-12; paras (a), (b), (d), (g), (j), & (k), EXPIRED: 1-1-15; amd by #10776, INTERIM, eff 1-31-15; ss by #10887, eff 7-17-15; amd by #12023, INTERIM, eff 11-1-16, EXPIRES: 4-30-17; amd by #12166, eff 4-29-17; ss by #14415, eff 10-22-25, EXPIRES: 10-22-35

He-W 520.02 Program Administration.

(a) The department shall:

(1) Administer and maintain the medicaid state plan, pursuant to 42 CFR 430.10 and RSA 161:2, VI;

(2) Provide the mandatory medicaid services pursuant to 42 CFR 440.210 and 42 CFR 440.220;

(3) Provide the medicaid optional services which are specified in the medicaid state plan;

(4) Describe the provider and recipient requirements for the medicaid services found in chapter He-W 500, and pursuant to RSA 161:4-a, X; and

(5) Authorize and train qualified entities to determine presumptive eligibility.

(b) The provider shall:

(1) Be a NH enrolled medicaid provider; and

(2) Request and obtain prior authorization from the department before providing any medicaid covered services requiring prior authorization.

Source. (See Revision Note at chapter heading He-W 500); ss by #6574, eff 9-12-97; ss by #6745, eff 5-1-98, EXPIRED: 12-31-98; ss by #6925, eff 1-1-99; ss by #8781, eff 1-1-07, EXPIRED: 1-1-15

New. #10776, INTERIM, eff 1-31-15, EXPIRES: 7-30-15; ss by #10887, eff 7-17-15; ss by 14415, eff 10-22-25, EXPIRES 10-22-35

He-W 520.03 Record Keeping Requirements. Providers shall maintain clinical records to support claims submitted for reimbursement for a period of at least 6 years from the date of service or until the resolution of any legal action(s) commenced in the 6-year period, whichever is longer.

Source. (See Revision Note at chapter heading He-W 500); ss by #6574, eff 9-12-97; ss by #6925, eff 1-1-99; ss and moved by #8781, eff 1-1-07 (from He-W 520.05), EXPIRED: 1-1-15

New. #10776, INTERIM, eff 1-31-15, EXPIRES: 7-30-15; ss by #10887, eff 7-17-15; ss by 14415, eff 10-22-25, EXPIRES 10-22-35

He-W 520.04 Surveillance and Utilization Review and Control.

(a) The purpose of a surveillance and utilization review and control program is for the department to:

(1) Assess the quality of the care, services, and supplies received by recipients and for which a medicaid program has reimbursed providers;

(2) Detect, correct, and prevent occurrences of unnecessary or inappropriate medical care, service, or supply usage by recipients, or provision by providers, for which a medicaid program has reimbursed providers; and

(3) Ensure that accurate and proper reimbursement has been made for the care, services, or supplies provided.

(b) The department or managed care organization (MCO) shall be responsible for surveillance and utilization review and control activities by:

(1) Performing the utilization reviews directly, or contracting with professional organizations for the performance of reviews; and

(2) Monitoring the results of reviews to ensure appropriate corrective action has been taken.

(1) Reviewing recipient utilization and provider service profiles in accordance with 42 CFR 456.23;

(2) Reviewing provider claims selected randomly;

(3) Reviewing claims for all or selected services for a given period of time;

(4) Application of the Centers for Medicare and Medicaid Services’ National Correct Coding Initiative (CMS NCCI) to review claims processed by the fiscal agent or MCO to ensure:

a. That the provider has coded claims properly; and

b. That the claims processing system has made proper payment through application of edits based upon the CMS NCCI;

(5) An on-site review of hospital, office, or other provider records to establish the accuracy of claims data and to ensure other documentation supports the claim for services rendered;

(6) Contacting recipients to verify that services or supplies claimed for reimbursement by providers were actually rendered;

(7) Contacting providers to recover overpayments or correct underpayments; and

(8) Referring cases of potential fraud for further investigation and possible criminal action, pursuant to 42 CFR 455.15.

Source. (See Revision Note at chapter heading He-W 500); ss by #6574, eff 9-12-97; ss by #6925, eff 1-1-99; ss and moved by #8781, eff 1-1-07 (from He-W 520.06); ss by #9365, eff 1-17-09; ss by #12188, eff 5-25-17; ss by 14415, eff 10-22-25, EXPIRES 10-22-35

He-W 520.05 Fraud Detection and Investigation.

(a) In accordance with 42 CFR 455.14, if the department or MCO receives a complaint of medicaid fraud or abuse from any source or identifies any questionable practices, they shall conduct a preliminary investigation.

(b) Cases where potential fraud has been detected as a result of a preliminary investigation pursuant to (a) above, shall be referred for a full investigation to the appropriate agency, in accordance with 42 CFR 455.15.

Source. (See Revision Note at chapter heading He-W 500); ss by #6574, eff 9-12-97; ss by #6925, eff 1-1-99; ss by #8781, eff 1-1-07, EXPIRED: 1-1-15

New. #10776, INTERIM, eff 1-31-15, EXPIRES: 7-30-15; ss by #10887, eff 7-17-15; ss by 14415, eff 10-22-25, EXPIRES 10-22-35

He-W 520.06 Provider Requirements.

(a) NH medicaid providers and provider applicants shall meet the provider participation requirements contained in chapter He-W 500, as applicable, for providers of the type of services they will be providing, as well as requirements in this section.

(b) The following individuals and entities shall be subject to a risk determination:

(1) NH medicaid provider applicants;

(2) NH medicaid providers who are applying to enroll a new practice location(s);

(3) NH medicaid providers who are re-enrolling; and

(4) NH medicaid providers being revalidated in accordance with 42 CFR 455.414.

(d) For provider types that exist in both medicare and medicaid, the department shall assign the same risk category as medicare.

(e) Any new provider type not defined by medicare shall be assigned as moderate risk for one year. At one year, the department shall determine if the provider or provider type should remain at moderate risk or be moved to limited risk.

(f) Limited provider types shall be subject to all federally required database checks of those with a 5% or greater ownership and controlling interest, and managing directors of the provider, for each location, as defined under 42 CFR 455.101 and described in 42 CFR 102 and 42 CFR 104. Limited provider types include the following:

(1) Physician or non-physician practitioners, including nurse practitioners, certified registered nurse anesthetists, occupational therapists, speech or language pathologists, and audiologists, and medical groups or clinics;

(2) Ambulatory surgical centers (ASCs);

(3) Competitive acquisition program/Part B vendors;

(4) End-stage renal disease facilities (ESRDs);

(5) Federally qualified health centers (FQHCs);

(6) Histocompatibility laboratories;

(7) Home infusion therapy suppliers;

(8) Hospitals, including critical access hospitals (CAHs), Department of Veterans Affairs hospitals, and other federally-owned hospital facilities;

(9) Health programs operated by an Indian Health Program, as defined in section 4(12) of the Indian Health Care Improvement Act, or an urban Indian organization, as defined in section 4(29) of the Indian Health Care Improvement Act, that receives funding from the Indian Health Service pursuant to Title V of the Indian Health Care Improvement Act;

(10) Mammography screening centers;

(11) Mass immunization roster billers;

(12) Opioid treatment programs, if 42 CFR 424.67(b)(3)(ii) applies;

(13) Organ procurement organizations (OPOs);

(14) Pharmacies newly enrolling or revalidating via the CMS-855B application;

(15) Radiation therapy centers (RTCs);

(16) Religious non-medical health care institutions (RNHCIs); and

(17) Rural health clinics (RHCs).

(g) Moderate risk providers are subject to the database checks described in (f) but also subject to a provider site visit. Moderate provider types include the following:

(1) Ambulance service suppliers;

(2) Community mental health centers (CMHCs);

(3) Comprehensive outpatient rehabilitation facilities (CORFs);

(4) Independent clinical laboratories (ICLs);

(5) Independent diagnostic testing facilities (IDTFs);

(6) Physical therapists enrolling as individuals or as group practices;

(7) Portable x-ray suppliers (PXRSs);

(8) Prospective, newly enrolling, and revalidating opioid treatment programs (OTP) that have been fully and continuously certified by the Substance Abuse and Mental Health Services Administration (SAHMSA) since October 23, 2018;

(9) Revalidating durable medical equipment, prosthetic devices, prosthetics, orthotics, and supplies (DMEPOS) suppliers;

(10) Revalidating home health agencies (HHAs);

(11) Revalidating medicare diabetes prevention program (MDPP) suppliers;

(12) Revalidating skilled nursing facilities (SNFs); and

(13) Revalidating hospices.

(h) High risk providers are subject to (f) and (g) above, and a criminal background check including fingerprinting as described in (j) below.

(i) Individuals and entities in (f) and (g) above who meet either of the following criteria shall be determined to be high-risk providers or high-risk provider applicants:

(1) The individual or entity, with the exception of those who are undergoing revalidation in accordance with 42 CFR 455.414, provides home health services, nursing facilities, or durable medical equipment services; or

(2) The individual’s or entity’s risk level was adjusted to high by the department as required by 42 CFR 455.450(e)(1) because any of the following occurred:

a. The department imposed a payment suspension on the individual or entity based on credible allegation of fraud, waste, or abuse;

b. The individual or entity has an existing medicaid overpayment;

c. The individual or entity was excluded from participation in a federally funded program by the office of inspector general or another state’s medicaid program within the 10 years preceding the date of application or date of revalidation; or

d. In accordance with 42 CFR 455.450(e)(2), NH medicaid or the Centers for Medicare and Medicaid Services (CMS) in the previous 6 months lifted a temporary moratorium for the particular provider type and a provider that was prevented from enrolling based on the moratorium applies for enrollment as a provider within 6 months from the date the moratorium was lifted.

(j) The following individuals and entities shall be subject to a state and federal criminal background check, including fingerprinting, in accordance with this section:

(1) Persons with a direct or indirect ownership interest in a high-risk provider or high-risk provider applicant described in (i)(1) above; and

(2) High-risk providers or high-risk provider applicants described in (i)(2) above.

(k) Those who meet the criteria in (h) above shall not be subject to an additional criminal background check, including fingerprinting, if, within the previous 36 months, they have undergone a criminal background check as required by:

(1) A Medicare administrative contractor;

(2) NH medicaid;

(3) Any other state’s medicaid agency, and the department is able to access the information from the other state’s medicaid agency; or

(4) Any other state’s children’s health insurance program (CHIP), and the department is able to access the information from the other state’s CHIP.

(l) Those who meet the criteria in (j) above, and who are not excluded in (k) above, shall be notified in writing of the following by the department:

(1) That a state and federal criminal background check, including fingerprinting, is required;

(2) Where the criminal background check, including fingerprinting, can be conducted as specified in (n)(1) below; and

(3) The deadline by which the criminal background check, including fingerprinting, shall be conducted as specified in (m) below.

(m) The deadline for undergoing a criminal background check, including fingerprinting, shall be 30 days from the date of the notification in (l) above.

(n) Those who meet the criteria in (j) above, and who are not excluded in (k) above, shall undergo a state and federal criminal background check by:

(1) Having a complete set of electronic fingerprints taken at any location maintained by the NH state police criminal records unit that has electronic fingerprinting capability, or by any other in or out of state law enforcement agency that conducts fingerprinting electronically; and

(2) Completing and submitting to the location in (1) above a notarized department of safety’s Form DSSP 417, “New Hampshire Health and Human Services Criminal History Record Information Authorization, New Hampshire Medicaid Program” incorporated by reference in Saf-C 5703.10, Table 5700-1, which authorizes the release of the individual’s criminal history record, if any, to the department.

(o) Those who meet the criteria in (j) above shall be terminated from, or denied enrollment in, the NH medicaid program if:

(1) The individual fails to get fingerprinted by the deadline in (m) above, as applicable; or

(2) The results of the criminal background check indicate that the individual has been convicted of any of the following federal or state felony offenses within the 10 years preceding the date of application or date of revalidation of enrollment:

a. Felony crimes against persons, such as murder, sexual assault, assault, interference with freedom, destruction of property, unauthorized entries, robbery and theft, fraud and corruption, and other similar crimes for which the individual was convicted, including guilty pleas;

b. Financial crimes, such as extortion, embezzlement, income tax evasion, insurance fraud, and other similar crimes for which the individual was convicted, including guilty pleas; or

c. Any felony that placed the medicaid program or its recipients at immediate risk, such as a malpractice suit that resulted in a conviction of criminal neglect or misconduct.

(p) An individual or entity being terminated from, or denied enrollment in, the NH medicaid program in accordance with (o) above shall receive a written notice from the department of the denial or termination.

(q) The notice in (p) above shall contain:

(1) The reason for, and legal basis of, the denial or termination; and

(2) Information that an appeal of the denial or termination may be requested, in accordance with He-C 200, within 30 calendar days of the date on the notice of the denial or termination.

(r) Appeals of the results of the criminal background check shall be made in accordance with the department of safety rules at Saf-C 5703.12.

Source. #12023, INTERIM, eff 11-1-16, EXPIRES: 4-30-17; ss by #12166, eff 4-29-17; ss by 14415, eff 10-22-25, EXPIRES 10-22-35

PART He-W 521 GENERAL PAYMENT INFORMATION

REVISION NOTE:

Document #13884, effective 2-22-24, adopted Part He-W 521 titled “General Payment Provisions.” The rules in Part He-W 521 had previously been filed under Document #5888, effective 8-31-94, and had expired 8-31-00. Document #13884 extensively changed the expired rules, including by deleting some rules and adding new rules. The expired He-W 512.01 titled “Definitions”, He-W 521.07 titled “Adjustment to Payments”, and He-W 521.08 titled “Liability” were the only sections retained in the new Part He-W 521, but the text was changed from that in the expired rules.

The following former rules were deleted: He-W 521.02 titled “Payment Rates”, as this information is part of the hospital billing manual and rules under subtitle “He-P” for hospitals and Special Health Care Services; He-W 521.06 titled “Prior Authorization”; He-W 521.11 titled “Exclusion of Medicaid Providers Who Have Been Excluded by Medicare”; and He-W 521.12 titled “Exclusion, Suspension or Termination of Medicaid Providers by Medicaid”. The provisions in the former He-W 521.11 and He-W 521.12 did not relate to general payment but to provider enrollment, and the subject matter is addressed in Part He-W 520. The following rules were added or were new: He-W 521.02 titled “Recipient Responsibilities”; He-W 521.06 titled “Self-Audits”; He-W 521.10 titled “Medicare”; and He-W 521.11 titled “Third Party Payment”.

He-W 521.01 Definitions.

(a) “Applicant” means a person on whose behalf application is being made for any of the department of health and human service's program.

(b) “Co-insurance” means the percentage of the other insurance or Medicare allowed charge that is not paid by the other insurance or Medicare, but is the responsibility of the recipient.

(d) “Deductible” means a set dollar amount that is the out-of-pocket expense an individual is responsible to pay, within a specific time frame, before insurance pays a claim.

(e) “Department” means the New Hampshire department of health and human services.

(f) “Formal provider bulletin” means official medicaid notices sent to the providers and maintained on the medicaid management information system website.

(g) “Managed care organization (MCO)” means an entity that has a comprehensive risk-based contract with the department to provide managed medicaid health care services.

(h) “Medicaid” means the Title XIX and Title XXI programs administered by the department which makes medical assistance available to eligible individuals.

(i) “Medicaid allowable” means the maximum amount medicaid shall pay for a service. Medicaid allowables are in the medicaid fee schedules on the medicaid management information system website.

(j) “Medicaid management information system (MMIS)” means the fee for the service system for mechanized claims processing and information retrieval recommended by the Centers for Medicare and Medicaid Services (CMS) for the implementation of the requirements of state fiscal administration pursuant to 42 CFR 433, Subpart C.

(k) “Medicare” means the health insurance program under Title XVIII of the Social Security Act for people who are age 65 or older, disabled, or both, regardless of income, obtained through the U.S. Department of Health and Human Services, Social Security Administration.

(l) “Provider” means “provider” as defined in RSA 167:58, V, namely “any individual, partnership, corporation or entity furnishing services under a written contract with the department.”

(m) “Recipient” means any individual who received or receives medical assistance under the medicaid program.

(n) “Recoupment” means medicaid recovers funds paid in error by reducing future payments until the recovery is complete.

(o) “Responsible party” means a person or organization who is wholly, or in part, responsible for paying for the medical services of an individual. Individual responsible parties are usually relatives such as a parent or spouse. Organization responsible parties are usually insurance carriers or Medicare.

(p) “Third party” means the process as described in RSA 167:4-b whereby any private insurer, health maintenance organization, hospital service organization, medical service or health services corporation, governmental agency, or any individual, organization, entity, or agency is authorized or under legal obligation to pay for medical services for an eligible recipient.

(q) “Third party liability” means the obligation of any private insurance, Medicare, individual, institution, corporation, or agency that is liable to pay all or part of the medical cost of illness, injury, disease, or disability of a recipient.

(r) “Third party payor” means the third party that pays or insures health or medical expenses on behalf of a recipient or recipients.

(s) “Self-audit” means an examination, review, or other inspection performed both by and within a given health care professional’s practice or business. It can be initiated by the entity or by an external entity.

Source. (See Revision Note at chapter heading for He-W 500) (See also part heading for He-W 521) #13884, eff 2-22-24

He-W 521.02 Applicant, Recipient, and Recipient’s Responsible Party Responsibilities.

(a) A medicaid recipient or recipient’s responsible party shall:

(1) Inform the provider of the recipient’s medicaid coverage and third party insurance coverage, if applicable, prior to receiving services;

(2) Present the recipient’s medicaid identification (ID) card and third party insurance card, if applicable, to the service provider at the time of service;

(3) Comply with all requirements of the recipient’s private insurance for payment of any item, supply, or service, if the recipient is covered under another third party insurance or Medicare;

(4) Inform the department of any other medical insurance coverage or changes to insurance coverage; and

(5) Report any changes in circumstance to the department that may affect the recipient’s eligibility or access to care, such as a change of name, address, or income, within 10 days of the change taking effect.

(b) The recipient or recipient’s responsible party shall be responsible for payment of an item, supply, or service if:

(1) The recipient was not eligible for medicaid on the date of service(s);

(2) The recipient selects an item, supply, or service that is not covered under the medicaid program and the provider has informed the recipient prior to service that the item, supply, or service shall not be covered by medicaid;

(3) It is an ancillary services not associated with a covered service paid by medicaid;

(4) The recipient receives an item, supply, or service from an individual or entity that is not an enrolled medicaid provider, unless the managed care organization (MCO) approves the provider as an out-of-network provider and approves the service for payment or it was an emergency service in which the recipient was unable to go to an in-network provider with medicaid, such as an out-of-state accident;

(5) A provider enrolled in medicaid informs the recipient in writing that the provider shall not accept the recipient as a medicaid patient, but the recipient still requests the item, supply, or service from the provider;

(6) The recipient is enrolled with a third party insurance and the recipient’s failure to comply with all requirements of that insurance carrier, as required by (a)(3) above, results in the third party coverage being denied; or

(7) The recipient otherwise requests that the item, supply, or service not be processed through medicaid.

(1) Notify the department or MCO of any third party insurance coverage, or any accidental or work related injury:

a. At the time of application for medical assistance;

b. At the time of redetermination of medical assistance eligibility;

c. Within 10 business days of the start of insurance coverage;

d. Within 10 business days of the accident or injury date; or

e. Within 10 business days of the effective date of any changes in insurance coverage;

(2) Supply the department or MCO with the following information regarding third party insurance:

a. Name of medicaid recipient covered by insurance policy;

b. Name of the insurance company;

c. Insurance policy number;

d. Insurance group number, if applicable;

e. Date the insurance became active;

f. Type of insurance coverage;

g. Subscriber’s name of the insurance; and

h. Copies, front and back, of the insurance cards, if requested; and

(3) Notify the department of coverage, or a change in coverage, by contacting the department or MCO.

Source. (See Revision Note at chapter heading for He-W 500) (See also part heading for He-W 521) #13884, eff 2-22-24

He-W 521.03 Provider Responsibilities.

(a) Prior to the delivery of items, supplies, or services, the provider shall verify the recipient’s medicaid coverage and other insurance information on the date of service.

(b) When an item, supply, or service requires prior authorization, the provider shall obtain approval from the department, the third party insurance, if applicable, or the recipient’s MCO prior to the delivery of said items, supplies, or services.

(1) The individual is not eligible for medicaid on the date of services;

(2) The recipient chooses to receive an item, supply, or service, from a provider who does not accept medicaid recipients. This also includes providers that accept third party insurance, but not medicaid, unless the recipient is on the health insurance premium payment (HIPP) program;

(3) The item, supply, or service is not covered under medicaid or exceeds the allowed limits and when providing an item, supply, or service not covered by medicaid, the provider has advised the recipient in writing and the recipient has declined alternative treatments that are covered by medicaid; or

(4) The provider informs the recipient in writing and the recipient agrees in writing prior to services being performed, including payment of charges for co-pays and deductibles of third party insurers. The written acknowledgement shall include, but is not limited to, the following information:

a. The provider’s name;

b. The provider’s medicaid ID number;

c. The recipient’s name;

d. The recipient’s medicaid ID number;

e. The date on which the item, supply, or service is requested;

f. A description of the item, supply, or service being requested; and

g. Certification by signature of the recipient that the recipient understands that:

1. The medicaid program shall not cover the item, supply, or service being requested; and

2. The recipient shall be responsible for payment if the recipient still chooses to receive the item, supply, or service.

(d) If the recipient is a minor or is incapacitated and unable to sign the written acknowledgement described in (c) above, the parent, guardian, or legal representative may sign on behalf of the recipient.

(e) When the provider accepts a patient into the practice as a medicaid patient, the provider shall accept medicaid payment as payment in full, less any medicaid cost-sharing requirement.

(f) The provider shall not bill medicaid recipients for any of the following:

(1) The difference between the provider’s usual and customary charge and the medicaid payment for services rendered, except any medicaid cost sharing;

(2) Missed, also known as no shows, or cancelled appointments;

(3) Costs associated with supplying copies of the recipient’s medical records to another health care provider;

(4) Any goods or services provided to the recipient that are offered to other individuals free of charge;

(5) Additional fees, such as membership, boutique, or concierge fees; or

(6) Any third party remaining co-insurance, co-payment, or deductible not paid by medicaid.

(g) If a recipient has paid for a service and then becomes retroactively eligible for medicaid, the provider may refund the recipient the amount paid and then bill medicaid for the covered services that were rendered.

(h) If the provider refuses to repay the recipient for a medical item, service, or prescribed medication, and the recipient wishes to be reimbursed, then the recipient may request reimbursement from the department.

(i) If the recipient wishes to pursue reimbursement from the department as described in (h) above, the recipient shall contact their district office and provide a statement signed by the provider stating that the provider refuses to refund the recipient and directly bill medicaid. In addition to the statement, the recipient shall also provide to the district office the following information:

(1) For each medical item:

a. The receipt verifying the recipient’s name who received the medical item;

b. The date on which the medical item was purchased;

c. The name of the medical item;

d. The amount charged for the medical item;

e. The amount paid for the medical item; and

f. The name of the individual who paid the bill;

(2) For each service provided:

a. The receipt verifying the recipient’s name who received the service;

b. The date on which the service was received;

c. The type of service received

d. The amount charged for the service;

e. The amount paid for the service; and

f. The name of the individual who paid the bill; or

(3) For each prescribed medication:

a. The name of the licensed professional prescribing the medication;

b. The receipt verifying the recipient’s name on the prescribed medication;

c. The date on which the medication was prescribed;

d. The specifics of the prescribed medication including:

1. The name of the medication;

2. The category of the medication;

3. The quantity of each medication;

4. The prescription number of each medication;

5. The refill number of each medication; and

6. The national drug code of the medication;

e. The amount charged for the prescribed medication;

f. The amount paid for the prescribed medication; and

g. The name of individual who paid for the prescribed medication.

(j) In order for the recipient to be reimbursed for services, as described in (h) above, the date of service shall have been after the recipient’s retroactive eligibility start date.

(k) If the recipient is reimbursed after complying with (i) and (j) above, the recipient shall only be reimbursed up to the medicaid allowable amount.

(l) The provider shall maintain accurate and complete medical, financial, and administrative records as required by the specific program state rules in chapters He-A 400, He-C 6000, He-E 800, He-M 300 - 500, He-M 1000, He-P 600, He-P 800, He-P 4000, and He-W 500, including relevant medical and third party records for payment from medicaid to justify the provision of and support for any items, supplies, or services supplied to medicaid recipients. Providers shall maintain complete records for at least 6 years from the date of service, or until the resolution of any personal action(s) commenced during the 6-year period, or whichever is longer.

(m) At a minimum, all medical records required in (l) above shall:

(1) Be typed or legibly written, recorded on paper, or in electronic format;

(2) Be dated;

(3) Clearly identify the recipient with full legal name and medicaid ID;

(4) Document the medical necessity of the service(s) billed;

(5) Document that the service(s) provided are consistent with the diagnosis of the recipient’s condition;

(6) Document that the service(s) are consistent with professionally recognized standards of care;

(7) Document the name of the performing or rendering provider and supervising provider, if required, and their credentials;

(8) Document all complaints and symptoms, medical history, examination findings, diagnostic test results, assessment results, clinical impressions or diagnosis, plans for care, dates of services, and the identity of the observing medical practitioner;

(9) Document all specific procedures or treatments performed;

(10) Document any medications administered or medical supplies utilized or provided;

(11) Record each item of service provided on the claim and include all supporting documentation;

(12) Include all physician orders; and

(13) Include a signature of a licensed qualified medical professional.

(n) The provider shall provide the records described in (l) above to the department, MCO, federal auditors, medicaid fraud control unit (MFCU), or the department’s designated representatives, upon request, as allowed by the Health Insurance Portability and Accountability Act (HIPAA) and 45 CFR 164.512(d). If records are not available, or do not support items, supplies, or service supplied, or the provider refuses to cooperate with the request, then payment for items, supplies, or service supplied shall be denied or shall be recovered, if already paid and recovery shall be done by the department or MCO by recoupment of future payments or direct billing.

(o) The provider shall report to the department within 35 days any changes related to the provider’s practice that may impact medicaid payments, including, but not limited to:

(1) A change of name or address;

(2) A lapse of licensure;

(3) A change in ownership; or

(4) A change in affiliations per 42 CFR 455.104(c)(1).

(p) If the changes described in (o) above are not reported, provider enrollment and payment shall be suspended if the provider is not in contact with the department, the provider is not responding to department inquiries, the provider does not submit the proper information, or the change precludes the department from paying claims, such as a lapse of license, until the issue is rectified.

(q) Providers shall maintain active licensure or certification per appropriate licensure board for services provided and any facility licensure or certification as required by state law.

(r) Providers shall follow all requirements outlined in the provider participation agreement upon enrollment and revalidation.

Source. (See Revision Note at chapter heading for He-W 500) (See also part heading for He-W 521) #13884, eff 2-22-24

He-W 521.04 Claim Submission.

(a) Except as allowed by (f) and (h) below, a provider shall submit fee-for-service claims for payment to the department’s fiscal agent within 12 months of the earliest date of service, as required by 42 CFR 447.45.

(b) Claims may be submitted electronically using the X-12 format.

(c) Paper claims shall be submitted using the most current version of the following forms as required in 42 CFR 424.32 and are available as noted in Appendix A:

(1) The Centers for Medicare and Medicaid Services (CMS) form CMS-1500, “Health Insurance Claim Form” (2/2012), for billing professional services;

(2) The uniform billing (UB) form CMS-1450 “UB-04” (January 2023) for billing services provided in institutional settings; and

(3) The American Dental Association (ADA) form, “ADA Dental Claim Form” (2024), for billing all dental services.

(d) Providers shall follow provider billing manual requirements and formal provider bulletins when submitting claims.

(e) The CMS current and approved diagnosis and treatment codes shall be used on all claims submitted for payment.

(f) A non-enrolled provider may submit a fee-for-service claim for emergency services, such as an out-of-state accident. The provider shall submit a NH provider application with the claims for processing under the NH medicaid fee schedule for only the emergency dates of service. The provider shall pass all federally mandated screenings for payment.

(g) If a provider submitted a claim within the time period required as described in (a) above, and the claim is denied by the department’s fiscal agent or MCO, but the cause for the denial can be corrected, the provider may resubmit the fee-for-service claim within 12 months from the earliest date of service for payment to be made, or for MCO claims per the MCO contract obligation.

(h) When a provider is resubmitting a denied fee-for-service claim beyond the 15 months from the earliest date of service as allowed by (g) above, the submission shall include the following:

(1) A completed form 957, “Override Request” (February 2024), located on the NH MMIS health enterprise portal website at www.nhmmis.nh.gov; and

(2) A copy of the remittance advice, which is the notice to the provider of the original denied claim with the denial circled.

(i) If a claim was not previously denied and the date of service is more than 15 months from the date of submission of the claim, the claim shall only be approved for payment if:

(1) There was a delay in determining the recipient’s eligibility for medicaid;

(2) The claim is for a medicaid covered item, supply, or service provided during a retroactive eligibility period;

(3) The claim was submitted within 6 months of the date that retroactive medicaid eligibility was determined; or

(4) The claim could not be processed due to a department or MCO system issue or error.

(j) For MCO claims submission and processing, providers shall follow the MCO contract and billing manuals.

Source. (See Revision Note at chapter heading for He-W 500) (See also part heading for He-W 521) #13884, eff 2-22-24

He-W 521.05 Provider Payments.

(a) Payment for a medical item, supply, or service shall be made for a recipient if:

(1) The recipient is eligible for medicaid on the date(s) of service(s);

(2) The medical item, supply, or service is covered under the medicaid program, in accordance with He-W 500;

(3) The provider is an enrolled medicaid provider at the time the service is provided; and

(4) A claim has been properly completed and submitted to the department’s fiscal agent or MCO for payment.

(b) A claim shall be denied when all of the requirements described in (a) above are not met.

(1) Fee-for-service claims rate as established by the department in accordance with RSA 161:4, VI(a);

(2) The provider’s usual and customary charge; or

(3) The third party’s patient liability up to the medicaid allowable amount.

(d) Reimbursement for any item, supply, or service that is first paid by Medicare shall be as follows:

(1) The full co-pay or deductible for hospital inpatient and outpatient claims; or

(2) The co-pay, deductible, or co-insurance up to the medicaid allowable amount less the Medicare payment for all other medical services and supplies. If the Medicare payment is greater than the medicaid allowable, then medicaid shall pay zero.

(e) Except for inpatient hospitalization and nursing facilities, payment for out-of-state hospitals, as defined by He-W 543.01(n), not in the medicaid network, shall be made:

(1) At the allowable medicaid rate in the state in which the services are provided; or

(2) In the absence of a medicaid program, at the approved Medicare rate.

(f) Payment for inpatient hospital services shall be made in accordance with He-W 543.13.

(h) The provider shall not deny services to any eligible individual due to the individual’s inability to pay the cost sharing amount imposed by medicaid in accordance with 42 CFR 447.15, and 42 CFR 447.52-54.

(i) The following items or services shall not be reimbursable by medicaid:

(1) All services or supplies that are not determined to be medically necessary, as defined in He-W 530.01(e) and He-W 546.01(e);

(2) Experimental or investigational drugs, biological agents, procedures, devices, or equipment, unless authorized prior by the department;

(3) Elective cosmetic surgeries or procedures;

(4) Service units beyond authorized service limits, as defined in He-W 530.01;

(5) Charges for missed, also known as no show, appointments or cancelled appointments;

(6) Anything prohibited in He-W 500; and

(7) All items or services that are considered to be part of the cost of doing business, including, but not limited:

a. Time involved in completing necessary forms, claims, or reports;

b. Copying of records;

c. Making referrals;

d. Renewing prescriptions; and

e. Providing medical documents for schools, sports, and camps.

(j) If a claim is paid in error, funds shall be recovered by the department or MCO through recoupment of future payments or direct billing.

(k) Medicaid co-payments shall be required for services specified in He-W 570 and implemented in accordance with 42 CFR 447.52-56.

He-W 521.06 Self-Audits.

(a) Self-audits may be performed either:

(1) Voluntarily by a provider and unsolicited by the department; or

(2) In response to a request by the department as follows:

a. A notice shall be sent to the provider identifying a specific matter to be addressed via the self-audit; and

b. At a minimum the notice shall provide the timeframe of the claims to audit, specific claims to audit, and the allotted period of time in which to conduct and complete the self-audit.

(b) The provider shall submit, at a minimum, the following information, for all audits initiated by (a) above:

(1) Billing provider name;

(2) Billing provider address;

(3) Billing provider medicaid ID number;

(4) Provider type;

(5) Billing provider tax ID number;

(6) Name, title, address, and telephone number of the designated contact for the provider regarding the self-audit;

(7) Date of service;

(8) Rendering or performing provider name;

(9) Procedure code and description;

(10) Number of units billed as defined in He-W 530.01;

(11) Recipient name and ID number;

(12) Internal control number; and

(13) Description of the non-compliance, for example, services not rendered, up-coding, brand drugs for generics, unqualified staff performing service, incorrect dates of service, incorrect recipient, duplicate services, unbundling, and services not documented.

(c) The provider shall submit all requested documentation to the department within 30 days from the last day of the allotted period of time to complete the audit referenced in (a)(2) above.

(d) Upon completion of department’s review of the self-audit, the self-audit shall either be accepted or declined and result in the following:

(1) Accepted self-audits shall result in the issuance of a final findings or action letter stating the amount of money to be repaid and shall provide repayment instructions;

(2) Self-audits that are not accepted shall be returned to the provider for corrections, with an explanation regarding why the self-audit could not be accepted; and

(3) If the documentation in (2) above is found to be incomplete or not submitted as stated in (c) above, the department shall conduct an on-site audit of the provider’s records.

(e) Participation in a self-audit does not eliminate the possibility of further review by the department and shall not affect in any manner the department or other regulatory or law enforcement agencies’ ability to pursue criminal, civil, or administrative remedies.

(f) The provider shall maintain copies of all self-audit information and documentation for 6 years from date of the department approval of the self-audit results.

Source. (See Revision Note at chapter heading for He-W 500) (See also part heading for He-W 521) #13884, eff 2-22-24

He-W 521.07 Adjustments to Payments.

(a) In response to all payment errors identified by the department, MCO, MFCU, CMS, U.S. Department of Health and Human Services Office of Inspector General (OIG), providers, or other reviewers, the provider shall repay medicaid or MCO, either through direct payment or recoupment, the total amount of overpayment identified. Payment errors may include incorrect claim submissions, payments in excess of the amount allowed, and fraudulently claimed payments identified.

(b) An adjustment to a payment may be requested by a provider when a claim for payment was billed in error, the bill was incorrect, or overpayment was detected.

(c) The provider shall submit a written request to the department’s fiscal agent for fee-for-service claims or the MCO for managed care claims for an adjustment or recoupment.

(d) The department’s fiscal agent or MCO shall process the adjustment and make any additional payment as necessary or recoup over payments from future claims.

Source. (See Revision Note at chapter heading for He-W 500) (See also part heading for He-W 521) #13884, eff 2-22-24

He-W 521.08 Third Party Liability.

(a) Acceptance of medical assistance by the recipient shall constitute assignment of rights to third party medical support in accordance with RSA 167:14-a.

(b) Third party liability shall be treated as the primary resource in the determination of payment of medical service claims.

(c) Except as allowed by (g) below, the provider shall determine if third party coverage exists at the time the item, supply, or service is provided, and file a proper and complete claim, following all of the third party’s policies, with the third party carrier before billing medicaid.

(d) Except as allowed by (g) below, medicaid shall not pay unless providers comply with third party coverage requirements, such as primary insurance prior authorizations, referrals, and service restrictions, when providing services.

(e) Except as allowed by (g) below, payments shall not be made for any services until all available third party benefits are exhausted.

(f) Failure by a provider to comply with the requirements for payment of any third party coverage, as described in (c), (d), and (e) above, shall result in non-payment of the item, supply, or service by medicaid.

(g) Providers may bill medicaid, prior to billing a known third party carrier, under the following circumstances:

(1) If the provider has confirmed with the department, a recipient has established good cause through the department for not cooperating and not utilizing third party coverage in accordance with 42 CFR 433.145 (a) and 42 CFR 433.147 (c); or

(2) For all preventive pediatric services in accordance with 42 CFR 433.139 (b).

(h) If the provider receives a denial from the third party for administrative reasons or non-compliance with third party procedures, then the provider shall be required to correct the error with the third party for payment. Medicaid shall not pay unless the claim correction is accepted by the third party and processed for payment.

(i) If any third party coverage is known to the department or MCO to provide coverage for a recipient’s medical service needs, that information may be obtained from the medicaid fiscal agent or the MCO.

(j) Providers shall not seek payment from a third party once they have submitted a claim to medicaid, unless they have received a rejection or denial from medicaid.

(k) If the provider has filed a proper claim with the liable third party, and a payment or denial is not forthcoming within 100 days from the date of service, the provider may submit a claim to medicaid and indicate the name and address of the possible third party payment source.

(l) If the provider receives a third party payment after receiving a medicaid payment due to (k) above for the same item, supply, or service, the provider shall reimburse the department or the MCO for the overpayment by submitting payment directly to the department or the MCO from which they were paid.

Source. (See Revision Note at chapter heading for He-W 500) (See also part heading for He-W 521) #13884, eff 2-22-24

He-W 521.09 Recovery For Expenses Related to Third Party Settlements.

(a) Pursuant to RSA 167:14-a, IV, the recipient or the recipient's legal representative shall notify the department or MCO of any accident or injury in which a liable third party is responsible for expenses.

(b) Upon notification of a personal injury of a medicaid recipient, the department or MCO shall determine if there is a claim for third party liability recovery.

(c) The department or MCO shall request accident related information regarding third party liability to the medicaid recipient. If the recipient or the recipient’s legal representative fails to respond to the department's notice of claim, the department or MCO shall withhold the processing of or deny the claim for medicaid payment until the department or MCO receives a response from the recipient or the recipient’s legal representative.

(d) Upon the department or MCO’s request, the recipient or the recipient’s legal representative shall provide the department or MCO with the following information and completed documents:

(1) The date and location of when and where the injury occurred;

(2) The type of injuries incurred due to the accident;

(3) A description of how the injury happened;

(4) The involved insurance company or other liable party;

(5) The amount of a proposed or anticipated offer of settlement made by the liable third party; and

(6) The letter of representation and completed and notarized authorization to release records if the recipient has legal representation.

(e) When the department or MCO makes a claim for recovery of medical expenses paid on behalf of a recipient, the recipient or the recipient's legal representative shall, within 15 business days of receipt of notification of the department or MCO's claim, submit a written statement to the department or MCO which:

(1) Acknowledges the department or MCO's claim; and

(2) Includes a proposed distribution of the recovery.

(f) In addition to the statement in (e) above, a disbursement of any award, judgment, or settlement shall not be made to a recipient without the recipient or the recipient's legal representative first providing at least 30-days written notice of any scheduled trial, alternative dispute resolution hearing, or settlement to the department or MCO per RSA 167:14-a, IV. The recipient or the recipient’s legal representative shall include the department or MCO in all settlement negotiations.

(g) Pursuant to RSA 167:14-a, III, when a recipient receives a settlement or an award from a liable third party prior to notifying the department or MCO, the recipient shall repay the amount of medical assistance furnished by the department or MCO.

(h) If the recipient or the recipient’s legal representative fails to respond to the department or MCO’s notice of lien, the department shall suspend further payments related to the incident until a response is received from the recipient or the recipient’s legal representative unless the recipient is a minor. Claims shall not be suspended when the recipient is under 18 years of age.

(i) If any injury is the result of a work-related accident, and the employer, the insurance carrier, or both, deny the injured employee medical expenses for the periods the injury requires, the recipient may request a hearing from the NH department of labor worker's compensation division, in accordance with Lab 204.01.

(j) Pursuant to RSA 167:14-a, III, when a recipient receives a settlement or an award from worker’s compensation or a liable third person or party, the recipient shall repay the amount of medical assistance furnished by the department to the extent that the amount of the recovery makes repayment possible.

Source. (See Revision Note at chapter heading for He-W 500) (See also part heading for He-W 521) #13884, eff 2-22-24

He-W 521.10 Medicare.

(a) Providers shall enroll with medicaid to receive payment of Medicare crossover claims. Providers shall not submit claims to medicaid or the MCOs if the provider submitted claims to Medicare and received payment. These claims shall be automatically submitted by Medicare to medicaid and MCO as crossover claims for processing.

(b) Providers shall not bill qualified medicare beneficiaries (QMB) for co-payments or deductibles. Sections 1902(n)(3)(B), 1902(n)(3)(C), 1905(p)(3), 1866(a)(1)(A), and 1848(g)(3)(A) of the Social

Security Act, prohibits providers from balance billing QMBs for Medicare cost-sharing.

Source. (See Revision Note at chapter heading for He-W 500) (See also part heading for He-W 521) #13884, eff 2-22-24

He-W 521.11 Third Party Payment.

(a) All third party payors shall comply with RSA 167:4-b.

(b) If third party coverage is determined after a medicaid claim is processed, then the third party payor shall reimburse medicaid even if the third party’s plan policies and procedures were not performed at time of service.

(c) Third party payors shall not deny medicaid’s or MCO’s claim for reimbursement for claim type, claim format, or failure to comply with the third party’s plan policies and procedures, which include, but are not limited to:

(1) No prior authorization obtained;

(2) Not submitted on Health Care Financing Administration or UB red forms;

(3) Claim not submitted electronically;

(4) No National Provider Identification number provided for medicaid;

(5) Medicaid is not a participating provider;

(6) Not submitting reimbursement within the third party payors’ time limit; and

(7) Not having subscriber information on payment request.

(d) If a third party payor has reimbursed medicaid, and then a provider requests payment on the same claim, the third party payor cannot reverse payment made to medicaid to pay the provider.

(e) If a third party payor has reimbursed medicaid or the MCO, then the third party payor requests a payment reversal or adjustment, such requests shall be received within 12 months of initial payment to medicaid or MCO. All reversal or adjustment requests after 12 months shall be denied, and the third party payor cannot recover those payments on future payments to medicaid or MCO.

(f) Third party payors cannot make a payment to a provider after paying medicaid or MCO and reverse or adjust the payment made to medicaid or MCO.

Source. (See Revision Note at chapter heading for He-W 500) (See also part heading for He-W 521) #13884, eff 2-22-24

PART He-W 522 INTERPRETER SERVICES - EXPIRED AND RESERVED

Source. (See Revision Note at chapter heading He-W 500); ss by #5735, eff 11-12-93, EXPIRED: 11-12-99

PART He-W 529 INDEPENDENT COVERAGE REVIEW - RESERVED

He-W 529.01 – 529.07

Source. #8983, INTERIM, eff 9-21-07, EXPIRES: 3-19-08; ss by #9103, eff 3-12-08; rpld by #10031, eff 11-19-11

PART He-W 530 SERVICE LIMITS, CO-PAYMENTS, AND NON-COVERED SERVICES

He-W 530.01 Definitions.

(a) “Co-payment” means an amount to be paid by the recipient to an enrolled New Hampshire medicaid provider.

(b) “Department” means the New Hampshire department of health and human services.

(c) “Generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, or the recommendations of physician specialists practicing in relevant clinical areas or of various physician specialty societies.

(d) “Medicaid” means the Title XIX and Title XXI programs administered by the department, which makes medical assistance available to eligible individuals.

(e) “Medically necessary” means health care services that a licensed health care provider, exercising prudent clinical judgment, would provide, in accordance with generally accepted standards of medical practice, to a recipient for the purpose of evaluating, diagnosing, preventing, or treating an acute or chronic illness, injury, disease, or its symptoms, and that are:

(1) Clinically appropriate in terms of type, frequency of use, extent, site, and duration, and consistent with the established diagnosis or treatment of the recipient’s illness, injury, disease, or its symptoms;

(2) Not primarily for the convenience of the recipient or the recipient’s family, caregiver, or health care provider;

(3) No more costly than other items or services which would produce equivalent diagnostic, therapeutic, or treatment results as related to the recipient’s illness, injury, disease, or its symptoms; and

(4) Not experimental, investigative, cosmetic, or duplicative in nature.

(f) “Multi-source pharmaceutical product” means a product which is available from more than one manufacturer.

(g) “Non-preferred prescription drug” means a medication that has been determined to have an alternative drug available that is clinically equivalent and has been clinically reviewed and approved by the NH Pharmacy and Therapeutics Committee or the NH Drug Use Review Board established in He-C 5010 and has been included in the department’s preferred drug list as non-preferred.

(h) “Preferred prescription drug” means a medication that has been clinically reviewed and approved by the NH Pharmacy and Therapeutics Committee or the NH Drug Use Review Board established in He-C 5010 and has been included in the department’s preferred drug list based on its proven clinical and cost effectiveness.

(i) “Preferred Drug List (PDL)” means a formal published list of specific prescription drug products by brand and generic name divided into 2 separate categories as either preferred or non-preferred.

(j) “Provider” means an entity or individual who furnishes health care services or supplies to medicaid recipients under an agreement with the department, and is licensed or certified pursuant to applicable state law to provide such services and supplies.

(k) “Recipient” means any individual who is eligible for and receiving medical assistance under the medicaid program.

(l) “Service” means medical care or a medical product for which payment is made by New Hampshire medicaid.

(m) “Service limit” means a finite number of visits or units of service per recipient per specified time period for which payment is made by New Hampshire medicaid.

(n) “Single source pharmaceutical product” means a brand name product which is available from only one manufacturer.

(o) “State fiscal year” means July 1 through June 30.

(p) “Third party entity” means the agency under contract with the department to collect and process premium payments for medicaid recipients.

(q) “Title XIX” means the joint federal-state program described in Title XIX of the Social Security Act and administered in New Hampshire by the department under the medicaid program.

(r) “Title XXI” means the joint federal-state program described in Title XXI of the Social Security Act and administered in New Hampshire by the department under the medicaid program.

(s) “Unit” means a determinate quantity for which a particular service is rendered.

(t) “Visit” means all services provided to a recipient per appointment or encounter with a provider.

Source. (See Revision Note at chapter heading He-W 500); ss by #5914, eff 11-1-94; ss by #6745, eff 5-1-98, EXPIRED: 12-31-98; ss by #6925, eff 1-1-99; ss by #8780, INTERIM, eff 1-1-07, EXPIRES: 6-30-07; ss by #8929, eff 6-30-07; amd by #8983, INTERIM, eff 9-21-07, EXPIRES: 3-19-08; ss by #9103, eff 3-12-08; amd by #10139, eff 7-1-12; ss by #11101, eff 5-25-16

He-W 530.02 Recipients Subject to Service Limits, Co-Payments, and Non-Covered Services.

(a) All recipients shall be subject to service limits in accordance with He-W 530.03.

(b) All recipients shall be subject to the co-payments specified in He-W 530.04, except for:

(1) Recipients with income at or below 100% of the federal poverty level (FPL);

(2) Recipients residing in a nursing facility, hospital, intermediate care facility for individuals with intellectual disabilities, or other medical institution;

(3) Recipients participating in the home and community based care (HCBC) waiver programs;

(4) Recipients receiving services that relate to pregnancy, in accordance with 42 CFR 447.53(b)(2), or any other medical condition that might complicate the pregnancy;

(5) Recipients under the age of 18;

(6) Women eligible through the Breast and Cervical Cancer Treatment Program, pursuant to 42 CFR 435.213;

(7) Recipients receiving hospice care pursuant to He-W 544; and

(8) Individuals who are members of a federally recognized Indian tribe or Alaskan natives who have ever been served through the Indian Health Services Programs, pursuant to 42 CFR 447.56(a)(x).

Source. (See Revision Note at chapter heading He-W 500); ss by #4863, eff 7-12-90, EXPIRED: 7-12-96

New. #6745, eff 5-1-98, EXPIRED: 12-31-98; ss by #6925, eff 1-1-99; ss by #8780, INTERIM, eff 1-1-07, EXPIRES:
6-30-07; ss by #8929, eff 6-30-07; amd by #10016, eff 11-1-11; amd by #10716, eff 11-18-14; ss by #10915, eff 8-26-15; ss by #11101, eff 5-25-16

He-W 530.03 Service Limits. The following service limits shall apply to each recipient who is subject to service limits, per state fiscal year, with exceptions noted:

(a) The hearing aid evaluation or a hearing aid consultation shall be limited to one service every 2 years since the last date of service;

(b) Hospital services shall be limited as follows:

(1) Outpatient hospital services shall be limited to 12 visits per state fiscal year;

(2) Services provided in an emergency department (ED) or an urgent care setting shall not be considered outpatient hospital services, and shall not apply toward the limit established in (1) above;

(3) Physician services shall be unlimited except when associated with an outpatient hospital visit, in which case they shall be limited to 12 visits per state fiscal year; and

(4) Services that are described individually in component parts of this chapter, such as therapy services or radiology services, and that are associated with an outpatient hospital, ED or urgent care visit shall be subject to the service limits which apply to that individual service;

(c) Physician and advanced practice registered nurse (APRN) services performed in the inpatient hospital setting shall be limited to one visit per each day of stay approved by the department or its designated quality improvement organization (QIO) as defined in He-W 531.01(h);

(d) Podiatry services shall be limited to 4 visits;

(e) Therapy services, including physical, occupational and speech therapy, shall be limited to 80, 15-minute units per recipient. The 80 units may be used for one type of therapy or for any combination of therapies;

(f) Vision care services shall be limited as follows:

(1) One refraction to determine the need for glasses, no more frequently than every 12 months;

(2) Replacement of lenses or at the discretion of the recipient, lenses and frames, when the refractive error changes .50 diopter or more in both eyes;

(3) Replacement of nickel frames after 12 months, if the recipient has a documented allergy to nickel demonstrated by skin irritation and wearing down of the frame in the affected area; and

(4) One repair of glasses every 12 months, including replacement of the broken part(s) only;

(g) Wheelchair van services shall be limited to 24 trips, either one-way or round trip;

(h) X-ray services shall be limited as follows:

(1) X-ray services for diagnostic purposes shall be limited to 15 x-rays; and

(2) X-ray services provided for radiation therapy shall not be limited; and

(i) If a recipient is covered by medicare and medicare pays at least half the medicaid program rate for a covered service which is subject to limits, that service shall not be counted against such limits.

Source. (See Revision Note at chapter heading He-W 500); ss by #4863, eff 7-12-90; amd He-W 530.03(d) by #5714, eff 10-1-93; amd He-W 530.03(f) by #6050, eff 6-17-95; ss by #6925, eff 1-1-99; ss by #8780, INTERIM, eff 1-1-07, EXPIRES: 6-30-07; ss by #8929, eff 6-30-07; amd by #8983, INTERIM, eff 9-21-07, EXPIRES: 3-19-08; amd by #9103, eff 3-12-08; amd by #9366, eff 1-17-09; amd by #9622, eff 1-1-10; amd by #9736, eff 6-25-10; amd by #10017, eff 11-1-11; amd by #10090, eff 3-1-12; amd by #10427, eff 9-28-13; amd by #10657, eff 8-15-14; ss by #10915, eff 8-26-15; amd by #12818, eff 7-1-19

He-W 530.04 Co-Payments.

(a) Recipients subject to co-payments shall make co-payments to the pharmacy provider for pharmaceutical products as follows, except as noted in (3) below:

(1) For recipients eligible for medicaid through the New Hampshire Health Protection Program (NHHPP) co-payments as required in He-W 512.

(2) For all other recipients subject to co-payments as required by this part:

a. A co-payment in the amount of $1.00 shall be required for each preferred prescription drug and each refill of a preferred prescription drug dispensed;

b. A co-payment in the amount of $2.00 shall be required for each non-preferred prescription drug and each refill of a non-preferred prescription drug dispensed unless the prescribing provider determines that a preferred drug will be less effective for the recipient, will have adverse effects for the recipient, or both, in which case, the co-payment shall be $1.00; and

c. A co-payment in the amount of $1.00 shall be required for a prescription drug that is not identified as either a preferred or non-preferred prescription drug; and

(3) Co-payments for pharmaceutical products shall not be required:

a. Of recipients exempt from co-payments in accordance with He-W 530.02(b);

b. For family planning products; and

c. For Clozaril (Clozapine) prescriptions.

(b) Recipients subject to co-payments shall make co-payments to the provider for services as follows, except as noted in (2) below:

(1) For recipients eligible for medicaid through the NHHPP, co-payments as described in He-W 512; and

(2) Recipients shall not be responsible for a co-payment for the following services:

a. Emergency services needed to evaluate or stabilize an emergency medical condition as defined in 42 CFR 438.114(a);

b. Provider-preventable services as described in 42 CFR §447.26(b);

c. Services furnished to pregnant women, including counseling and pharmacotherapy for cessation of tobacco use;

d. Family planning services and supplies; and

e. Preventive services.

(c) Pursuant to 42 CFR 447.56(f), co-payment obligations shall be suspended for the remainder of the calendar year quarter when the total co-payments made out of pocket by the recipient reaches 5 percent of the recipient’s household income.

(d) All recipients subject to co-payments required by this part shall not be denied services by any medicaid enrolled provider on account of the recipient’s inability to pay the co-payments required by this part.

Source. (See Revision Note at chapter heading He-W 500); ss by #4863, eff 7-12-90, EXPIRED: 7-12-96

New. #6925, eff 1-1-99; ss by #7976, eff 10-22-03; ss by #8780, INTERIM, eff 1-1-07, EXPIRES: 6-30-07; ss by #8929, eff 6-30-07; amd by #10017, eff 11-1-11; ss by #10716, eff 11-18-14; ss by #11101, eff 5-25-16

He-W 530.05 Non-Covered Services.

(a) Non-covered services shall be those services for which the Medicaid program shall make no payment.

(b) Non-covered services shall include:

(1) Acupuncture;

(2) Services ancillary to, or directly related to, a non-covered service or procedure;

(3) Biofeedback;

(4) Experimental or investigational procedures described as such in the National Coverage Determinations (NCD) found in the Centers for Medicare and Medicaid Services “Medicare Coverage Database” at http://www.cms.gov/medicare-coverage-database/ (under the “Quick Search” function, select “National Coverage Documents”, optionally enter a filter by entering a “keyword” to narrow the search results, and select the “Search by Type” button, or, if a keyword is not entered, the entire list of NCD titles will appear alphabetically and may be selected), including thermogenic therapy and electrosleep therapy;

(5) Reversal of voluntary sterilization;

(6) Operations for impotency;

(7) Operations, devices, and procedures for the purpose of contributing to or enhancing fertility or procreation;

(8) Plastic surgery, to include cosmetic surgery, for the purpose of preserving or improving appearance or disfigurement, except when required for the prompt repair of accidental injury or for the improvement in functioning of a malformed body part;

(9) Hypnosis, except when performed by a psychiatrist as part of an established treatment plan;

(10) Routine foot care, except as described in He-W 532;

(11) Services or items that are free to the public;

(12) Physician care in a non-medical government or public institution;

(13) Dietary services, including commercial weight loss, nutritional counseling, and exercise programs, except as otherwise allowed in He-W 500;

(14) Homemaker services, except when provided as part of an authorized Choices for Independence (CFI) program support plan to CFI recipients as described in He-E 801;

(15) Academic performance testing not related to a medical condition;

(16) Detoxification services provided outside an acute care facility or a medical services clinic;

(17) Services provided by halfway houses;

(18) Hospital inpatient care which is not medically necessary;

(19) Autopsies;

(20) Auditory training, except for auditory trainer devices which are covered;

(21) Respite, except as a service under a home and community based care waiver in accordance with 42 CFR 400.180 and 440.181;

(22) Child care;

(23) Chiropractor services;

(24) Institutions for Mental Diseases, in accordance with Section 1905(a)(24)(B) of the Social Security Act;

(25) Duplicative services, which are services that deliver the same functionality to the same recipient during the same period of time, regardless of whether those services are provided solely under medicaid or by medicaid in combination with another program or entity;

(26) Services provided outside the United States and its territories;

(27) Vaccinations for out of country travel;

(28) Services provided by individuals who are not licensed, certified or otherwise recognized by the provisions of He-W 500 to provide such services;

(29) Personal clothing or footwear;

(30) Service and therapy animals;

(31) Equine-assisted psychotherapy;

(32) Any service which is not specifically listed elsewhere in He-W 522 through He-W 589 as covered, or covered with prior authorization, and which is not covered as follows:

a. The service is not covered by Medicare, as indicated by the National Coverage Determinations (NCD) found in the Centers for Medicare and Medicaid Services “Medicare Coverage Database” at http://www.cms.gov/medicare-coverage-database/ (under the “Quick Search” function, select “National Coverage Documents”, optionally enter a filter by entering a “keyword” to narrow the search results, and select the “Search by Type” button, or, if a keyword is not entered, the entire list of NCD titles will appear alphabetically and may be selected); or

b. The service is not covered by New Hampshire or New England commercial insurance policies and coverage criteria as follows:

1. Anthem Medical Policies and Clinical UM Guidelines, http://www.anthem.com/wps/portal/ahpprovider?content_path=provider/wi/f5/s1/t4/pw_ad080065.htm&state=wi&rootLevel=0&label=Anthem%20Medical%20Policies (select the “Continue” button to confirm that the page has been read and proceed to the “Overview” page, then select the “Click Here to Search” button in the middle of this page to continue to the search engine, enter search criteria for the specific coverage policy, and then select the specific coverage policy);

2. Cigna Coverage Policies, https://cignaforhcp.cigna.com (select “RESOURCES” at the top of the page, then select “Coverage Policies”, then select “Medical A-Z Index” for an alphabetical list of policies, and then select the specific coverage policy); or

3. Aetna Clinical Policy Bulletins, http://www.aetna.com/healthcare-professionals/policies-guidelines/cpb_alpha.html (select specific bulletin from the alphabetical listing of clinical policy bulletins); and

(33) Any service for which coverage is not specified within the New Hampshire Medicaid State Plan, and as such the department is unable to claim federal financial participation (FFP) for said service.

Source. #6745, eff 5-1-98, EXPIRED: 12-31-98; ss by #6925, eff 1-1-99; ss by #8780, INTERIM, eff 1-1-07, EXPIRES: 6-30-07; ss by #8929, eff 6-30-07; amd by #9103, eff 3-12-08; amd by #9366, eff 1-17-09; amd by #9622, eff 1-1-10; amd by #9836, eff 12-18-10; ss by #10504, eff 1-9-14; amd by #10561, eff 3-29-14

He-W 530.06 Recipient Responsibility for Payment.

(a) The recipient shall be responsible for payment of the entire cost of a service if:

(1) The individual is not eligible for medicaid on the date of service;

(2) The service is not covered by medicaid;

(3) The provider is not a NH enrolled medicaid provider; or

(4) The provider is no longer taking additional medicaid recipients, but the recipient chooses to receive the service anyway as a private patient.

(b) The recipient shall be informed of these provisions verbally at the initial determination of eligibility and at each redetermination of eligibility by the department.

Source. (See Revision Note at chapter heading He-W 500); ss by #5874, eff 8-1-94; ss by #6925, eff 1-1-99; ss by #8780, INTERIM, eff 1-1-07, EXPIRES: 6-30-07; ss by #8929, eff
6-30-07; ss by #10915, eff 8-26-15

He-W 530.07 Prior Authorization of Services Which Exceed Service Limits.

(a) When the individual medical care plan of a recipient who is under 21 years of age indicates the need for services in excess of the service limits described in He-W 530.03, authorization to exceed the service limit shall be requested in accordance with He-W 546.

(b) When the individual medical care plan of a recipient who is 21 years of age or older indicates the need for services in excess of the service limits described in He-W 530.03, the provider shall request from the department additional visits or units of covered service(s).

(c) All requests in (b) above shall be in advance of the service(s) being rendered, except that services provided during a retroactive eligibility period shall be exempt from this requirement.

(d) Requests for additional units of covered service(s) may be made by the following providers:

(1) Advanced practice registered nurses;

(2) Associate psychologists;

(3) Occupational therapists;

(4) Optometrists;

(5) Osteopathic physicians;

(6) Psychotherapy providers licensed by the board of mental health practice;

(7) Physicians;

(8) Physician’s assistants;

(9) Podiatrists;

(10) Psychologists;

(11) Physical therapists; and

(12) Speech and language therapists.

(e) Providers shall direct requests for prior authorization of services in excess of the limits described in He-W 530.03 to the department.

(f) Prior to payment by the department, requests for prior authorization of covered services in excess of the limits described in He-W 530.03 shall:

(1) With the exception of services provided during a retroactive eligibility period, be submitted in advance of rendering additional services;

(2) Be submitted in writing to the department via mail, e-mail or fax;

(3) Be signed by a provider described in (d) above; and

(4) Be based on the provider’s medical care plan developed for the recipient.

(g) Except as allowed by He-W 573.10, requests for prior authorization shall include, at a minimum:

(1) The recipient’s name;

(2) The recipient’s Title XIX program identification number;

(3) The recipient’s diagnosis;

(4) A copy of the recipient’s medical care plan;

(5) The number of additional visits or units of service being requested;

(6) The provider number of the individuals or agencies to whom the recipient is being referred for these additional services;

(7) Clinical documentation that addresses how the requested additional services meet the definition of medically necessary;

(8) Except as provided by (9) below, if the requested additional services do not meet the definition of medically necessary, clinical documentation that addresses:

a. Any extenuating circumstances unique to the recipient that would make denial of the additional services clinically contraindicative; or

b. Any new scientific evidence in the medical literature or by experts in the field about the efficacy or medical appropriateness of the services;

(9) If the requested additional services are for therapy services, as described in He-W 568, documentation demonstrating that the request meets the clinical criteria set forth in the Milliman Care Guidelines, 17th edition (February/March 2013), available as noted in Appendix A;

(10) A statement of the anticipated medical outcome if the requested additional services are provided; and

(11) A statement of the anticipated medical outcome, and either the estimated cost of such outcome or a description of medical services that might be required as the result of such outcome, if the requested additional services are not provided.

(h) Except as allowed by He-W 573.10, prior authorization requested in accordance with (b) through (g) above shall be approved by the department if the department determines that the requested additional services meet the definition of medically necessary or that coverage is supported by clinical documentation provided in accordance with (g)(8) above.

(i) If the department approves the prior authorization request in accordance with (h) above, the state’s fiscal agent shall send written confirmation of the approval to the provider.

(j) The provider shall be responsible for determining that the recipient is Title XIX eligible on the date of service.

(k) Providers may monitor the number of services used by a recipient based on claims processed and paid by contacting the department’s fiscal agent for this information.

(l) With the exception of requests for services provided during a retroactive eligibility period and wheelchair van services requested in accordance with He-W 573.10, requests for retroactive authorization for services rendered prior to the authorization request shall be denied by the department.

(m) Except as allowed by He-W 573.10, the department shall deny a prior authorization request when the department determines that the requested additional services do not meet the definition of medically necessary and that the coverage is not supported by clinical documentation provided in accordance with (g)(8) or (9) above.

(n) If the department denies the prior authorization request, the department shall forward a notice of denial to the recipient and the wheelchair van provider.

(o) The notice of denial shall contain the information required by 42 CFR 431.210, including:

(1) The reason for, and legal basis of, the denial; and

(2) Information that an appeal of the denial may be requested, in accordance with He-C 200, within 30 calendar days of the date on the notice of the denial.

Source. (See Revision Note at chapter heading He-W 500); ss by #4863, eff 7-12-90, EXPIRED: 7-12-96

New. #6745, eff 5-1-98, EXPIRED: 12-31-98; ss by #6925, eff 1-1-99; ss by #8780, INTERIM, eff 1-1-07, EXPIRES:
6-30-07; ss by #8929, eff 6-30-07; ss by #9366, eff 1-17-09; amd by #9622, eff 1-1-10; amd by #10017, eff 11-1-11; amd by #10031, eff 11-19-11; amd by #10342, eff 6-1-13; ss by #10605, eff 5-23-14; amd by #11101, eff 5-25-16

PART He-W 531 PHYSICIAN SERVICES

He-W 531.01 Definitions.

(a) “Cosmetic purpose” means a procedure done for the sole purpose of changing a physical appearance.

(b) “Current procedural terminology (CPT) code” means a unique identifying code in the field of medical nomenclature and designated by the United States Department of Health and Human Services as the national coding standard utilized in government and private health insurance programs for reporting medical services and procedures.

(d) “Healthcare Common Procedure Coding System (HCPCS)” means a standardized coding system used by Medicare that describes services and procedures. HCPCS includes CPT codes that are used primarily to identify products, supplies, and services not included in the normal CPT code list, such as ambulance services and durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS), when used outside a physician’s office.

(e) “Medicaid” means the Title XIX and Title XXI programs administered by the department which makes medical assistance available to eligible individuals.

(f) “National Correct Coding Initiative (NCCI) edits” means standardized coding edits developed by the Centers for Medicare and Medicaid Services (CMS) to reduce improper coding and prevent inappropriate payments when incorrect code combinations are reported.

(g) “Prior authorization agent” means an individual or organization contracted by the department, responsible for reviewing all prior authorization requests.

(h) “Quality improvement organization (QIO)” means an organization or agency established in accordance with 42 CFR 475 that performs utilization and quality control peer reviews in accordance with 42 CFR 476 when contracted by the department for the performance of such reviews.

(i) “Recipient” means any individual who is eligible for and receiving medical assistance under the medicaid program.

(j) “Title XIX” means the joint federal-state program described in Title XIX of the Social Security Act and administered in New Hampshire by the department under the medicaid program.

(k) “Title XXI” means the joint federal-state program described in Title XXI of the Social Security Act and administered in New Hampshire by the department under the medicaid program.

Source. (See Revision Note at chapter heading He-W 500); ss by #6051, eff 6-17-95; ss by #7895, eff 5-21-03; ss by #9915, INTERIM, eff 5-15-11, EXPIRES: 11-14-11; ss by #10018, eff 11-14-11; amd by #10139, eff 7-1-12; amd by #10561, eff 3-29-14; amd by #12818, eff 7-1-19; ss by #12999, eff 3-5-20

He-W 531.02 Recipient Eligibility. All medicaid recipients shall be eligible for physician services in accordance with He-W 531.

He-W 531.03 Provider Participation.

(a) Each participating physician provider shall:

(1) Be licensed to practice by the state in which he or she practices;

(2) Be a New Hampshire enrolled medicaid provider; and

(3) Request and obtain prior authorization in accordance with He-W 531.07.

(b) Medicaid enrolled physicians and physician practices shall not charge a membership fee to medicaid recipients or a recipient’s parent, family member, agent or legal guardian.

He-W 531.04 Service Limits. All physician services shall be subject to the service limits set forth in He-W 530.03.

He-W 531.05 Covered Services.

(a) The following physician services, subject to the prior authorization requirements in He-W 531.07, as applicable, shall be covered services:

(1) Anesthesia not administered by the operating surgeon;

(2) Care provided by 2 or more physicians on the same day for unrelated diagnoses regardless of the setting, for example, inpatient or outpatient;

(3) Consultation services, as documented in a written report, provided by a physician whose opinion or advice regarding evaluation and management of a specific problem is requested by another physician or health care professional;

(4) Second opinion;

(5) Eye care provided by ophthalmologists as described in He-W 565;

(6) Family planning services as described in He-W 541;

(7) Inpatient hospital visits for acute care days of stay approved in accordance with He-W 543.11;

(8) Laboratory and radiology services as described in He-W 577 and He-W 569;

(9) Obstetrical or gynecological procedures that relate to care and treatment of pregnant women and the female reproductive system, except for those procedures for which the sole purpose is to contribute to, promote, or restore fertility, procreation, or sexual activity;

(10) Face-to-face services rendered by a physician in any setting, including walk-in clinics, urgent care centers, emergency departments, outpatient hospital settings, nursing facilities, and recipients’ homes;

(11) Surgical procedures, subject to the prior authorization requirements in He-W 531.07, as applicable, including:

a. Operative procedures for the treatment of illnesses, injuries and congenital anomalies;

b. The treatment of fractures and dislocations;

c. The treatment of burns; and

d. Invasive diagnostic and treatment services;

(12) Services in addition to those usually and customarily carried out to treat preoperative or postoperative complications, provided that the physician has followed the procedures described in He-W 531.07;

(13) The following tissue transplants:

a. Cornea transplants;

b. Skin transplants with the exception of hairplasty; and

c. Bone grafts; and

(14) Immunizations.

(b) The following organ transplants from a human donor to a recipient performed at facilities described in He-W 543.05(f) shall be covered subject to the prior authorization requirements in He-W 531.07 and in accordance with the applicable coverage criteria in Interqual Connect Clinical Guidelines,
2019 Edition, available as noted in Appendix A:

(1) Kidney transplants;

(2) Heart transplants;

(3) Heart and lung transplants;

(4) Lung transplants;

(5) Allogenic bone marrow transplants;

(6) Autologous bone marrow transplants;

(7) Liver transplants;

(8) Pancreas transplants; and

(9) Pancreas and kidney transplants.

(c) Bariatric surgical procedures shall be covered, subject to the prior authorization requirements in He-W 531.07 and in accordance with the coverage criteria in Interqual Connect Clinical Guidelines,
2019 Edition , available as noted in Appendix A, except that the recipient shall also have lost at least 15% of body weight prior to scheduling bariatric surgery as documented in the recipient’s medical record.

(d) Breast reduction surgery shall be covered, subject to the prior authorization requirements in He-W 531.07 and in accordance with the coverage criteria in Interqual Connect Clinical Guidelines,
2019 Edition , available as noted in Appendix A.

(e) Blepharoplasty shall be covered, subject to the prior authorization requirements in He-W 531.07 and in accordance with the coverage criteria in Interqual Connect Clinical Guidelines,
2019 Edition , available as noted in Appendix A.

(f) Panniculectomy shall be covered, subject to the prior authorization requirements in He-W 531.07 and in accordance with the coverage criteria in Interqual Connect Clinical Guidelines,
2019 Edition , available as noted in Appendix A.

(g) Septoplasty and rhinoplasty shall be covered, subject to the prior authorization requirements in He-W 531.07 and in accordance with the coverage criteria in Interqual Connect Clinical Guidelines,
2019 Edition, available as noted in Appendix A.

(h) Coverage of routine visits to nursing facilities for non-acute services shall be limited to one visit per calendar month.

Source. (See Revision Note at chapter heading He-W 500); ss by #6051, eff 6-17-95; ss by #7895, eff 5-21-03; ss by #9915, INTERIM, eff 5-15-11, EXPIRES: 11-14-11; ss by #10018, eff 11-14-11; amd by #10091, eff 2-24-12; ss by #10561, eff 3-29-14; ss by #12999, eff 3-5-20

He-W 531.06 Non-Covered Services.

(a) Physician services for the surgery, inpatient hospital services for the surgical admission(s), and organ procurement services related to the following types of transplants shall be non-covered services:

(1) Any type of organ transplant not specified in He-W 531.05(b) or tissue transplant not specified in He-W 531.05(a)(13);

(2) Organ transplants requiring prior authorization but which are not prior authorized; or

(3) More than 2 transplants of the same type of organ per recipient per lifetime.

(b) Psychiatric services when provided at or through a community mental health center shall be non-covered as a physician service.

(c) Treatment shall be non-covered when the sole purpose is to contribute to, promote, or restore fertility, procreation, or sexual activity.

(d) Procedures or surgery for the sole purpose of preserving or improving appearance shall be non-covered, except when required for the prompt repair of accidental injury or for the improvement of the functioning of a malformed body member.

(e) With the exception of procedures covered in accordance with the coverage criteria in He-W 531.05(b)-(g), experimental or investigational procedures described as such in the National Coverage Determinations (NCD) found in the Centers for Medicare and Medicaid Services “Medicare Coverage Database” at http://www.cms.gov/medicare-coverage-database/ (under the “Quick Search” function, select “National Coverage Documents”, optionally enter a filter by entering a “keyword” to narrow the search results, and select the “Search by Type” button, or, if a keyword is not entered, the entire list of NCD titles will appear alphabetically and may be selected) shall be non-covered.

(f) Thermogenic therapy, which treats certain types of resistant infectious diseases through the production of artificial fever, shall be non-covered.

(g) Electrosleep therapy, which consists of the application of pulses of direct current to the recipient’s brain through external electrodes, shall be non-covered.

(h) Any services directly related to a non-covered service or procedure shall be non-covered.

(i) Inpatient hospital visits for non-acute inpatient stays shall be non-covered, including but not limited to:

(1) Visits to recipients who are in an inpatient hospital setting awaiting placement to a long term care facility; and

(2) Visits for days that have not been approved by the department or its designated Quality Improvement Organization (QIO) in accordance with He-W 543.

(j) Components of surgical preparatory regimens that are not described as covered services in accordance with He-W 520 through He-W 577 shall be non-covered, including:

(1) Services rendered by dieticians or nutritionists; and

(2) Exercise regimens.

Source. (See Revision Note at chapter heading He-W 500); ss by #6051, eff 6-17-95; ss by #7895, eff 5-21-03; ss by #9915, INTERIM, eff 5-15-11, EXPIRES: 11-14-11; ss by #10018, eff 11-14-11; ss by #10561, eff 3-29-14; amd by #12403, eff 10-20-17; amd by #12818, eff 7-1-19; ss by #12999, eff 3-5-20

He-W 531.07 Prior Authorization.

(a) The following services and procedures, as described in He-W 531.05, shall require prior authorization from the department’s prior authorization agent:

(1) All organ transplants, except kidney transplants;

(2) Bariatric surgical procedures;

(3) Breast reduction surgery;

(4) Blepharoplasty;

(5) Panniculectomy; and

(6) Septoplasty and rhinoplasty.

(b) Prior to payment by the department, requests for prior authorization of services and procedures described in He-W 531.05 shall:

(1) Be submitted in advance of rendering the service;

(2) Be submitted in writing to the department’s prior authorization agent via mail or fax on Form 273S “Physician Request for Prior Authorization for Certain Surgical Procedures, Including Organ Transplants” (02/2020), along with any supporting documentation;

(3) Be signed by the provider; and

(4) Be based on the provider’s medical care plan developed for the recipient.

(c) Requests for prior authorization shall include a physician’s order, letter of medical necessity, and clinical notes to enable the department’s prior authorization agent to evaluate the request.

(d) Prior authorization requested in accordance with (a) through (c) above shall be approved by the department’s prior authorization agent if the department’s prior authorization agent determines that the submitted documentation supports the applicable requirements in He-W 531.05.

(e) If the department approves the prior authorization request, the department’s fiscal agent shall send written confirmation of the approval to the provider.

(f) The provider shall be responsible for determining that the recipient is Title XIX eligible on the date of service.

(g) If the department’s prior authorization agent denies the prior authorization request, the department’s prior authorization agent shall forward a notice of denial to the recipient and the ordering provider on the department Form 272a, “Medical Assistance Program Denial for Prior Authorized Services,” including the following:

(1) The reason for, and legal basis of, the denial; and

(2) Information that a fair hearing on the denial may be requested within 30 calendar days of the date on the notice of the denial, in accordance with He-C 200.

Source. (See Revision Note at chapter heading He-W 500); ss by #6051, eff 6-17-95; ss by #7895, eff 5-21-03; ss by #9915, INTERIM, eff 5-15-11, EXPIRES: 11-14-11; ss by #10018, eff 11-14-11; ss by #10561, eff 3-29-14; ss by #12999, eff 3-5-20

He-W 531.08 Utilization Review and Control.

(a) The department’s provider integrity unit shall monitor utilization of physician services, to identify, prevent, and correct potential occurrences of fraud, waste, and abuse, in accordance with 42 CFR 455, CFR 456, 42 CFR 1001, and He-W 520.

(b) The department shall recoup state and federal medicaid payments as permitted by 42 CFR 455, 42 CFR 447, and 42 CFR 456 for a provider’s failure to maintain supporting records in accordance with He-W 520 and He-W 531.

Source. (See Revision Note at chapter heading He-W 500); ss by #6051, eff 6-17-95; ss by #7895, eff 5-21-03; ss by #9915, INTERIM, eff 5-15-11, EXPIRES: 11-14-11; ss by #10018, eff 11-14-11; ss by #10561, eff 3-29-14; ss by #12999, eff 3-5-20

He-W 531.09 Third Party Liability. All third party obligations shall be exhausted before medicaid shall be billed, in accordance with 42 CFR 433.139.

Source. #10018, eff 11-14-11; ss by #12999, eff 3-5-20

He-W 531.10 Payment for Services.

(a) Payment to physicians shall be made in accordance with rates established by the department in accordance with RSA 161:4, VI(a).

(b) The payment rates for surgery, established by the department in accordance with RSA 161:4, VI(a), shall be at a global rate in accordance with the CPT codes and National Correct Coding Initiative (NCCI) edits, inclusive of the following:

(1) Local infiltration, metacarpal/metatarsal/digital block, or topical anesthesia;

(2) Subsequent to the decision for surgery, any related evaluation and management encounter that occurs up to 5 days prior to or on the date of procedure, including history and physical;

(3) Immediate postoperative care, including dictating operative notes, and talking with the family and other physicians;

(4) Writing orders;

(5) Evaluating the patient in the post anesthesia recovery area; and

(6) Typical post-operative follow-up care up to 30 days post surgery.

(c) Rates established by the department in accordance with (a) above shall be considered to include all costs of doing business including, but not limited to:

(1) Missed or cancelled appointments; and

(2) Administrative services such as:

a. Copying records;

b. Referrals;

c. Renewing prescriptions; and

d. Providing medical documents for schools, sports, and camps.

(d) Payment for second surgical opinions shall be made in accordance with rates established by the department in accordance with RSA 161:4, VI(a).

(e) Physicians who request reimbursement for clinical laboratory services, in accordance with He-W 577, shall receive reimbursement provided that a contract or agreement exists between the physician and the laboratory and requests for reimbursement shall be made by the physician.

(f) The provider shall use CPT and HCPCS procedure codes when billing.

(g) The provider shall submit claims for payment to the department’s fiscal agent.

(h) The provider shall maintain supporting records in accordance with He-W 520.

Source. #10018, eff 11-14-11 (from He-W 531.08); ss by #10561, eff 3-29-14; ss by #12999, eff 3-5-20

PART He-W 532 PODIATRY SERVICES

He-W 532.01 Definitions.

(a) “Current procedural terminology (CPT) code” means a unique identifying code in the field of medical nomenclature and designated by the United States Department of Health and Human Services as the national coding standard utilized in government and private health insurance programs for reporting medical services and procedures.

(b) “Department (DHHS)” means the New Hampshire department of health and human services.

(c) “Medicaid” means the Title XIX and Title XXI programs administered by the department which makes medical assistance available to eligible individuals.

(d) “Mycotic nail” means a fungus infection of a toenail.

(e) “Pathological condition” means any disease, trauma, tumors, or deformities affecting anatomy or physiology.

(f) “Podiatry service” means the diagnosis and treatment of ailments of the human foot and lower leg by any medical, mechanical, electrical, and surgical means available and performed by a podiatrist.

(g) “Recipient” means any individual who is eligible for and receiving medical assistance under the medicaid program.

(h) “Routine foot care” means preventive and hygienic maintenance of the feet, of the type which is ordinarily considered self-care, including observation and cleansing of the feet, and the use of skin creams to maintain skin tone.

(i) “State fiscal year” means July 1 through June 30.

(j) “Title XIX” means the joint federal-state program described in Title XIX of the Social Security Act and administered in New Hampshire by the department under the medicaid program.

(k) “Title XXI” means the joint federal-state program described in Title XXI of the Social Security Act and administered in New Hampshire by the department under the medicaid program.

(l) “Visit” means all podiatry services provided to a recipient on one day by one podiatrist.

Source. (See Revision Note at chapter heading He-W 500); ss by #4818, eff 6-1-90, EXPIRED: 6-1-96

New. #6756, eff 5-22-98, EXPIRED: 5-22-06

New. #8642, INTERIM, eff 5-26-06, EXPIRES: 11-22-06; ss by #8745, eff 10-24-06; amd by #10139, eff 7-1-12; ss by #10814, eff 4-21-15; ss by #14327, eff 7-23-25, EXPIRES: 7-23-35

He-W 532.02 Recipient Eligibility. All medicaid recipients, including those confined to medical care institutions, including hospitals or nursing facilities, shall be eligible for podiatry services in accordance with this part.

Source. (See Revision Note at chapter heading He-W 500); ss by #4818, eff 6-1-90, EXPIRED: 6-1-96

New. #6756, eff 5-22-98, EXPIRED: 5-22-06

New. #8642, INTERIM, eff 5-26-06, EXPIRES: 11-22-06; ss by #8745, eff 10-24-06; ss by #10814, eff 4-21-15; ss by #14327, eff 7-23-25, EXPIRES: 7-23-35

He-W 532.03 Provider Participation. Each participating podiatrist shall:

(a) Be licensed by the state in which they practice; and

(b) Be a NH enrolled medicaid provider.

Source. (See Revision Note at chapter heading He-W 500); ss by #4818, eff 6-1-90, EXPIRED: 6-1-96

New. #6756, eff 5-22-98, EXPIRED: 5-22-06

New. #8642, INTERIM, eff 5-26-06, EXPIRES: 11-22-06; ss by #8745, eff 10-24-06; ss by #10814, eff 4-21-15; ss by #14327, eff 7-23-25, EXPIRES: 7-23-35

He-W 532.04 Service Limits. Podiatry services shall be limited to 4 visits per recipient per state fiscal year.

Source. (See Revision Note at chapter heading He-W 500); ss by #4818, eff 6-1-90, EXPIRED: 6-1-96

New. #6756, eff 5-22-98, EXPIRED: 5-22-06

New. #8642, INTERIM, eff 5-26-06, EXPIRES: 11-22-06; ss by #8745, eff 10-24-06; ss by #9736, eff 6-25-10; ss by #10814, eff 4-21-15; ss by #14327, eff 7-23-25, EXPIRES: 7-23-35

He-W 532.05 Covered Services. The following podiatry services shall be covered only if they are medical or surgical treatments of the human foot or lower leg for pathological conditions of the foot due to localized illness, injury, or symptoms involving the foot:

(a) Routine foot care, and trimming and burring of nails, including mycotic nails, performed by a podiatrist, provided that:

(1) The recipient’s primary health care provider has documented in the recipient’s medical record that the recipient’s current medical condition justifies the need for such foot care to be performed by a podiatrist;

(2) The recipient’s primary health care provider has written a referral to a podiatrist for such care, documenting in the recipient’s medical record that the referral was made; and

(3) The referral is documented as received by, and is retained by, the podiatrist in the recipient’s medical record;

(b) Prevention and reduction of corns, calluses, and warts shall be covered by cutting or surgical means only; and

(c) Casting, strapping, and taping when performed by a podiatrist for the treatment of fractures, dislocations, sprains, strains, and open wounds of the ankle, foot, and toes.

Source. (See Revision Note at chapter heading He-W 500); ss by #4818, eff 6-1-90, EXPIRED: 6-1-96

New. #6756, eff 5-22-98, EXPIRED: 5-22-06

New. #8642, INTERIM, eff 5-26-06, EXPIRES: 11-22-06; ss by #8745, eff 10-24-06; ss by #10814, eff 4-21-15; ss by #14327, eff 7-23-25, EXPIRES: 7-23-35

He-W 532.06 Non-Covered Services. The following podiatry services shall not be covered:

(a) Routine foot care, and trimming and burring of nails, except as described in He-W 532.05;

(b) Prevention and reduction of corns, calluses, and warts other than by cutting or surgical means only;

(d) Any podiatry service performed in the absence of pathological conditions of the foot due to localized illness, injury, or symptoms involving the foot; and

(e) Office visits occurring on the same date of service as a podiatry surgical procedure, except where additional non-podiatry related medical conditions are addressed.

Source. (See Revision Note at chapter heading He-W 500); ss by #4818, eff 6-1-90, EXPIRED: 6-1-96

New. #6756, eff 5-22-98, EXPIRED: 5-22-06

New. #8642, INTERIM, eff 5-26-06, EXPIRES: 11-22-06; ss by #8745, eff 10-24-06; ss by #10814, eff 4-21-15; ss by #14327, eff 7-23-25, EXPIRES: 7-23-35

He-W 532.07 Documentation. The podiatrist shall maintain:

(a) Supporting clinical records in accordance with He-W 520;

(b) Specific written documentation in the recipient’s medical record justifying the need for podiatry care in accordance with He-W 532.05(a);

(c) Specific written documentation in the recipient’s medical record, by the podiatrist, specifying the frequency of the podiatry service(s) being performed;

(d) Specific written documentation in the recipient’s podiatry medical record of all podiatry services performed; and

(e) A completed recipient medical history maintained in the recipient’s podiatry medical record.

Source. (See Revision Note at chapter heading He-W 500); ss by #4818, eff 6-1-90, EXPIRED: 6-1-96

New. #6756, eff 5-22-98, EXPIRED: 5-22-06

New. #8642, INTERIM, eff 5-26-06, EXPIRES: 11-22-06; ss by #8745, eff 10-24-06; ss by #10814, eff 4-21-15; ss by #14327, eff 7-23-25, EXPIRES: 7-23-35

He-W 532.08 Utilization Review and Control.

(a) The department’s bureau of program integrity shall monitor utilization of podiatry services to identify, prevent, and correct potential occurrences of fraud, waste, and abuse, in accordance with 42 CFR 455, 42 CFR 456, and He-W 520.

Source. (See Revision Note at chapter heading He-W 500); ss by #4818, eff 6-1-90, EXPIRED: 6-1-96

New. #6756, eff 5-22-98, EXPIRED: 5-22-06

New. #8642, INTERIM, eff 5-26-06, EXPIRES: 11-22-06; ss by #8745, eff 10-24-06; ss by #10814, eff 4-21-15; ss by #14327, eff 7-23-25, EXPIRES: 7-23-35

He-W 532.09 Third Party Liability.

(a) All third party obligations shall be exhausted before claims shall be submitted to the department’s fiscal agent in accordance with 42 CFR 433.139.

(b) Podiatry service providers shall request information from the recipient regarding other insurance coverage.

(c) If other insurance coverage is available, providers shall contact the insurer to verify benefits initially and at least annually thereafter or when the insurance carrier changes.

(d) Podiatry service providers shall maintain a record of any other insurance verifications in the recipient’s medical record in accordance with He-W 520.

Source. (See Revision Note at chapter heading He-W 500); ss by #4818, eff 6-1-90, EXPIRED: 6-1-96

New. #6756, eff 5-22-98, EXPIRED: 5-22-06

New. #8642, INTERIM, eff 5-26-06, EXPIRES: 11-22-06; ss by #8745, eff 10-24-06; ss by #10814, eff 4-21-15; ss by #14327, eff 7-23-25, EXPIRES: 7-23-35

He-W 532.10 Payment for Services.

(a) Rates of payment for podiatry services shall be established by the department in accordance with RSA 161:4, VI(a).

(b) The payment rates for podiatry surgical procedures shall include:

(1) Pre-operative visits and consultations, regardless of the treatment location;

(2) The podiatry surgical procedure;

(3) Casting at the time of surgery, if required; and

(4) Normal uncomplicated follow-up for 30 days following the podiatry surgical procedure, regardless of treatment location.

(d) Providers of podiatry services shall bill for podiatry services utilizing CPT codes.

Source. (See Revision Note at chapter heading He-W 500); ss by #4818, eff 6-1-90, EXPIRED: 6-1-96

New. #6756, eff 5-22-98, EXPIRED: 5-22-06

New. #8642, INTERIM, eff 5-26-06, EXPIRES: 11-22-06; ss by #8745, eff 10-24-06; ss by #10814, eff 4-21-15; ss by #14327, eff 7-23-25, EXPIRES: 7-23-35

PART He-W 533 - RESERVED

He-W 533.01 - 533.09

Source. (See Revision Note at chapter heading He-W 500); ss by #4817, eff 6-1-90, EXPIRED: 6-1-96

New. #6700, eff 2-28-98, EXPIRES: 2-29-05; ss by #8573, eff 2-24-06; rpld by #9622, eff 1-1-10

PART He-W 534 ADVANCED REGISTERED NURSE PRACTITIONER SERVICES

He-W 534.01 Definitions.

(a) “Advanced practice registered nurse (APRN)” means a registered nurse currently licensed by the New Hampshire board of nursing under RSA 326-B:18 or, in states other than New Hampshire, a registered professional nurse practitioner who, in accordance with 42 CFR 440.166, meets that state’s advanced educational and clinical practice requirements, if any, beyond the 2 to 4 years of basic nursing education required of all registered nurses.

(b) “Current procedural terminology (CPT) code” means a unique identifying code in the field of medical nomenclature and designated by USDHHS as the national coding standard utilized in government and private health insurance programs for reporting medical services and procedures.

(e) “Medicaid” means the Title XIX and Title XXI programs administered by the department, which makes medical assistance available to eligible individuals.

(f) “Recipient” means any individual who is eligible for and receiving medical assistance under the medicaid program.

(g) “Title XIX” means the joint federal-state program described in Title XIX of the Social Security Act and administered in New Hampshire by the department under the medicaid program.

(h) “Title XXI” means the joint federal-state program described in Title XXI of the Social Security Act and administered in New Hampshire by the department under the medicaid program.

Source. (See Revision Note at chapter heading He-W 500); ss by #4793, eff 3-30-90, EXPIRED: 3-30-96

New. #6701, eff 2-28-98, EXPIRES: 2-28-05; ss by #8574, eff 2-24-06; amd by #10139, eff 7-1-12; ss by #10512, eff
1-24-14

He-W 534.02 Recipient Eligibility. All NH medicaid recipients shall be eligible to receive APRN services, in accordance with He-W 534.

Source. (See Revision Note at chapter heading He-W 500); ss by #4793, eff 3-30-90, EXPIRED: 3-30-96

New. #6701, eff 2-28-98, EXPIRES: 2-28-05; ss by #8574, eff 2-24-06; ss by #10512, eff 1-24-14

He-W 534.03 Provider Participation. Each participating APRN shall:

(a) Be a New Hampshire (NH) enrolled medicaid provider;

(b) If practicing in NH, be licensed as an APRN by the NH board of nursing in accordance with RSA 326-B:18; and

(c) If practicing in another state, submit current proof of meeting that state’s advanced education and clinical requirements to practice as a registered nurse in an advance practice role.

Source. (See Revision Note at chapter heading He-W 500); ss by #4793, eff 3-30-90, EXPIRED: 3-30-96

New. #6701, eff 2-28-98, EXPIRES: 2-28-05; ss by #8574, eff 2-24-06; ss by #10512, eff 1-24-14

He-W 534.04 Service Limits. All services shall be subject to the service limits set forth in He-W 530.

Source. (See Revision Note at chapter heading He-W 500); ss by #4793, eff 3-30-90, EXPIRED: 3-30-96

New. #6701, eff 2-28-98, EXPIRES: 2-28-05; ss by #8574, eff 2-24-06; ss by #10512, eff 1-24-14; ss by #10657, eff
8-15-14

He-W 534.05 Covered Services. Covered services shall be those services set forth in Nur 304.05.

Source. (See Revision Note at chapter heading He-W 500); ss by #4793, eff 3-30-90, EXPIRED: 3-30-96

New. #6701, eff 2-28-98, EXPIRES: 2-28-05; ss by #8574, eff 2-24-06; ss by #10512, eff 1-24-14

He-W 534.06 Utilization Review & Control. The department’s provider program integrity unit shall monitor utilization of APRN services to identify, prevent, and correct potential occurrences of fraud, waste and abuse in accordance with in accordance with He-W 520, 42 CFR 455, and 42 CFR 456.

Source. (See Revision Note at chapter heading He-W 500); ss by #4793, eff 3-30-90, EXPIRED: 3-30-96

New. #6701, eff 2-28-98, EXPIRES: 2-28-05; ss by #8574, eff 2-24-06; ss by #10512, eff 1-24-14

He-W 534.07 Third Party Liability. All third party obligations shall be exhausted before medicaid may be billed, in accordance with 42 CFR 433.139.

Source. (See Revision Note at chapter heading He-W 500); ss by #4793, eff 3-30-90, EXPIRED: 3-30-96

New. #6701, eff 2-28-98, EXPIRES: 2-28-05; ss by #8574, eff 2-24-06; ss by #10512, eff 1-24-14

He-W 534.08 Payment for Services.

(a) The payment rates for APRN services shall be established by the department in accordance with RSA 161:4, IV.

(b) The APRN shall submit claims for payment to the department’s fiscal agent.

(c) The APRN shall use CPT and HCPCS codes and coding guidelines established for use with these procedure codes when billing.

(d) The APRN shall maintain supporting records, in accordance with He-W 520.

Source. (See Revision Note at chapter heading He-W 500); ss by #4793, eff 3-30-90, EXPIRED: 3-30-96

New. #6701, eff 2-28-98, EXPIRES: 2-28-05; ss by #8574, eff 2-24-06; ss by #10512, eff 1-24-14

PART He-W 535 PSYCHOTHERAPY SERVICES - EXPIRED

Source. (See Revision Note at chapter heading He-W 500); ss by #6050, eff 6-17-95, EXPIRED: 6-17-03

PART He-W 536 MEDICAL SERVICES CLINIC

He-W 536.01 Definitions.

(a) “Department” means the New Hampshire department of health and human services.

(b) “Medicaid” means the Title XIX and Title XXI programs administered by the department which makes medical assistance available to eligible individuals.

(c) “Medical services clinic” means a facility or a mobile immunization provider that is not part of a hospital but is organized to provide preventive, diagnostic, therapeutic, rehabilitative, or palliative services to outpatients.

(d) “Mobile immunization provider” means an agency organized to provide immunizations at host facilities.

(e) “Recipient” means any individual who is eligible for and receiving medical assistance under the medicaid program.

(f) “Title XIX” means the joint federal-state program described in Title XIX of the Social Security Act and administered in New Hampshire by the department under the medicaid program.

(g) “Title XXI” means the joint federal-state program described in Title XXI of the Social Security Act and administered in New Hampshire by the department under the medicaid program.

Source. (See Revision Note at chapter heading He-W 500); ss by #6133, eff 11-30-95; ss by #7825, eff 2-8-03; ss by #9860, eff 2-8-11; amd by #10139, eff 7-1-12; ss by #12732, INTERIM, eff 2-22-19, EXPIRED: 8-21-19

New. #12877, eff 9-25-19

He-W 536.02 Recipient Eligibility. All recipients shall be eligible for services delivered by a medical services clinic in accordance with He-W 536.

Source. (See Revision Note at chapter heading He-W 500); ss by #6133, eff 11-30-95; ss by #7825, eff 2-8-03; ss by #9860, eff 2-8-11, EXPIRED: 2-8-19

New. #12732, INTERIM, eff 2-22-19, EXPIRED: 8-21-19

New. #12877, eff 9-25-19

He-W 536.03 Provider Participation. All participating medical services clinics shall meet the following criteria in either (a) or (b) below:

(a) Medical services clinics that are not mobile immunization providers shall meet the following criteria:

(1) Be composed of New Hampshire licensed practitioners who meet the provider requirements for the particular medical service being performed as set forth in He-W 511 through He-W 577;

(2) Provide recipient care that is under the supervision of a licensed physician affiliated with the clinic which shall mean that:

a. The physician is readily available to provide direction either by phone or in person;

b. The physician has seen the recipient as a patient at least once and assesses the need for continuing care as necessary; and

c. The physician assumes professional responsibility for the services provided to the recipient;

(3) Provide medical care on an outpatient basis;

(4) Be organized and operated independently from a hospital pursuant to 42 CFR 440.90;

(5) Be an enrolled New Hampshire medicaid provider; and

(6) Request and obtain prior authorization from the department before providing services which require prior authorization as specified in He-W 511 through He-W 577; or

(b) Medical services clinics that are mobile immunization providers shall meet the following criteria:

(1) Be composed of, and provide immunizations by, New Hampshire licensed practitioners whose licensure allows them to provide immunizations;

(2) Be under contract with, or have a current vaccine provider agreement with, the department’s division of public health services;

(3) Provide immunizations to recipients in settings such as walk-in clinics, retail stores and outlets, pharmacies, and schools;

(4) Provide immunizations as medicaid services only in those settings and for those types or ages of recipients addressed in the contract or agreement in (2) above;

(5) Provide services “under the direction of a physician”, which means through standing orders or other indirect supervision where the physician is not necessarily on site but who assumes professional responsibility for the services provided to the recipient;

(6) Affiliate with the directing physician through a contractual agreement or any other formal arrangement which obligates the physician to supervise the care provided to the recipient by the clinic;

(7) Be organized and operated independently from a hospital pursuant to 42 CFR 440.90; and

(8) Be an enrolled New Hampshire medicaid provider.

Source. (See Revision Note at chapter heading He-W 500); ss by #6133, eff 11-30-95; ss by #7825, eff 2-8-03; ss by #9860, eff 2-8-11, EXPIRED: 2-8-19

New. #12732, INTERIM, eff 2-22-19, EXPIRES: 8-21-19

He-W 536.04 Service Limits. The services provided by a medical services clinic shall be subject to each of the specific service limits and provider requirements for the services delivered and which are set forth in He-W 511 through He-W 577.

Source. (See Revision Note at chapter heading He-W 500); ss by #6133, eff 11-30-95; ss by #7825, eff 2-8-03; ss by #9860, eff 2-8-11; ss by #9860, eff 2-8-11, EXPIRED: 2-8-19

New. #12732, INTERIM, eff 2-22-19, EXPIRED: 8-21-19

New. #12877, eff 9-25-19

He-W 536.05 Covered Services.

(a) Except for those clinic providers who meet the mobile immunization criteria in He-W 536.03(b), covered services provided by a medical services clinic shall include medicaid covered services that are referenced in He-W 511 through He-W 577.

(b) Covered services provided by clinic providers who meet the mobile immunization criteria in He-W 536.03(b) shall include only medically necessary immunizations ordered by the directing physician.

Source. (See Revision Note at chapter heading He-W 500); ss by #6133, eff 11-30-95; ss by #7825, eff 2-8-03; ss by #9860, eff 2-8-11; ss by #9860, eff 2-8-11, EXPIRED: 2-8-19

New. #12732, INTERIM, eff 2-22-19, EXPIRED: 8-21-19

New. #12877, eff 9-25-19

He-W 536.06 Utilization Review and Control.

(a) The department’s program integrity unit shall monitor utilization of medical services clinics to identify, prevent, and correct potential occurrences of fraud, waste, and abuse in accordance with 42 CFR 455, 42 CFR 456, 42 CFR 1001, and He-W 520.

Source. (See Revision Note at chapter heading He-W 500); ss by #6133, eff 11-30-95; ss by #7825, eff 2-8-03; ss by #9860, eff 2-8-11, EXPIRED: 2-8-19

New. #12732, INTERIM, eff 2-22-19, EXPIRED: 8-21-19

New. #12877, eff 9-25-19

He-W 536.07 Third Party Liability. All third party obligations shall be exhausted before medicaid shall be billed in accordance with 42 CFR 433.139.

Source. (See Revision Note at chapter heading He-W 500); ss by #6133, eff 11-30-95; ss by #7825, eff 2-8-03; ss by #9860, eff 2-8-11, EXPIRED: 2-8-19

New. #12732, INTERIM, eff 2-22-19, EXPIRED: 8-21-19

New. #12877, eff 9-25-19

He-W 536.08 Payment for Services.

(a) Payment for the services provided to recipients shall be made in accordance with the rates established by the department for the individual services provided in accordance with RSA 161:4, VI(a).

(b) The provider shall submit claims for payment to the department’s fiscal agent.

Source. (See Revision Note at chapter heading He-W 500); ss by #6133, eff 11-30-95; ss by #7825, eff 2-8-03; ss by #9860, eff 2-8-11, EXPIRED: 2-8-19

New. #12732, INTERIM, eff 2-22-19, EXPIRED: 8-21-19

New. #12877, eff 9-25-19

PART He-W 537 RURAL HEALTH CLINICS/FEDERALLY QUALIFIED HEALTH CENTERS

He-W 537.01 Definitions.

(a) “Encounter code” means a procedure code assigned to each provider by the medicaid administration bureau which reflects the individual payment rate and is utilized by the rural health clinic and federally qualified health center service providers for billing purposes.

(b) “Federally qualified health center (FQHC)” means “federally qualified health center” as described in 42 CFR 491, Subpart A, which is located in a rural or urban area that is designated as either a shortage area or an area that has a medically underserved population.

(c) “Hospital based rural health clinic” means “rural health clinic” as described in 42 CFR 491, Subpart A, which is an integral part of a hospital that is participating in medicare, and is licensed, governed, and supervised with other departments of the hospital.

(d) “Independent rural health clinic” means “rural health clinic” as described in 42 CFR 491, Subpart A, which is a freestanding facility not administered by another facility.

(e) “Medically underserved population” means a population of an urban or rural area which ahs a shortage of personal health services as described in 42 CFR 491, Subpart A.

(f) “Rural health clinic (RHC),” means a primary care facility or agency, either independent or hospital based, which is not a rehabilitation agency nor a facility primarily for the care and treatment of mental diseases and which is certified by medicare pursuant to 42 CFR 491, Subpart A.

(g) “Shortage area” means “shortage area” as defined by 1302(7) of the Public Health Services Act.

(h) “Visit” means a face-to-face encounter which takes place on a single day, at a single location, between a recipient and a health professional in a rural health clinic or FQHC.

Source. (See Revision Note at chapter heading He-W 500); ss by #4884, eff 8-1-90, EXPIRED: 8-1-96

New. #6725, eff 4-1-98, EXPIRED: 4-1-06

He-W 537.02 Recipient Eligibility. All medicaid recipients shall be eligible for services delivered by a RHC or FQHC, in accordance with He-W 537.

Source. (See Revision Note at chapter heading He-W 500); ss by #4884, eff 8-1-90, EXPIRED: 8-1-96

New. #6725, eff 4-1-98, EXPIRED: 4-1-06

He-W 537.03 Provider Participation. All participating RHCs and FQHCs shall:

(a) Be composed of licensed and N.H. board certified practitioners;

(b) Be certified to participate in medicare as RHC and FQHC;

(d) Be an enrolled New Hampshire medicaid provider; and

(e) Request and obtain prior authorization from the medicaid administration bureau before providing service which requires prior authorization, as specified in He-W 521.

Source. (See Revision Note at chapter heading He-W 500); ss by #4884, eff 8-1-90, EXPIRED: 8-1-96

New. #6725, eff 4-1-98

He-W 537.04 Service Limits. The individual services which compromise a RHC and a FQHC visit shall be subject to the applicable limits, in accordance with He-W 530.

Source. (See Revision Note at chapter heading He-W 500); ss by #4884, eff 8-1-90, EXPIRED: 8-1-96

New. #6725, eff 4-1-98, EXPIRED: 4-1-06

He-W 537.05 Covered Services.

(a) Covered services for FQHCs and independent RHCs shall include the following outpatient services:

(1) The services of a physician, when the physician has an agreement to be paid by the clinic for such services;

(2) The services of a nurse practitioner, or physician assistant, provided within the scope of his/her training or certification;

(3) The services and supplies that are furnished as incidental to the professional services of a physician, nurse practitioner, or physician assistant;

(4) Laboratory services essential to the immediate diagnosis and treatment of the patient; and

(5) Other ambulatory services provided within the scope of the FQHC or RHC practice.

(b) Covered services for hospital-based RHCs shall include the following outpatient services:

(1) The services of a physician, when the physician has an agreement to be paid by the clinic for such services;

(2) The services of a nurse practitioner, or physician assistant, provided within the scope of his/her training or certification; and

(3) The services and supplies that are furnished as incidental to the professional services of a physician, nurse practitioner, or physician assistant.

Source. (See Revision Note at chapter heading He-W 500); ss by #4884, eff 8-1-90, EXPIRED: 8-1-96

New. #6725, eff 4-1-98, EXPIRED: 4-1-06

He-W 537.06 Utilization Review and Control. The department of health and human services shall monitor utilization of RHC and FQHC services, in accordance with He-W 520.

Source. (See Revision Note at chapter heading He-W 500); ss by #4884, eff 8-1-90, EXPIRED: 8-1-96

New. #6725, eff 4-1-98, EXPIRED: 4-1-06

He-W 537.07 Third Party Liability. All third party obligations shall be exhausted before medicaid may be billed in accordance with He-W 521.

Source. (See Revision Note at chapter heading He-W 500); ss by #4884, eff 8-1-90, EXPIRED: 8-1-96

New. #6725, eff 4-1-98, EXPIRED: 4-1-06

He-W 537.08 Payment for Services.

(a) Payment for the RHC and FQHC services described in He-W 537.05 above shall be made on the basis of an all-inclusive rate per visit.

(b) RHC and FQHC providers shall bill for the services described in He-W 537.05 above utilizing the encounter code assigned by the department of health and human services.

(c) RHC and FQHC providers shall bill for services other than the outpatient RHC/FQHC services described in He-W 537.05 above utilizing the appropriate procedure code listed in the current edition of Current Procedural Terminology.

(d) Recipient encounters with more than one health professional, or multiple encounters with the same health professional, which take place on the same day for the same diagnosis or treatment, shall be counted as one visit.

(e) RHCs and FQHCs shall bill for only one visit per recipient per day, except for cases in which the patient, subsequent to the first visit, suffers an illness or injury requiring additional diagnosis and treatment.

(f) Payment shall be made in accordance with encounter code rates established by the department of health and human services.

(g) Independent RHCs and RQHCs shall submit claims for payment to the department of health and human services’ fiscal agent on form HCFA 1500.

(h) Hospital-based RHCs shall submit claims for payment to the department of health and human services’ fiscal agent on form UB 92, also known as HCFA 1450.

(i) The RHC and FQHC shall maintain supporting records, in accordance with He-W 520.

(j) The form HCFA 1500 in (g) above, and the form UB 92, also know as HCFA 1450 in (h) above, pursuant to 42 CFR 424.32, shall include:

(1) Patient and insured information;

(2) Physician or supplier information; and

(3) Carrier information.

Source. (See Revision Note at chapter heading He-W 500); ss by #4884, eff 8-1-90, EXPIRED: 8-1-96

New. #6725, eff 4-1-98, EXPIRED: 4-1-06

PART He-W 538 CERTIFIED MIDWIFE SERVICES

He-W 538.01 Definitions.

(a) “Department” means the NH department of health and human services.

(b) “Medicaid” means the Title XIX and Title XXI programs administered by the department which makes medical assistance available to eligible individuals.

(c) “Midwifery” means the practice of providing the necessary supervision, care, and advice to women during pregnancy, labor, and the postpartum period, pursuant to RSA 326-D:2, V.

(d) “New Hampshire certified midwife (NHCM)” means a person who is certified to practice midwifery in accordance with RSA 326-D:6.

(e) “Recipient” means any individual who is eligible for and receiving medical assistance under the medicaid program.

(f) “Title XIX” means the joint federal-state program described in Title XIX of the Social Security Act and administered in New Hampshire by the department under the medicaid program.

(g) “Title XXI” means the joint federal-state program described in Title XXI of the Social Security Act and administered in New Hampshire by the department under the medicaid program.

Source. #7657, eff 3-5-02, EXPIRED: 3-5-10

New. #9737, eff 6-25-10; amd by #10139, eff 7-1-12, paras (a), (c), (d), and (g) EXPIRED: 6-25-18; ss by #12783, eff 5-21-19

He-W 538.02 Recipient Eligibility. All recipients shall be eligible for NHCM services, in accordance with this part.

Source. #7657, eff 3-5-02, EXPIRED: 3-5-10

New. #9737, eff 6-25-10, EXPIRED: 6-25-18

New. #12783, eff 5-21-19

He-W 538.03 Provider Participation. All NHCM providers shall:

(a) Be enrolled New Hampshire medicaid providers; and

(b) Be certified to practice midwifery in New Hampshire pursuant to RSA 326-D:6.

Source. #7657, eff 3-5-02, EXPIRED: 3-5-10

New. #9737, eff 6-25-10, EXPIRED: 6-25-18

New. #12783, eff 5-21-19

He-W 538.04 Covered Services. Pursuant to RSA 326-D:2, V, covered NHCM services shall include:

(a) Providing supervision and advice during the recipient's:

(1) Pregnancy;

(2) Labor; and

(3) Postpartum period;

(b) Providing care during the recipient's:

(1) Pregnancy, including:

a. Preventive care;

b. The detection of abnormal conditions of the mother and fetus; and

c. The execution of emergency measures in the absence of medical help;

(2) Labor, including:

a. The conduction of vaginal deliveries on their own responsibility; and

b. The execution of emergency measures in the absence of medical help; and

(3) Postpartum period, including:

a. Preventive care for the mother and newborn;

b. The detection of abnormal conditions of the mother and newborn; and

c. The execution of emergency measures for the mother and newborn in the absence of medical help; and

Source. #7657, eff 3-5-02, EXPIRED: 3-5-10

New. #9737, eff 6-25-10, EXPIRED: 6-25-18

New. #12783, eff 5-21-19

He-W 538.05 Non-Covered Services. Non-covered services shall be those services which a NHCM is not legally recognized to perform, pursuant to RSA 326-D:1, V, including:

(a) Operative obstetrics;

(b) Cesarean sections;

(d) Contraction stress tests;

(e) Treatment to enhance fertility or procreation;

(f) Any artificial, forcible, or mechanical means to assist the delivery; and

(g) Induced abortions.

Source. #7657, eff 3-5-02, EXPIRED: 3-5-10

New. #9737, eff 6-25-10, EXPIRED: 6-25-18

New. #12783, eff 5-21-19

He-W 538.06 Utilization Review and Control.

(a) The department’s provider integrity unit shall monitor utilization of NHCM services to identify, prevent, and correct potential occurrences of fraud, waste, and abuse in accordance with 42 CFR 455, 42 CFR 456, 42 CFR 1001, and He-W 520.

(b) Failure to maintain supporting records in accordance with He-W 520 and He-W 538 shall entitle the department to recoupment of state and federal medicaid payments pursuant to 42 CFR 455, 42 CFR 447, and 42 CFR 456.

Source. #7657, eff 3-5-02, EXPIRED: 3-5-10

New. #9737, eff 6-25-10, EXPIRED: 6-25-18

New. #12783, eff 5-21-19

He-W 538.07 Third Party Liability. All third party obligations shall be exhausted before medicaid shall be billed, in accordance with 42 CFR 433.139.

Source. #7657, eff 3-5-02, EXPIRED: 3-5-10

New. #9737, eff 6-25-10, EXPIRED: 6-25-18

New. #12783, eff 5-21-19

He-W 538.08 Payment for Services.

(a) Payment for services to NHCM’s shall be made in accordance with rates established by the department in accordance with RSA 161:4, VI(a).

(b) The NHCM shall submit claims for payment to the department’s fiscal agent.

(d) All electronic or written documentation shall be legible and written in English.

(e) All NHCM’s shall provide documentation to the department upon request.

Source. #7657, eff 3-5-02, EXPIRED: 3-5-10

New. #9737, eff 6-25-10, EXPIRED: 6-25-18

New. #12783, eff 5-21-19

PART He-W 539 - RESERVED

PART He-W 540 PRIVATE DUTY NURSING SERVICES

He-W 540.01 Definitions.

(a) “Clinically appropriate” means care that is:

(1) Provided in a timely manner and meets professionally recognized standards of acceptable medical care;

(2) Delivered in the appropriate medical setting; and

(3) The least costly of multiple, equally effective alternative treatments or diagnostic modalities.

(b) “Department” means the New Hampshire department of health and human services.

(c) “Medicaid” means the Title XIX and Title XXI programs administered by the department which makes medical assistance available to eligible individuals.

(d) “Order” means a written authorization issued by a licensed practitioner for medications, treatments, recommendations, and referrals, and signed by the licensed practitioner using terms such as authorized by, authenticated by, approved by, reviewed by, or any other term that denotes approval by the licensed practitioner.

(e) Licensed practitioner” means:

(1) Physician;

(2) Physician's assistant;

(3) Advanced practice registered nurse (APRN); or

(4) Any practitioner with diagnostic and prescriptive powers licensed by the appropriate state licensing board.

(f) “Plan of care” means a plan of care prepared in accordance with 42 CFR 484.60.

(g) “Prior authorization agent” means an individual or organization contracted by the department, responsible for reviewing prior authorization requests.

(h) “Private duty nursing (PDN)” means the provision of skilled nursing services for recipients who require more individual and continual skilled nursing observation, judgment, assessment, or interventions than are available from a visiting nurse, in contrast to part-time or intermittent care, such as wound care.

(i) “Reasonable attempt” means such action taken to accomplish the purpose as may be customary, appropriate, and suitable to the circumstances and that is in the best interests of the recipient.

(j) “Recipient” means any individual who is eligible for and receiving medical assistance under the medicaid program.

(k) “Skilled nursing services” means services that are provided by a registered nurse (RN) or a licensed practical nurse (LPN) because the nature of the service is inherently complex or the recipient’s condition is such that the service can be safely and effectively provided only by a licensed nurse in accordance with the nurse practice act, RSA 326-B.

(l) “Title XIX program” means the joint federal-state program described in Title XIX of the Social Security Act (SSA) and administered in New Hampshire by the department under the medicaid program.

(m) “Title XXI” means the joint federal-state program described in Title XXI of the Social Security Act and administered in New Hampshire by the department under the medicaid program.

Source. (See Revision Note at chapter heading He-W 500); ss by #6134, eff 11-30-95, EXPIRED: 11-30-03

New. #8069, eff 4-17-04; ss by #10107, INTERIM, eff
4-17-12, EXPIRES: 10-15-12; amd by #10139, eff 7-1-12; ss by #10186, eff 10-15-12; ss by #13544, eff 1-28-23

He-W 540.02 Recipient Eligibility. All recipients shall be eligible for PDN in accordance with He-W 540 if the recipient:

(a) Requires continual skilled nursing observation, judgment, assessment, or interventions for more than a 2 hour duration which can only be provided by an RN or LPN, to maintain or improve the recipient’s health status; and

(b) Is receiving nursing care under a written plan of care established or approved by the recipient’s physician or other licensed practitioner.

Source. (See Revision Note at chapter heading He-W 500); ss by #6134, eff 11-30-95, EXPIRED: 11-30-03

New. #8069, eff 4-17-04; ss by #10107, INTERIM, eff
4-17-12, EXPIRES: 10-15-12; ss by #10186, eff 10-15-12; ss by #13544, eff 1-28-23

He-W 540.03 Provider Participation. Each participating provider of PDN shall:

(a) Be a home health care provider licensed in accordance with RSA 151:2, and He-P 809;

(b) Require all staff providing PDN to be an RN or an LPN licensed by the state in which the RN or LPN practices;

(c) Request and obtain prior authorization from the department or its prior authorization agent, in accordance with He-W 540.07, before providing PDN; and

(d) Provide to each recipient, or the recipient’s caregiver if the recipient is a minor, the home health care provider’s written grievance policy that includes the phone number of the department’s ombudsman’s office upon the initiation of PDN.

New. #8069, eff 4-17-04; ss by #10107, INTERIM, eff
4-17-12, EXPIRES: 10-15-12; ss by #10186, eff 10-15-12; ss by #10186, eff 10-15-12; ss by #13544, eff 1-28-23

He-W 540.04 Covered Services. PDN shall be a covered service when:

(a) It is part of the recipient’s medical regimen and rendered under the order and general direction of the recipient’s physician or other licensed practitioner;

(b) It is provided in one of the following locations:

(1) The recipient’s home; or

(2) In locations other than the recipient’s home when routine life activities take the recipient outside of the home if the services would have otherwise been provided in the recipient’s home; and

Source. (See Revision Note at chapter heading He-W 500); ss by #6134, eff 11-30-95, EXPIRED: 11-30-03

New. #8069, eff 4-17-04; ss by #10107, INTERIM, eff
4-17-12, EXPIRES: 10-15-12; ss by #10186, eff 10-15-12; ss by #13544, eff 1-28-23

He-W 540.05 Non-covered Services.

(a) PDN shall not be a covered service when the recipient resides in any one of the following:

(1) A nursing facility licensed pursuant to RSA 151:2 and He-P 803;

(2) A hospital licensed pursuant to RSA 151:2 and He-P 802;

(3) An assisted living residence-supported residential health care (ALR-SRHC) facility licensed pursuant to RSA 151:2 and He-P 805;

(4) A private non-medical institution as defined in 42 CFR 434.2, and licensed pursuant to RSA 151:2 and He-P 800;

(5) An intermediate care facility for individuals with intellectual disabilities (ICF/IID) as defined in 42 CFR 440.150; and

(6) An institution for mental diseases (IMD) as defined in 42 CFR 435.1010.

(b) Services that consist only of assistance with activities of daily living or other non-skilled services needed to live at home that do not require a nurse, including but not limited to assistance with grooming, toileting, eating, dressing, getting into or out of a bed or chair, and walking shall not be covered as PDN.

Source. (See Revision Note at chapter heading He-W 500); ss by #6134, eff 11-30-95, EXPIRED: 11-30-03

New. #8069, eff 4-17-04; ss by #10107, INTERIM, eff
4-17-12, EXPIRES: 10-15-12; ss by #10186, eff 10-15-12; ss by #13544, eff 1-28-23

He-W 540.06 Required Documentation. For each recipient, PDN service providers shall maintain complete and timely records as follows:

(a) A written, signed, and dated physician’s or other licensed practitioner’s order for care provided, updated and signed every 60 days, which shall include:

(1) The recipient’s diagnosis, with a description of the severity of the illness or condition; and

(2) A detailed explanation of the medical need for PDN, including:

a. The specific nursing services that are required; and

b. A description of the specific medical complications necessitating PDN;

(b) A nursing assessment with information that supports the need for PDN including, but not limited to, the following:

(1) Recipient identification information including:

a. Recipient name;

b. Medicaid identification number (MID); and

c. Date of birth;

(2) Contact information of the recipient’s parent, guardian, or primary caregiver including addresses and phone numbers;

(3) Private health insurance information including coverage dates;

(4) Information regarding the recipient’s participation in any medicaid program, including medicaid to schools, waiver programs, and licensed nursing assistant (LNA) services, or participation in the special medical services program;

(5) Name and contact information of the recipient’s treating physician or other licensed practitioner, including the primary care physician, and any specialists;

(6) A summary of the recipient's physical and behavioral health status including:

a. A list of the recipient’s current conditions; and

b. A history of the conditions leading to the need for PDN;

(7) An assessment of the recipient’s body systems including a medication profile;

(8) A functional assessment of the recipient’s physical and cognitive status including a list of any durable medical equipment being utilized;

(9) A description of the household make-up including the nature of the household member’s relationship with the recipient and their ability and availability to provide care and support to the recipient;

(10) Information about the recipient’s school participation including the number of hours per week the recipient attends and whether a nurse or aide is available to assist the recipient while at school;

(11) The recipient’s emergency plan in the event that the primary caregiver is unable to provide care; and

(12) Any additional medical or social information, such as family stressors and their impact on the mental and emotional health of the recipient that the recipient wants to provide that supports the need for PDN.

(c) A plan of care documenting the extent of the recipient’s nursing needs, prepared by the PDN service provider, signed and dated by the recipient’s physician or other licensed practitioner, and updated every 60 days in accordance with 42 CFR 484.60(c)(1);

(d) Nurses’ notes that fully document, for each date of service, the provision of services and the care and treatment provided to the recipient, including:

(1) The location of where the care was provided, and the time that the nursing shift began and ended;

(2) A description of each nursing service provided, including the type of nursing service, the time of the service delivery, and the recipient’s response to the service so that an independent reviewer can replicate what happened during the shift;

(3) Details showing that the nursing services are consistent with the care plan and orders of the recipient’s physician or other licensed practitioner;

(4) Any adverse findings and, if so, a plan of action to address those findings; and

(5) The recipient’s progress towards established goals; and

(e) Documentation of a face-to-face encounter between the recipient’s physician or other licensed practitioner and the recipient within 90 days prior to, or within 30 days following the start of, the PDN service provision, as established in 42 USC 1395n of the SSA and in accordance with 42 CFR 440.

Source. (See Revision Note at chapter heading He-W 500); ss by #6134, eff 11-30-95, EXPIRED: 11-30-03

New. #8069, eff 4-17-04; ss by #10107, INTERIM, eff
4-17-12, EXPIRES: 10-15-12; amd by #10139, eff 7-1-12; ss by #10186, eff 10-15-12; ss by #13544, eff 1-28-23

He-W 540.07 Prior Authorization and Review.

(a) All requests for PDN shall require written prior authorization from the department or its prior authorization agent before the recipient receives PDN.

(b) The PDN service provider shall submit a prior authorization request to the department or its prior authorization agent, along with sufficient current medical and psychosocial information to enable the department or its prior authorization agent to evaluate the request and make a determination.

(1) A written, signed, and dated physician’s or other licensed practitioner’s order, as described in He-W 540.06(a);

(2) The nursing assessment, as described in He-W 540.06(b); and

(3) The plan of care, as described in He-W 540.06(c).

(d) If further medical information is necessary, the department or its prior authorization agent shall contact the recipient’s physician, other licensed practitioner, or PDN service provider directly by letter, fax, or telephone and request the additional information.

(e) The department or its prior authorization agent shall determine if PDN is appropriate, and if so, the number of hours authorized and the start and end date of the PDN authorization period, based on an evaluation of the following clinical information provided or gathered in accordance with (b)-(d) above:

(1) The order and direction of the recipient’s physician or other licensed practitioner;

(2) The frequency of the recipient’s need for skilled nursing observation, judgment, assessment, or interventions;

(3) The nursing assessment;

(4) The identified problems and goals in the plan of care; and

(5) For authorization extensions in (o) below, as applicable, the assessment of needs based on the face-to-face nursing visit in (k) and (l) below.

(f) The term of prior authorized services shall be valid for no less than 6 months, unless a shorter term is identified by the practitioner ordering the PDN services, from the start date and may be longer based on the clinical prognosis of the recipient,

(g) Requests for prior authorization shall be denied by the department or its prior authorization agent if, based on the evaluation in (e) above:

(1) Any of the requirements in He-W 540 are not met, including eligibility requirements in He-W 540.02, coverage requirements in He-W 540.04 and 540.05, documentation requirements in He-W 540.06, or prior authorization requirements in He-W 540.07; or

(2) It is determined that:

a. The recipient does not require skilled nursing services;

b. The recipient does not require continual skilled nursing observation, judgment, assessment, or interventions for more than a 2 hour duration; or

c. There are less costly and equally effective alternatives available, such as care provided by alternative providers including personal care attendants, licensed nursing assistants, or homemakers, which will provide the recipient with the same level of service.

(h) If a request for prior authorization is denied by the department or its prior authorization agent, notice of denial shall be forwarded to the recipient, to include:

(1) The reason for, and legal basis of, the denial; and

(2) Information that an administrative appeal on the denial may be requested within 30 calendar days of the date on the notice of the denial, in accordance with He-C 200.

(i) If an initial request for authorization is approved, the department or its prior authorization agent shall issue a temporary initial authorization for a 90-day period.

(j) Notice of the initial authorization in (h) above shall be sent to the recipient and the PDN service provider and include a face-to-face or virtual nursing visit between the department, or its designated party, and the recipient shall be completed within a 90-day period

(k) If the department or its prior authorization agent approves the prior authorization request, then the PDN service provider shall receive notification, which confirms the approval, includes the number of hours authorized and, documents the start and end date of the PDN authorization period.

(l) Within the 90 days in (i) above, and at least once annually for all approved authorization requests, the department or its designated party shall conduct a face-to-face or virtual nursing visit with the recipient in order to:

(1) Assess the recipient’s needs;

(2) Identify other supports in the home;

(3) Verify the clinical appropriateness of the initial authorization or subsequent authorization extensions made based on the clinical evaluation in (e) above; and

(4) Provide education to the recipient.

(m) The face-to-face nursing visit may be conducted in person virtually by electronic means.

(n) The requirements of (i) through (m) above shall not apply to recipients being discharged from any of the locations listed in He-W 540.05(a) when the department has participated in the recipient’s discharge planning, except that the requirements for an annual nursing visit as described in (l) above shall still apply.

(o) The department shall review subsequent authorization requests within 90 days for continued approval.

(p) If the face-to-face or virtual nursing visit confirms the initial authorization was clinically appropriate, the department or its prior authorization agent shall issue notification which confirms the approval, includes the number of hours authorized, and documents the start and end date of the PDN authorization period.

(q) For PDN to extend beyond the authorized duration, the PDN service provider shall request and obtain prior authorization in accordance with this section.

Source. (See Revision Note at chapter heading He-W 500); ss by #6134, eff 11-30-95, EXPIRED: 11-30-03

New. #8069, eff 4-17-04; ss by #10107, INTERIM, eff
4-17-12, EXPIRES: 10-15-12; ss by #10186, eff 10-15-12; ss by #13544, eff 1-28-23

He-W 540.08 Utilization Review and Control.

(a) The department’s program integrity unit shall monitor utilization of PDN, in accordance with 42 CFR 455, 42 CFR 456, 42 CFR 1001 and He-W 520; and

Source. (See Revision Note at chapter heading He-W 500); ss by #6134, eff 11-30-95, EXPIRED: 11-30-03

New. #8069, eff 4-17-04; ss by #10107, INTERIM, eff
4-17-12, EXPIRES: 10-15-12; ss by #10186, eff 10-15-12; ss by #13544, eff 1-28-23

He-W 540.09 Third Party Liability.

(a) All third party obligations shall be exhausted before medicaid shall be billed, in accordance with 42 CFR 433.139.

(b) PDN service providers shall request information from the recipient regarding other insurance coverage.

(c) If other insurance coverage is available, providers shall contact the insurer to verify benefits initially and at least annually thereafter or when the insurance carrier changes.

(d) PDN service providers shall maintain a record of any other insurance verifications in the recipient’s medical record in accordance with He-W 520.

Source. (See Revision Note at chapter heading He-W 500); ss by #6134, eff 11-30-95, EXPIRED: 11-30-03

New. #8069, eff 4-17-04; ss by #10107, INTERIM, eff
4-17-12, EXPIRES: 10-15-12; ss by #10186, eff 10-15-12; ss by #13544, eff 1-28-23

He-W 540.10 Payment for Services.

(a) Payment for PDN shall be made in accordance with rates established by the department in accordance with RSA 161:4, VI(a).

(b) Payments for services billed shall be for direct care only, and shall not include administrative work or travel time.

(d) The provider shall maintain supporting records, in accordance with He-W 520.

Source. (See Revision Note at chapter heading He-W 500); ss by #6134, eff 11-30-95, EXPIRED: 11-30-03

New. #8069, eff 4-17-04; ss by #10107, INTERIM, eff 4-17-12, EXPIRES: 10-15-12; ss by #10186, eff 10-15-12; ss by #13544, eff 1-28-23

PART He-W 541 FAMILY PLANNING SERVICES

He-W 541.01 Definitions.

(a) “Clean claim(s)” means a claim that can be processed without obtaining additional information from the provider or from a third party, including a claim with errors originating in the state’s claims system, but not including a claim from a dispensing provider who is under investigation for fraud or abuse or a claim under review for medical necessity.

(b) “Department” means the New Hampshire department of health and human services.

(c) “Family planning services” means medical services, medical procedures, and pharmaceutical supplies and devices provided by or under the supervision of a physician or other health professional that allow a recipient to prevent or delay pregnancy or to otherwise control family size, and which receive an enhanced match rate of 90% federal match.

(d) “Hysterectomy” means a surgical procedure for the purpose of removing the uterus.

(e) “Institutionalized individual” means an individual who:

(1) Is involuntarily confined or detained under a civil or criminal statute, in a correctional or rehabilitative facility, including a mental hospital or other facility for the care and treatment of mental illness; or

(2) Is confined under a voluntary commitment in a mental hospital or other facility for the care and treatment of mental illness.

(f) “Medicaid” means the Title XIX and Title XXI programs administered by the department which makes medical assistance available to eligible individuals.

(g) “Mentally incompetent individual” means a mentally incompetent individual as defined in 42 CFR 441.251.

(h) “Recipient” means any individual who is eligible for and receiving medical assistance under the medicaid program.

(i) “Sterilization” means any medical procedure, treatment or surgical procedure which is intended to render an individual permanently incapable of reproducing.

(j) “Title XIX program” means the joint federal-state program described in Title XIX of the Social Security Act and administered in New Hampshire by the department under the medicaid program.

(k) “Title XXI” means the joint federal-state program described in Title XXI of the Social Security Act and administered in New Hampshire by the department under the medicaid program.

Source. (See Revision Note at chapter heading He-W 500); ss by #5874, eff 8-1-94; ss by #7329, eff 8-1-00, EXPIRED: 8-1-08

New. #9272, eff 9-19-08; amd by #10139, eff 7-1-12; ss by #12053, eff 11-19-16

He-W 541.02 Recipient Eligibility.

(a) All Medicaid recipients of child bearing age and not known to be pregnant shall be eligible for family planning services, in accordance with He-W 541.

(b) Acceptance of any family planning services shall be voluntary on the part of the recipient and shall not be a prerequisite or impediment to eligibility for any other service or assistance program administered by the department.

Source. (See Revision Note at chapter heading He-W 500); ss by #5874, eff 8-1-94; ss by #7329, eff 8-1-00, EXPIRED: 8-1-08

New. #9272, eff 9-19-08; ss by #12053, eff 11-19-16

He-W 541.03 Provider Participation. All family planning providers shall be:

(a) Licensed by the state in which she or he practices or be a NH certified midwife; and

(b) A New Hampshire enrolled Medicaid provider.

Source. (See Revision Note at chapter heading He-W 500); ss by #5874, eff 8-1-94; ss by #7329, eff 8-1-00, EXPIRED: 8-1-08

New. #9272, eff 9-19-08; ss by #12053, eff 11-19-16

He-W 541.04 Service Limits. Family planning services for recipients shall be subject to the limits described in He-W 530.

Source. (See Revision Note at chapter heading He-W 500); ss by #5874, eff 8-1-94; ss by #7329, eff 8-1-00, EXPIRED: 8-1-08

New. #9272, eff 9-19-08; ss by #12053, eff 11-19-16

He-W 541.05 Covered Services. The following services shall be covered as family planning services only if the items and procedures are clearly provided or performed for family planning purposes:

(a) Physician services, in accordance with He-W 531, certified midwife services in accordance with He-W 538, and advanced practice registered nurse services in accordance with He-W 534;

(b) Contraceptive devices or drugs, both prescription and non-prescription, in accordance with He-W 570;

(c) Pregnancy tests and screening for sexually transmitted diseases only when performed routinely as part of an initial, regular, or follow-up family planning visit; and

(d) Sterilization, in accordance with 42 CFR 441.253 and 42 CFR 441.254, as follows:

(1) The recipient shall be at least 21 years old at the time consent is obtained;

(2) The recipient shall not be a mentally incompetent individual;

(3) The recipient shall not be an institutionalized individual;

(4) The recipient shall voluntarily give informed consent in accordance with the requirements at 42 CFR 441.257 through 42 CFR 441.258;

(5) The provider shall submit the federal health and human services office of management and budget form HHS-687 “Consent for Sterilization” (OMB No. 0937-0166) to the department prior to the department’s payment for the sterilization claim;

(6) At least 30 days, but not more than 180 days, shall have passed between the date of informed consent and the date of sterilization, with the exception of cases of premature delivery or emergency abdominal surgery as described in (7) below; and

(7) A recipient may consent to be sterilized at the time of a premature delivery or emergency abdominal surgery if at least 72 hours have passed since the recipient gave informed consent for the sterilization and, in the case of premature delivery, if the informed consent was given at least 30 days before the expected date of delivery.

Source. (See Revision Note at chapter heading He-W 500); ss by #5874, eff 8-1-94; ss by #7329, eff 8-1-00, EXPIRED: 8-1-08

New. #9272, eff 9-19-08; ss by #12053, eff 11-19-16

He-W 541.06 Non-Covered Services.

(a) The following services shall not be covered as family planning services:

(1) Sterilizations which do not meet the requirements of He-W 541.05(d) above;

(2) Hysterectomies;

(3) Medical, surgical, or pharmaceutical treatment for the purpose of enhancing, promoting or restoring fertility;

(4) Medical procedures performed for medical reasons such as the removal of an IUD due to an infection, diagnostic examination of the cervix or vagina by means of a special microscope, colposcopy, biopsy, or cryotherapy of the cervix or vagina;

(5) Treatment of medical complications caused by, or following, a family planning procedure;

(6) Any medical service, procedure, or pharmaceutical supply or device provided to a recipient who is known to be pregnant; and

(7) Pregnancy and sexually transmitted disease tests, except for those performed as part of an initial or annual family planning examination.

(b) The services in (a)(2) and (a)(4) through (a)(7) above which are non-covered as family planning services shall be covered in accordance with He-W 531, He-W 534, He-W 538, He-W 570, and 42 CFR 441, Subpart F.

Source. (See Revision Note at chapter heading He-W 500); ss by #5874, eff 8-1-94; ss by #7329, eff 8-1-00, EXPIRED: 8-1-08

New. #9272, eff 9-19-08; ss by #12053, eff 11-19-16

He-W 541.07 Co-Payments. In accordance with He-W 570, co-payments for family planning pharmaceutical products shall not be required.

Source. (See Revision Note at chapter heading He-W 500); ss by #5874, eff 8-1-94; ss by #7329, eff 8-1-00, EXPIRED: 8-1-08

New. #9272, eff 9-19-08; ss by #12053, eff 11-19-16

He-W 541.08 Utilization Review and Control. The department’s program integrity unit shall monitor utilization of family planning services to identify, prevent, and correct potential occurrences of fraud, waste, and abuse, in accordance with 42 CFR 455, 42 CFR 447, 42 CFR 456, and He-W 520.

Source. (See Revision Note at chapter heading He-W 500); ss by #5874, eff 8-1-94; ss by #7329, eff 8-1-00, EXPIRED: 8-1-08

New. #9272, eff 9-19-08 (from He-W 541.07); ss by #12053, eff 11-19-16

He-W 541.09 Third Party Liability. All third party obligations shall be exhausted before medicaid shall be billed, in accordance with 42 CFR 433.

Source. (See Revision Note at chapter heading He-W 500); ss by #5874, eff 8-1-94; ss by #7329, eff 8-1-00, EXPIRED: 8-1-08

New. #9272, eff 9-19-08 (from He-W 541.08); ss by #12053, eff 11-19-16

He-W 541.10 Payment for Services.

(a) Rates of payment for family planning services shall be established by the department in accordance with RSA 161:4, VI(a).

(b) The provider shall submit clean claims for payment.

(c) The provider shall maintain supporting records in accordance with He-W 520 and shall keep documentation supporting claims and records necessary to disclose the extent of services the provider furnishes to medicaid recipients in accordance with He-W 520.

Source. #9272, eff 9-19-08 (from He-W 541.09); ss by #12053, eff 11-19-16

PART He-W 542 ABORTION SERVICES - EXPIRED

Source. (See Revision Note at chapter heading He-W 500); ss by #4968, eff 11-7-90, EXPIRED: 11-7-96

PART He-W 543 HOSPITAL SERVICES

He-W 543.01 Definitions.

(a) “Acute care” means those services provided to recipients, other than swing bed patients, in a hospital.

(b) “Budget neutrality factors” means adjustments applied to rate-setting methodology to reduce spending growth.

(c) “Centers for Medicare and Medicaid Services (CMS)” means the division of the federal Department of Health and Human Services that administers medicare, medicaid, the children’s health insurance program, and the health insurance marketplace.

(d) “Day outlier” means those cases for which the actual length of stay exceeds the trim point per diagnosis related group.

(e) “Department” means the New Hampshire (NH) department of health and human services.

(f) “Diagnosis related group (DRG)” means the taxonomy of diagnoses as classified in the medicare DRG classification system which groups hospital inpatient cases according to factors such as principal diagnosis, age, and sex, and assigns a relative weight which represents hospital resource use associated with treatment for the diagnosis, pursuant to 42 CFR 412.60.

(g) “Generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, or the recommendations of physician specialists practicing in relevant clinical areas or of various physician specialty societies.

(h) “Hospital” means any facility providing acute care services, to include acute care rehabilitation services, not operating as a psychiatric hospital or an institution for mental diseases and which provides the inpatient hospital services defined in 42 CFR 440.10.

(i) “In-state hospital” means a hospital which is located within the physical boundaries of NH.

(j) “Medicaid” means the Title XIX and Title XXI programs administered by the department which makes medical assistance available to eligible individuals.

(k) “Medically necessary” means:

(1) For individuals under age 21, reasonably calculated to prevent, diagnose, correct, cure, alleviate, or prevent the worsening of conditions that endanger life, cause pain, result in illness or infirmity, threaten to cause or aggravate a handicap, or cause physical deformity or malfunction, and no other equally effective course of treatment is available or suitable for the early and periodic screening, diagnosis, and treatment services (EPSDT) recipient requesting a medically necessary service; and

(2) For individuals age 21 and over, health care services that a licensed health care provider, exercising prudent clinical judgment, would provide, in accordance with generally accepted standards of medical practice, to a recipient for the purpose of evaluating, diagnosing, preventing, or treating an acute or chronic illness, injury, disease, or its symptoms, and that are:

a. Clinically appropriate in extent, site, and duration, and consistent with the established diagnosis or treatment of the recipient’s illness, injury, disease, or its symptoms;

b. Not primarily for the convenience of the recipient or the recipient’s family, caregiver, or health care provider;

c. No more costly than other items or services which would produce equivalent diagnostic, therapeutic, or treatment results as related to the recipient’s illness, injury, disease, or its symptoms; and

d. Not experimental, investigative, cosmetic, or duplicative in nature.

(l) “Observation services” means services furnished by a hospital on the hospital’s premises, including the use of a bed and periodic monitoring by a hospital’s nursing or other staff, which are reasonable and necessary to evaluate an outpatient’s condition or determine the need for a possible admission to the hospital as an inpatient.

(m) “Out-of-state hospital” means a hospital located outside of NH.

(n) “Recipient” means an individual who is eligible for and receiving medical assistance under the medicaid program.

(o) “Title XIX” means the joint federal-state program described in Title XIX of the Social Security Act and administered in NH by the department under the medicaid program.

(p) “Title XXI” means the joint federal-state program described in Title XXI of the Social Security Act and administered in NH by the department under the medicaid program.

Source. (See Revision Note at chapter heading He-W 500); ss by #5897, eff 9-19-94; amd by #6548, eff 7-26-97; ss by #7399, eff 11-2-00, EXPIRED: 11-2-08

New. #9324, eff 11-21-08; amd by #10139, eff 7-1-12; ss by #12103, eff 2-9-17; amd by #12818, eff 7-1-19; ss by #14384, eff 9-20-25, EXPIRES: 9-20-35

He-W 543.02 Recipient Eligibility. All recipients shall be eligible to receive inpatient and outpatient hospital services in accordance with He-W 543, and within the service limits described in He-W 530.

Source. (See Revision Note at chapter heading He-W 500); ss by #5897, eff 9-19-94, EXPIRED: 9-19-00

New. #7399, eff 11-2-00, EXPIRED: 11-2-08

New. #9324, eff 11-21-08; ss by #12103, eff 2-9-17; ss by #14384, eff 9-20-25, EXPIRES: 9-20-35

He-W 543.03 Provider Participation.

All in-state and out-of-state hospital providers shall:

(a) Be licensed by the department in accordance with RSA 151, or by the relevant state licensing authority in the state within which the provider operates;

(b) Meet medicare participation requirements; and

(1) In-state hospitals shall be enrolled as in-state hospital providers; and

(2) Out-of-state hospitals shall be enrolled as out-of-state hospital providers.

Source. (See Revision Note at chapter heading He-W 500); ss by #5897, eff 9-19-94, EXPIRED: 9-19-00

New. #7399, eff 11-2-00, EXPIRED: 11-2-08

New. #9324, eff 11-21-08; ss by #12103, eff 2-9-17; ss by #14384, eff 9-20-25, EXPIRES: 9-20-35

He-W 543.04 Covered Services.

(a) Covered services shall include those services described in the various service component rules found in He-W 500 which might be provided in a hospital setting as either an inpatient or outpatient hospital service.

(b) Inpatient hospital services shall be covered when those services are rendered:

(1) By or under the direction of a licensed clinician within their scope of practice;

(2) To a recipient who has been admitted to a hospital as an inpatient;

(3) For a continuous period of 24 hours or longer;

(4) By a hospital offering room, board, and professional services; and

(5) By a NH medicaid participating hospital which meets the requirements set forth in He-W 543.03.

(1) As preventive, diagnostic, therapeutic, rehabilitative, emergency, or palliative outpatient services;

(2) Within the service limits set forth in He-W 530;

(3) By or under the direction of a licensed clinician within their scope of practice;

(4) To a recipient who has not been admitted as an inpatient;

(5) For a period of time less than 24 hours; and

(6) By a NH medicaid participating hospital which meets the requirements set forth in He-W 543.03.

(d) Observation services, as defined in He-W 543.01, shall be covered in accordance with He-W 543.04(c), above.

(e) Organ transplant procedures and procurements shall be covered when performed as an inpatient service at an organ transplant facility approved by CMS and in accordance with the requirements and limits in He-W 531.

Source. (See Revision Note at chapter heading He-W 500); ss by #5897, eff 9-19-94, EXPIRED 9-19-00

New. #7399, eff 11-2-00, EXPIRED: 11-2-08

New. #9324, eff 11-21-08 (from He-W 543.04); ss by #12103, eff 2-9-17; ss by #14384, eff 9-20-25 (formerly He-W 543.05), EXPIRES: 9-20-35

He-W 543.05 Non-Covered Services.

(a) Services which are not described in the various service component rules in He-W 500 shall be non-covered in a hospital setting as either inpatient or outpatient hospital services.

(b) Services provided to recipients by psychiatric hospitals or in institutions for mental diseases shall be non-covered services under He-W 543.

Source. (See Revision Note at chapter heading He-W 500); ss by #5897, eff 9-19-94, EXPIRED 9-19-00

New. #7399, eff 11-2-00, EXPIRED: 11-2-08

New. #9324, eff 11-21-08; ss by #12103, eff 2-9-17; ss by #14384, eff 9-20-25 (formerly He-W 543.06), EXPIRES: 9-20-35

He-W 543.06 Readmission to Hospital. A separate payment shall not be made for readmission to any hospital for the same diagnosis if the readmission occurs within 30 days of discharge, except for those cases where the department has determined the readmission was medically necessary as defined in He-W 543.01.

Source. (See Revision Note at chapter heading He-W 500); ss by #5897, eff 9-19-94, EXPIRED 9-19-00

New. #7399, eff 11-2-00, EXPIRED: 11-2-08

New. #9324, eff 11-21-08 (from He-W 543.05); ss by #12103, eff 2-9-17; ss by #12818, eff 7-1-19; ss by #14384, eff 9-20-25 (formerly He-W 543.07), EXPIRES: 9-20-35

He-W 543.07 Transfer of Recipient.

(a) A hospital which transfers or discharges a recipient from a unit in a hospital to the same type of unit in another hospital for continued inpatient hospital services shall be paid 100 percent of the per diem for each day of care, not to exceed the DRG rate, except for rehabilitative cases, which shall be paid in accordance with He-W 543.12(a).

(b) A hospital which transfers or discharges a recipient to a different type of unit in another hospital, or different type of unit within the same hospital for continued inpatient hospital services, shall be paid according to the DRG payment designated for the type of services provided, plus day outlier payments, if applicable.

(c) The receiving hospital which does not transfer a recipient to another hospital shall be paid the DRG rate, plus day outlier payments, if applicable, when the recipient is discharged.

(d) If a recipient is transferred back or readmitted to the original admitting hospital unit for continuing treatment, only one DRG payment, plus day outlier payments if applicable, shall be paid for the combined initial admission and subsequent readmission to that hospital unit.

(e) The hospital unit which receives and then transfers a recipient back to the original admitting hospital unit shall also be considered a transferring hospital and shall be paid in accordance with He-W 543.07(a) or He-W 543.07(b), as applicable, above.

Source. (See Revision Note at chapter heading He-W 500); ss by #5897, eff 9-19-94, EXPIRED 9-19-00

New. #7399, eff 11-2-00, EXPIRED: 11-2-08

New. #9324, eff 11-21-08; ss by #12103, eff 2-9-17; ss by #14384, eff 9-20-25 (formerly He-W 543.08), EXPIRES: 9-20-35

He-W 543.08 Split Eligibility. When a recipient is eligible for only part of a hospital stay, the medicaid payment shall be made at 100 percent of the per diem for each day of care on which the recipient is medicaid eligible, not to exceed the DRG rate, except for rehabilitative cases, which shall be paid in accordance with He-W 543.12(a).

Source. (See Revision Note at chapter heading He-W 500); ss by #5897, eff 9-19-94, EXPIRED 9-19-00

New. #7399, eff 11-2-00, EXPIRED: 11-2-08

New. #9324, eff 11-21-08 (from He-W 543.07); ss by #12103, eff 2-9-17; ss by #14384, eff 9-20-25 (formerly He-W 543.09), EXPIRES: 9-20-35

He-W 543.09 Medicare Participation. For inpatient services, the 60-day lifetime reserve medicare inpatient hospital benefit for medicare-eligible recipients shall be used before medicaid inpatient hospital payments are made.

Source. (See Revision Note at chapter heading He-W 500); ss by #5897, eff 9-19-94, EXPIRED 9-19-00

New. #7399, eff 11-2-00, EXPIRED: 11-2-08

New. #9324, eff 11-21-08 (from He-W 543.08); ss by #12103, eff 2-9-17; ss by #14384, eff 9-20-25 (formerly He-W 543.10), EXPIRES: 9-20-35

He-W 543.10 Utilization Review.

(a) Evaluations of the quality, medical necessity, appropriateness of care, and length of stay determinations for all inpatient hospital services shall be made by the department in accordance with 42 CFR 456.100 and those sections of 42 CFR 456 described therein.

(b) The department’s bureau of program integrity shall monitor utilization of hospital services to identify, prevent, and correct potential occurrences of fraud, waste, and abuse, in accordance with 42 CFR 455, 42 CFR 447, 42 CFR 456, and He-W 520.

Source. (See Revision Note at chapter heading He-W 500); ss by #5897, eff 9-19-94; amd by #6548, eff 7-26-97; ss by #7399, eff 11-2-00; ss by #7558, eff 10-1-01; ss by #9324, eff 11-21-08 (from He-W 543.09); ss by #12103, eff 2-9-17; amd by #12818, eff 7-1-1-19; ss by #14384, eff 9-20-25 (formerly He-W 543.11), EXPIRES: 9-20-35

He-W 543.11 Third Party Liability. All third party obligations shall be exhausted before medicaid may be billed, in accordance with 42 CFR 433.139

Source. #9324, eff 11-21-08 (from He-W 543.10); ss by #12103, eff 2-9-17; ss by #14384, eff 9-20-25 (formerly He-W 543.12), EXPIRES: 9-20-35

He-W 543.12 Payment for Services.

(a) Payment for hospital services shall be made at rates established by the department in accordance with RSA 161:4, VI(a).

(b) Hospital providers shall submit claims for payment to the department’s fiscal agent using the form currently designated and approved by CMS for this purpose.

(c) Hospital providers billing for newborns who do not have their own medicaid identification number shall complete the claim form as follows:

(1) The newborn’s name shall be entered in the patient field;

(2) The medicaid identification number field shall be left blank; and

(3) The mother’s name and medicaid identification number shall be entered in the remarks section.

(d) Payment for inpatient hospital services made for acute care days of stay shall be subject to a post-payment review by the department.

(e) All outpatient hospital services rendered to a medicaid recipient within 3 calendar days prior to their inpatient admission, with a calendar day beginning at 12:00 AM and ending at 11:59 PM, shall be inclusive of the inpatient payment and not be billed separately, with the exception of:

(1) Prenatal outpatient services; and

(2) Diagnostic and nondiagnostic outpatient services that are unrelated to the recipient’s inpatient hospital admission.

Source. #9324, eff 11-21-08 (from He-W 543.11); ss by #12103, eff 2-9-17; amd by #12818, eff 7-1-19; ss by #14384, eff 9-20-25 (formerly He-W 543.13), EXPIRES: 9-20-35

PART He-W 544 HOSPICE SERVICES

REVISION NOTE:

Document #13847, effective 1-6-24, adopted or repealed all of the rules in Part He-W 544 titled “Hospice Services.” Most of the rules had expired, and some rules were subsequently renumbered by Document #13847 when they were adopted again, as indicated in the source notes. The rule He-W 544.08 titled “Discharge from Hospice Care” was new.

Document #13847 repealed the former rule He-W 544.17 titled “Required Forms”. Although it was originally effective 7-1-10 by Document #9726-B, and amended by Document #9867-B, effective 2-11-11, the rule did not expire because, when the rule was adopted and amended, forms were non-expiring pursuant to RSA 541-A:17, II.

He-W 544.01 Definitions.

(a) “Agent” means an adult to whom authority to make health care decisions is delegated under an activated durable power of attorney for health care in accordance with RSA 137-J, or a surrogate decision-maker in accordance with RSA 137-J:35.

(b) “Bereavement counseling” means emotional, psychosocial, and spiritual support and services provided before and after death of the recipient to assist with issues related to grief, loss, and adjustment.

(c) "Care plan" means a written guide developed by the licensee, or its personnel, in consultation with the patient, guardian, agent, or personal representative, if any, as a result of the assessment process for the provision of care and services.

(d) “Continuous home care” means hospice care consisting of primarily nursing care provided by hospice personnel on a continuous basis at home.

(e) “Day” means the 24-hour period starting at 12:00AM and ending at 11:59PM of the same calendar date.

(f) “Department” means the New Hampshire (NH) department of health and human services.

(g) “Dietary counseling” means education and interventions provided to the recipient and family regarding appropriate nutritional intake as the recipient’s condition progresses and provided by qualified individuals including a registered nurse, dietician, or nutritionist, when identified in the recipient’s care plan.

(h) “Election period” means one or more periods for which a recipient may elect to receive medicaid coverage for hospice care during one or more of the following:

(1) An initial 90-day period;

(2) A subsequent 90-day period; or

(3) An unlimited number of subsequent 60-day periods.

(i) “Employee” means:

(1) A person who is hired by a hospice organization;

(2) A person of the agency, if the agency or organization is a subdivision of a hospice organization, who has been appropriately trained and assigned to the hospice unit; or

(3) A volunteer under the jurisdiction of the hospice.

(j) “General inpatient care” means hospice care received in an inpatient facility, for pain control or symptom management, which cannot be managed in other settings.

(k) "Guardian" means a person appointed in accordance with RSA 464-A to make informed decisions relative to the patient’s health care and other personal needs.

(l) "Home hospice care provider (HHCP)” means an agency which provides hospice services to patients and their families in the patient's residence.

(m) “Hospice” means a specialized program of care and supportive services, which provides a combination of medical, social, and spiritual services to terminally ill patients and their families.

(n) “Hospice care” means a comprehensive set of services described in 1861(dd)(1) of the Social Security Act, identified and coordinated by an interdisciplinary group to provide for the physical, psychosocial, spiritual, and emotional needs of a terminally ill patient and family members, as delineated in a specific patient care plan.

(o) “Interdisciplinary group” (IDG) means the team responsible for the holistic care of the hospice recipient.

(p) "License" means the document issued by the department to an applicant at the start of operation as an HHCP which authorizes operation in accordance with RSA 151 and He-P 823, and includes the name of the licensee, the name of the business, the physical address, the license classification, the effective date, and license number.

(q) "Licensed practitioner" means a:

(1) Medical doctor;

(2) Licensed practitioner's assistant;

(3) Advanced practice registered nurse (APRN); or

(4) Any other practitioner with diagnostic and prescriptive powers licensed by the appropriate state licensing board.

(r) “Medicaid” means the Title XIX and Title XXI programs administered by the department which makes medical assistance available to eligible individuals.

(s) “Palliative care” means recipient and family-centered care that optimizes quality of life by anticipating, preventing, and treating suffering. Palliative care throughout the continuum of illness involves addressing physical, intellection, emotional, social, and spiritual needs and to facilitate recipient autonomy, access to information, and choice.

(t) “Quarter” means one of 4 calendar periods ending March 31, June 30, September 30, and December 31.

(u) “Recipient” means any individual who is eligible for and receiving medical assistance under the medicaid program.

(v) “Respite care” means short-term inpatient care provided to the recipient only when necessary to relieve the family members or other persons caring for the recipient.

(w) “Room and board services” includes performance of personal care services, including assistance in the activities of daily living, in socializing activities, administration of medication, maintaining the cleanliness of a resident’s room, and supervision and assistance in the use of durable medical equipment and prescribed therapies.

(x) “Routine home care” means hospice care received at the place of residence and which is not continuous home care as defined in (d) above.

(y) “Terminally ill” means that the recipient has a medical prognosis with a life expectancy of 6 months or less if the illness runs its normal course.

(z) “Title XIX” means the joint federal-state program described in Title XIX of the Social Security Act (SSA) and administered in NH by the department under the medicaid program.

(aa) “Title XXI” means the joint federal-state program described in Title XXI of the Social Security Act (SSA) and administered in NH by the department under the medicaid program.

Source. #9726-A, eff 7-1-10; amd by #10139, eff 7-1-12, EXPIRED 7-1-18 in paragraphs (a)-(k), (m), (n), (o), and (q)-(t), and EXPIRED 7-1-22 in paragraphs (l), (p), (u), and (v).

New. (See Revision Note at part heading for He-W 544) #13847, eff 1-6-24

He-W 544.02 Recipient Eligibility Requirements.

(a) To be eligible to receive hospice care, recipients age 21 and over shall:

(1) Be certified as terminally ill in accordance with He-W 544.06;

(2) Elect hospice care in accordance with He-W 544.04; and

(3) Upon election of hospice care pursuant to (2) above, agree to waive all rights to the following medicaid services:

a. Hospice care provided by a hospice other than the one designated by the recipient, unless provided under arrangements made by the designated hospice;

b. Medicaid services that are:

1. Related to the treatment of the terminal illness for which hospice care was elected;

2. Related to the treatment of a condition or complication related to the terminal illness for which hospice care was elected; or

3. Equivalent to, or duplicative of, hospice services; and

c. Medicaid home and community-based care waiver services that are equivalent to, or duplicative of, hospice services.

(b) To be eligible to receive hospice care, recipients under the age of 21:

(1) Shall be certified as terminally ill in accordance with He-W 544.06;

(2) Shall elect hospice care in accordance with He-W 544.04; and

(3) Shall not, in accordance with 42 U.S.C. 1395d(d)(2), be required to waive rights to medicaid services that are related to treatment of the recipient's condition for which a diagnosis of terminal illness has been made.

(c) A recipient shall not be required to waive rights to the following services, which shall be covered in addition to hospice services:

(1) Services provided by the recipient’s medicaid licensed practitioner if that licensed practitioner is not an employee of the designated hospice or is not receiving compensation from the hospice for those services; and

(2) Room and board services provided by a residential care facility or a nursing facility if the recipient meets the facility’s level of care.

Source. #9726-A, eff 7-1-10; ss by #9867-A, eff 2-11-11, EXPIRED: 2-11-19

New. (See Revision Note at part heading for He-W 544) #13847, eff 1-6-24

He-W 544.03 Provider Participation. Each participating hospice provider shall:

(a) Be medicare certified as a hospice provider;

(b) Be an NH enrolled medicaid provider;

(c) Hold a current NH state license as a home hospice care provider or hospice house in accordance with RSA 151:2 and He-P 823 or He-P 824 or be licensed as such by the state in which they practice; and

(d) Notify the department of a recipient’s discharge from the hospice provider within 5 business days of the discharge.

Source. #9726-A, eff 7-1-10, EXPIRED 7-1-18

New. (See Revision Note at part heading for He-W 544) #13847, eff 1-6-24

He-W 544.04 Election of Hospice Care.

(a) If a recipient seeks to elect hospice care, the hospice provider shall obtain an election statement signed and dated by the recipient or the recipient’s agent or legal guardian.

(b) The election statement obtained by the hospice provider shall:

(1) Specify the hospice provider designated by the recipient to provide care;

(2) Specify the effective date of the election, which shall not be earlier than the date the recipient or the recipient’s agent or legal guardian signs the election statement; and

(3) Specify that by waiving rights in accordance with He-W 544.02(a)(3), the recipient or the recipient’s agent or legal guardian acknowledges that the recipient has been given a full understanding of the explanation of palliative rather than curative nature of hospice care, as it relates to the recipient’s terminal illness.

(c) If a recipient elects hospice care in accordance with (a) and (b) above, the designated hospice provider shall notify the department of the effective date of the election in (b)(2) above, within 5 business days of the election.

(d) All hospice care and services offered to medicaid recipients and their families shall follow an individualized written care plan that meets the recipient’s needs. The hospice interdisciplinary group establishes the care plan together with the attending licensed practitioner, the recipient, or the recipient’s representative, and the primary caregiver.

Source. #9726-A, eff 7-1-10, EXPIRED 7-1-18

New. (See Revision Note at part heading for He-W 544) #13847, eff 1-6-24

He-W 544.05 Hospice Election Periods.

(a) The recipient shall be allowed hospice coverage divided into election periods as follows:

(1) An initial 90-day period;

(2) A subsequent 90-day period; and

(3) An unlimited number of subsequent 60-day periods.

(b) The recertification associated with a hospice patient’s third benefit period, and every subsequent recertification, as referenced in (a)(3) above, shall include documentation that a hospice licensed practitioner or a hospice nurse practitioner had a face-to-face (FTF) encounter with the patient, and that the FTF encounter shall document the clinical findings supporting a life expectancy of 6 months or less.

(c) Election of hospice care in accordance with He-W 544.04 shall be considered to continue through the election periods specified in (a) above without a break in care if the recipient:

(1) Remains in the care of the hospice provider; and

(2) Does not revoke the election under the provisions of He-W 544.09.

Source. #9726-A, eff 7-1-10, EXPIRED 7-1-18

New. (See Revision Note at part heading for He-W 544) #13847, eff 1-6-24

He-W 544.06 Certification of Terminal Illness.

(a) The hospice provider shall obtain certification of terminal illness as follows:

(1) For the first 90-day election period, the hospice provider shall obtain, within 2 calendar days after hospice care is initiated, written certification of terminal illness signed and dated by:

a. The medical director of the hospice provider or the licensed practitioner member of the hospice interdisciplinary group; and

b. The recipient’s medicaid attending licensed practitioner.

(2) For subsequent election periods of coverage specified in He-W 544.05(a)(2) and (3) above, within 2 calendar days after the beginning of each election period, a written certification of terminal illness signed and dated by the medical director of the hospice provider or the licensed practitioner member of the hospice interdisciplinary group;

(3) A hospice licensed practitioner or hospice nurse practitioner shall have a FTF encounter with each hospice recipient whose total stay across all hospices is anticipated to reach the 3rd benefit period. The FTF encounter shall occur prior to, but no more than 30 calendar days prior to, the 3rd benefit period recertification, and every benefit period recertification thereafter, to gather clinical findings to determine continued eligibility for hospice care; and

(4) If the written certification in (a) above cannot be obtained within 2 days, a verbal certification shall be considered acceptable and be:

a. Documented in the recipient’s medical records;

b. Followed by a written certification pursuant to (a)(1) and (2) above prior to submission of claim for payment;

c. Completed no more than 15 calendar days prior to the effective date of election; and

d. Completed no more than 15 calendar days prior to the start of the subsequent benefit period.

(b) A medicaid payment shall be made only after the agency has provided certification in accordance with (a)(1) – (a)(4) above.

Source. #9726-A, eff 7-1-10, EXPIRED 7-1-18

New. (See Revision Note at part heading for He-W 544) #13847, eff 1-6-24

He-W 544.07 Change in Designated Hospice Provider.

(a) The recipient or the recipient’s agent or legal guardian may change the designated hospice provider once in each of the election periods specified in He-W 544.05(a).

(b) The recipient or the recipient’s agent or legal guardian shall provide written notification of a change of the designated provider to the current hospice provider and to the newly designated hospice provider.

(c) The recipient’s current hospice provider shall notify the department within 5 business days of a recipient changing the recipient’s designated hospice provider.

(d) The recipient’s current hospice provider shall forward the following to the newly designated hospice provider:

(1) A copy of the election statement obtained by the current hospice provider in accordance with He-W 544.04; and

(2) A copy of the certification of terminal illness obtained by the current hospice provider in accordance with He-W 544.06.

(e) The newly designated hospice provider shall comply with all requirements of He-W 544.

Source. #9726-A, eff 7-1-10, EXPIRED 7-1-18

New. (See Revision Note at part heading for He-W 544) #13847, eff 1-6-24

He-W 544.08 Discharge from Hospice Care. All medicaid recipients discharged from hospice care shall have a discharge planning process in accordance with 42 CFR 418.26.

Source. (See Revision Note at part heading for He-W 544) #13847, eff 1-6-24

He-W 544.09 Revocation of Hospice Care.

(a) The recipient or the recipient’s agent or legal guardian may revoke the recipient’s election of hospice care at any time in accordance with 42 CFR 418.28.

(b) To revoke the election of hospice care, the following shall occur:

(1) The recipient or the recipient’s agent or legal guardian shall provide a signed and dated written statement of revocation to the recipient’s election of hospice care;

(2) If a signed statement cannot be obtained, a verbal statement shall be obtained, and the date of which shall be documented in the recipient’s medical record; and

(3) If a verbal statement is obtained pursuant to (b) above, then the recipient or the recipient’s agent or legal guardian shall provide the written statement described in (a) above at a later date.

(c) A recipient or the recipient’s agent or legal guardian shall not designate a revocation effective date earlier than the date the revocation is made as allowed in (a) and (b) above.

(d) Within 5 business days of a recipient revoking the recipient’s election of hospice care, the designated hospice shall notify the department of the date that the revocation is to be effective.

(e) Effective with the revocation date specified, the recipient shall no longer be covered under the hospice benefit and shall resume eligibility for all medicaid benefits previously waived pursuant to He-W 544.02(a)(4).

(f) A recipient who revokes the recipient’s election of hospice care shall be eligible to elect hospice care for any remaining election periods in accordance with He-W 544.04.

Source. #9726-A, eff 7-1-10, EXPIRED: 7-1-18

New. (See Revision Note at part heading for He-W 544) #13847, eff 1-6-24 (formerly He-W 544.08)

He-W 544.10 Covered Hospice Services.

(a) The designated hospice provider shall create a care plan for the recipient in accordance with 42 CFR 418.56(c) that specifies the services to be provided to the recipient, which are reasonable and necessary for the palliation or management of the symptoms of the terminal illness and conditions or complications related to the terminal illness.

(b) Services covered as part of the hospice benefit shall include:

(1) Nursing care provided by or under the supervision of a registered nurse;

(2) Medical social services provided by a social worker who has at least a bachelor’s degree from a school accredited or approved by the council on social work education, and licensed practitioner;

(3) The following services performed by hospice licensed practitioner:

a. General supervisory services of the medical director;

b. Participation in the establishment of plans of care, supervision of care and services, periodic review and updating of plans of care, and establishment of governing policies by the licensed practitioner member of the interdisciplinary group; and

c. Licensed practitioner services described in He-W 544.16(b)(2);

(4) Counseling services, including bereavement, spiritual, and dietary counseling, provided to the recipient, family members, and others caring for the recipient for the purpose of training the recipient’s family or caregivers to provide care;

(5) General inpatient care as follows:

a. Such care shall be provided in a medicaid enrolled hospice house, licensed in accordance with RSA 151 and He-P 824, hospital, or nursing facility that meets the requirements in 42 CFR 418.100 (a) and (e) regarding staffing and patient areas; and

b. Care shall be for pain control or symptom management which cannot be provided in another setting;

(6) Inpatient respite care provided to the recipient as follows:

a. Only for recipients who are not residing in a nursing facility;

b. Only when necessary to relieve the family members or other caregivers of caring for the recipient;

c. Not for more than one period of 5 consecutive days at a time per election period, except that the sixth and any subsequent consecutive days shall be covered and paid at the routine home care rate; and

d. Only in those intermediate care facilities that meet the requirements of 42 CFR 418.100 (a) and (e) regarding 24-hour nursing and patient areas;

(7) Durable medical equipment and supplies for self-help and personal comfort related to the palliation or management of the recipient’s terminal illness or conditions related to the terminal illness while the recipient is under hospice care;

(8) Drugs for the palliation and management of the recipient’s terminal illness or conditions related to the terminal illness;

(9) Home health aide and homemaker services;

(10) Physical therapy, occupational therapy, and speech language pathology services for the purpose of symptom control or to enable the recipient to maintain activities of daily living and basic functional skills;

(11) Transportation;

(12) Any other service that is specified in the recipient’s care plan as reasonable and necessary for the palliation and management of the recipient’s terminal illness and related conditions; and

(13) Continuous home care, which shall be:

a. Provided in the community setting of the recipient’s place of residence;

b. Provided only during a period of crisis, which is a period in which a recipient requires continuous care which is primarily nursing care to achieve palliation or management of acute medical symptoms;

c. Provided by a registered nurse or licensed practical nurse, who shall provide care for more than half the period of care; and

d. Only for brief periods of crisis and only as needed to maintain the recipient’s care in the home.

(c) The recipient’s care plan shall include bereavement counseling for the recipient’s family after the recipient’s death.

(d) Bereavement counseling in (c) above shall not be billable to medicaid nor to the recipient’s family.

Source. #9726-A, eff 7-1-10, EXPIRED: 7-1-18

New. (See Revision Note at part heading for He-W 544) #13847, eff 1-6-24 (formerly He-W 544.09)

He-W 544.11 Documentation of Hospice Services.

(a) Documentation of hospice services shall be completed promptly and accurately in accordance with 42 CFR 418.56 (c) and (d).

(b) Hospice providers shall maintain documentation in their records to fully support each claim billed for services.

(d) Within 30 days following the end of each quarter, for each recipient who died within that quarter, hospice providers shall notify the department of hospice service utilization incorporated by reference in He-W 544.12, except for those who are dual-eligible hospice recipients who reside in a nursing facility.

Source. #9726-A, eff 7-1-10, EXPIRED: 7-1-18

New. (See Revision Note at part heading for He-W 544) #13847, eff 1-6-24 (formerly He-W 544.10)

He-W 544.12 Utilization Review and Control. The department’s surveillance and utilization review of subsystems unit shall monitor utilization of hospice services in accordance with 42 CFR 455, 42 CFR 456, He-W 520, and documentation of hospice services as required by He-W 544.

Source. #9726-A, eff 7-1-10, EXPIRED: 7-1-18

New. (See Revision Note at part heading for He-W 544) #13847, eff 1-6-24 (formerly He-W 544.11)

He-W 544.13 Third Party Liability.

(a) All third party obligations shall be exhausted before medicaid shall be billed, in accordance with 42 CFR 433.139.

(b) Recipients who elect or revoke the medicaid hospice benefit shall also elect or revoke the hospice benefit under medicare and other insurance, as applicable.

Source. #9726-A, eff 7-1-10, EXPIRED: 7-1-18

New. (See Revision Note at part heading for He-W 544) #13847, eff 1-6-24 (formerly He-W 544.12)

He-W 544.14 Payment for Hospice Services.

(a) Hospice providers shall submit claims for payment to the department.

(b) Payment for hospice care, with the exception of licensed practitioner services which are paid in accordance with He-W 544.17, shall be at a per diem rate for each day that the recipient is under the care of the hospice provider.

(1) Be determined in accordance with 42 U.S.C. 1395f(i)(1)(C)(ii) and 42 USC 1396a(13)(B); and

(2) Be based upon the level of care as follows:

a. Routine home care;

b. Continuous home care;

c. Inpatient respite care; and

d. General inpatient care.

(d) Payment for inpatient respite care shall be limited to one period of no more than 5 consecutive days in each election period.

(e) Inpatient respite care provided in excess of the 5-day limit per election period shall be paid at the routine home care rate.

(f) If there is a change in designated provider, admission status, or level of care, payment shall be made as follows:

(1) If admission occurs on the same day as discharge, revocation or death, the day shall be considered a hospice care day and the hospice shall be paid in accordance with (c) above;

(2) If the level of care changes, payment shall be made for the new level of care beginning with the day it commences;

(3) If a change of hospice provider occurs, payment shall not be made to the discharging hospice for the day of discharge, but payment shall be made to the newly designated hospice; and

(4) If the recipient is discharged from an inpatient unit, the routine home care rate shall be paid, unless the recipient dies as an inpatient, in which case the general inpatient or respite care rate shall be paid for the discharge date.

(g) If certification is not obtained in accordance with the provisions of He-W 544.06(a) and (b) payment shall not be made for days prior to certification.

(h) Bereavement counseling pursuant to He-W 544.10(c) shall not be billable to medicaid nor to the recipient’s family pursuant to He-W 544.10(d).

Source. #9726-A, eff 7-1-10, EXPIRED: 7-1-18

New. (See Revision Note at part heading for He-W 544) #13847, eff 1-6-24 (formerly He-W 544.13)

He-W 544.15 Hospice Payment Limitations and Adjustments.

(a) Hospice payments for inpatient care shall be limited and paid in accordance with 42 CFR 418.302 (a), (b), (c), and (g).

(b) Hospice payments for inpatient care shall be considered to be interim payments with adjustments made for any payments over the limit.

(c) Hospice providers shall refund any excess reimbursement as determined and requested by the department in accordance with (a) and (b) above.

Source. #9726-A, eff 7-1-10, EXPIRED: 7-1-18

New. (See Revision Note at part heading for He-W 544) #13847, eff 1-6-24 (formerly He-W 544.14)

He-W 544.16 Hospice Payment for Recipients in Nursing Facilities.

(a) No medicaid payments shall be made directly to a residential care or nursing facility.

(b) When hospice services are provided to a recipient residing in a nursing facility, the hospice provider shall:

(1) Bill for, in addition to routine or continuous home care, room, and board; and

(2) Be reimbursed by medicaid at a room and board rate which is, in accordance with 42 U.S.C. 1396d, at least 95% of the per diem rate that would have been paid to the nursing facility for the recipient for the same dates of service under rates established in accordance with He-P 803.

Source. #9726-A, eff 7-1-10, EXPIRED: 7-1-18

New. (See Revision Note at part heading for He-W 544) #13847, eff 1-6-24 (formerly He-W 544.15)

He-W 544.17 Payment for Licensed Practitioners’ Services.

(a) If a recipient’s attending licensed practitioner, who is not an employee of the designated hospice or providing services under arrangement with the designated hospice, provides licensed practitioner services related or unrelated to the treatment of the terminal illness:

(1) These licensed practitioner services shall not be considered as part of the per diem rate described in He-W 544.14; and

(2) The licensed practitioner shall bill for these licensed practitioner services separately and be reimbursed at the regular licensed practitioner services rate in accordance with He-W 531.

(b) If a recipient does not have an attending licensed practitioner at the time of electing the hospice benefit, the medical director of the designated hospice provider or the licensed practitioner member of the hospice interdisciplinary group shall:

(1) Be the recipient’s attending licensed practitioner; and

(2) Bill and receive payment as follows:

a. Licensed practitioner services that are related to the treatment of the terminal illness shall be considered hospice services and be included in the per diem rate described in He-W 544.14; and

b. Licensed practitioner services that are unrelated to treatment of the terminal illness shall be considered licensed practitioner services and shall be billed separately by the licensed practitioner and be reimbursed at the regular licensed practitioner services rate in accordance with He-W 531. These services shall not be billed by the hospice provider.

(c) If a recipient’s attending licensed practitioner, who is not an employee of the designated hospice or providing services under arrangement with the designated hospice, requests through an order that the medical director or hospice licensed practitioner provide licensed practitioner services not described in He-W 544.10 these licensed practitioner services shall be billed as in (a)(1) and (a)(2) above.

Source. #9726-A, eff 7-1-10, EXPIRED: 7-1-18

New. (See Revision Note at part heading for He-W 544) #13847, eff 1-6-24 (formerly He-W 544.16)

PART He-W 545 – RESERVED

PART He-W 546 EARLY AND PERIODIC SCREENING, DIAGNOSIS, AND TREATMENT SERVICES

He-W 546.01 Definitions.

(a) “Department” means the New Hampshire (NH) department of health and human services.

(b) “Early and periodic screening, diagnosis and treatment (EPSDT) services” means a program, as defined in 42 CFR 440.40(b), designed to provide preventative health care, diagnostic services, and early detection and treatment of disease or abnormalities to medicaid eligible individuals under age 21.

(c) “Medicaid” means the Title XIX and Title XXI programs administered by the department which makes medical assistance available to eligible individuals.

(d) “Medical” means related to the following:

(1) Treatment of disease;

(2) Maintenance of health; or

(3) Prevention, alleviation, or curing of disease.

(e) “Medically necessary” means reasonably calculated to prevent, diagnose, correct, cure, alleviate, or prevent the worsening of conditions that endanger life, cause pain, result in illness or infirmity, threaten to cause or aggravate a handicap, or cause physical deformity or malfunction, and no other equally effective course of treatment is available or suitable for the EPSDT recipient .

(f) “Periodicity schedule” means a regularly recurring schedule of preventive health care, dental care, or screening services as determined by standards of practice.

(g) “Primary care physician” means the physician who routinely provides health care to the recipient.

(h) “Recipient” means an individual who is eligible for and is receiving medical assistance under the medicaid program.

(i) “Title XIX program” means the joint federal-state program described in Title XIX of the Social Security Act and administered in NH by the department under the medicaid program.

(j) “Title XXI” means the joint federal-state program described in Title XXI of the Social Security Act and administered in NH by the department under the medicaid program.

(k) “Treating physician” means the physician who is managing a present illness or condition, in conjunction with or aside from the recipient’s primary care physician.

Source. (See Revision Note at chapter heading He-W 500); ss by #5532, eff 12-17-92, EXPIRED: 12-17-98

New. #6940, eff 1-30-99; ss by #8782, eff 1-1-07; amd by #10139, eff 7-1-12; ss by #10829, eff 5-19-15; ss by #14383, eff 9-20-25, EXPIRES: 9-20-35

He-W 546.02 Recipient Eligibility. All recipients under the age of 21 shall be eligible for EPSDT services.

Source. (See Revision Note at chapter heading He-W 500); ss by #5532, eff 12-17-92, EXPIRED: 12-17-98

New. #6940, eff 1-30-99; ss by #8782, eff 1-1-07; ss by #10829, eff 5-19-15; ss by #14383, eff 9-20-25, EXPIRES: 9-20-35

He-W 546.03 Provider Participation. All participating EPSDT providers shall:

(a) Meet the state licensing or board certification requirements, of the state in which they practice, to provide medical or dental care;

(b) Be a NH enrolled medicaid provider;

(d) Request and obtain prior authorization from the department before providing services which require prior authorization, in accordance with He-W 530 and He-W 546.06.

Source. (See Revision Note at chapter heading He-W 500); ss by #5532, eff 12-17-92, EXPIRED: 12-17-98

New. #6940, eff 1-30-99; ss and moved by #8782, eff 1-1-07 (from He-W 546.04); ss by #10829, eff 5-19-15; ss by #14383, eff 9-20-25, EXPIRES: 9-20-35

He-W 546.04 Informing Requirements. The department shall carry out the informing requirements specified in 42 CFR 441.56 as follows:

(a) The department or its designee shall inform all pregnant women and children who are eligible for a medicaid program, or the parent(s) or legal representative(s) of eligible children, about EPSDT services within 60 days of the individual’s initial eligibility determination for a medicaid program, and, in the case of families which have not utilized EPSDT services, annually thereafter, pursuant to 42 CFR 441.56(a)(4);

(b) The department or its designee shall complete the requirements set out in this section through written communications, oral communications, or any combination of both; and

(c) The department or its designee shall provide to recipients, or their parent(s) or legal representative(s), information about:

(1) The services available under the EPSDT program;

(2) The location of, and the requirements to obtain and use, the health care or dental services available under the EPSDT program;

(3) The benefits of preventative health and dental care;

(4) The availability of medicaid payment for medical and dental services provided under the EPSDT program;

(5) The existence of other medical or social agencies available to assist a recipient, or to which a recipient might be referred, such as the department’s bureau of maternal and child health services or bureau of special medical services;

(6) The availability of assistance in locating and accessing medical and dental services, upon request; and

(7) The availability of assistance with scheduling of medical or dental appointments and obtaining transportation, upon request.

Source. (See Revision Note at chapter heading He-W 500); ss by #5532, eff 12-17-92, EXPIRED: 12-17-98

New. #6940, eff 1-30-99; ss and moved by #8782, eff 1-1-07 (from He-W 546.03); ss by #10829, eff 5-19-15; ss by #14383, eff 9-20-25, EXPIRES: 9-20-35

He-W 546.05 Covered Services.

(a) The department shall cover the following EPSDT screening services:

(1) Comprehensive and age-appropriate medical assessments and screenings of a child’s physical and mental status in accordance with the American Academy of Pediatrics’ 2023 periodicity schedule entitled “Recommendations for Preventive Pediatric Health Care”, available as noted in Appendix A, including:

a. Comprehensive health and developmental history;

b. Comprehensive unclothed physical examination;

c. Developmental and behavioral assessment with a standardized validated tool of the provider’s choice;

d. Measurements of the child’s height, weight, head circumference, and blood pressure;

e. Appropriate immunizations;

f. Appropriate laboratory tests to include:

1. Testing for lead toxicity for EPSDT eligible children at 12 and 24 months of age; and

2. Testing for lead toxicity for EPSDT eligible children between 36 and 72 months of age, if not previously screened for lead toxicity;

g. Appropriate vision testing;

h. Appropriate hearing testing;

i. Assessment of nutritional status;

j. Health education about the benefits of healthy lifestyles and practices; and

k. Anticipatory guidance about child safety and injury prevention; and

(2) Dental screening services furnished by direct referral to a dentist for diagnosis and treatment, and in accordance with the periodicity schedule contained in the American Academy of Pediatric Dentistry’s “Periodicity of Examination, Preventive Dental Services, Anticipatory Guidance/Counseling, and Oral Treatment for Infants, Children, and Adolescents” (2022 revision), available as noted in Appendix A.

(b) The department shall cover EPSDT diagnostic and treatment services, if medically necessary as a result of assessment and screening.

(c) Any services not listed in He-W 522 through He-W 589 as covered services, including experimental or investigational services which are medically necessary and given prior authorization, shall be given independent review by the department for coverage based on medical necessity in accordance with He-W 546.06.

(d) Transportation services, pursuant to He-W 574, 42 CFR 431.53, and 42 CFR 441.62, shall be covered:

(1) For EPSDT-eligible children;

(2) For any person who needs to accompany an eligible child to the child’s medical service; and

(3) If a child is receiving residential or facility-based care, for a parent, family member, or caregiver if their presence is necessary to actively participate in the treatment or intervention for the direct benefit of the child, without the child present.

(e) Services in excess of the service limits in He-W 530 shall be covered for EPSDT-eligible children, if medically necessary, in accordance with the requirements in He-W 546.06.

Source. (See Revision Note at chapter heading He-W 500); ss by #5532, eff 12-17-92, EXPIRED: 12-17-98

New. #6940, eff 1-30-99; ss by #8437, eff 9-24-05; ss by #8782, eff 1-1-07; ss by #10829, eff 5-19-15; ss by #14383, eff 9-20-25, EXPIRES: 9-20-35

He-W 546.06 Prior Authorization for Coverage Based on Medical Necessity.

(a) Prior authorization shall be required for services described in He-W 546.05(c) and (e).

(b) Requests for prior authorization shall include the following:

(1) The recipient’s name, address, and medicaid identification number;

(2) The recipient’s diagnosis and prognosis, including an indication of whether the diagnosis is a pre-existing condition or a presenting condition;

(3) An estimation of the effect on the recipient if the requested service is not provided;

(4) The medical justification for the services or equipment being requested;

(5) The recommended timetable of the prescribed treatment;

(6) A discussion of why the service is medically necessary as defined in He-W 546.01;

(7) The expected outcome of providing the requested service;

(8) The recommended timeframe to achieve the expected outcome;

(9) A summary of any previous treatment plans, including outcomes, which were used to treat the diagnosed condition for which the requested service is being recommended;

(10) Listings of individuals or agencies to whom the recipient is being referred; and

(11) Assurance that the requested service is the least restrictive, most cost-effective service available to meet the recipient’s needs.

(c) Requests for prior authorization shall include a statement signed by a provider acting within their scope of practice indicating that they concur with the request.

(d) Prior authorizations for coverage of services requested in accordance with He-W 546.06 shall be approved by the department if the department determines that the information provided in (b) above demonstrates medical necessity.

(e) Confirmation of department approvals shall be sent to the treating provider in writing.

(f) Providers shall be responsible for determining that the recipient is medicaid eligible on the date of service.

(g) If the requested service is denied, or denied in part, by the department, the department shall forward a notice of denial to the recipient and the treating provider with the following information:

(1) The reason for, and the legal basis of, the denial; and

(2) Instructions that a fair hearing on the denial may be requested by the recipient within 30 calendar days of the date on the notice of the denial, in accordance with He-C 200.

(h) Decisions made by the department in accordance with (d) and (g) above shall not be superseded by the treating or consultative provider’s prescription, orders, or recommendations.

Source. (See Revision Note at chapter heading He-W 500); ss by #5532, eff 12-17-92, EXPIRED: 12-17-98

New. #6940, eff 1-30-99; ss by #8782, eff 1-1-07; ss by #10829, eff 5-19-15; ss by #14383, eff 9-20-25, EXPIRES: 9-20-35

He-W 546.07 Support Services. The department shall provide support services to enhance recipients’ participation in the EPSDT program, including, but not limited to:

(a) Inter- or intra-departmental coordination of programs;

(b) Providing information to recipients about other available community services;

(c) Making recipient referrals to human service agencies or social services, as requested by the recipient or as appropriate; and

(d) Assisting the recipient with accessing health care or dental services.

Source. (See Revision Note at chapter heading He-W 500); ss by #5532, eff 12-17-92, EXPIRED: 12-17-98

New. #6940, eff 1-30-99; ss by #8782, eff 1-1-07; ss by #10829, eff 5-19-15; ss by #14383, eff 9-20-25, EXPIRES: 9-20-35

He-W 546.08 Non-Covered Services.

(a) The following services shall not be covered:

(1) Any service for which there is no medical necessity or for which the medical necessity has not been established;

(2) Services which are not medical or dental in nature, except that transportation shall be covered in accordance with He-W 546.05(d);

(3) Services that have not been proven to be safe or effective, as documented in medical peer review literature; and

(4) Services which are more costly than other services which could be expected to provide the recipient with the same outcome.

(b) Services listed in He-W 522 through He-W 589 as non-covered services shall not be covered unless the service is determined to be medically necessary for the recipient pursuant to He-W 546.06.

Source. (See Revision Note at chapter heading He-W 500); ss by #5532, eff 12-17-92, EXPIRED: 12-17-98

New. #6940, eff 1-30-99; ss by #8782, eff 1-1-07; ss by #10829, eff 5-19-15; ss by #14383, eff 9-20-25, EXPIRES: 9-20-35

He-W 546.09 Utilization Review and Control.

(a) The department’s bureau of program integrity shall monitor utilization of EPSDT services to identify, prevent, and correct potential occurrences of fraud, waste, and abuse, in accordance with 42 CFR 455, 42 CFR 456, and He-W 520.

Source. (See Revision Note at chapter heading He-W 500); ss by #5532, eff 12-17-92, EXPIRED: 12-17-98

New. #6940, eff 1-30-99; ss by #8782, eff 1-1-07; ss by #10829, eff 5-19-15; ss by #14383, eff 9-20-25, EXPIRES: 9-20-35

He-W 546.10 Third Party Liability.

(a) All third party obligations shall be exhausted before medicaid is billed, in accordance with 42 CFR 433.139, except as noted in (b) below.

(b) The following services shall be exempt from third party billing requirements:

(1) Services provided to children who are covered by third party liability enforced by the department’s bureau of child support services; and

(2) All preventive pediatric care services, in accordance with 42 CFR 433.139(b)(3)(i).

(c) Providers may bill medicaid directly for the services described in (b) above and medicaid shall then seek reimbursement from the third party.

Source. (See Revision Note at chapter heading He-W 500); ss by #5532, eff 12-17-92, EXPIRED: 12-17-98

New. #6940, eff 1-30-99; ss by #8782, eff 1-1-07; ss by #10829, eff 5-19-15; ss by #14383, eff 9-20-25, EXPIRES: 9-20-35

He-W 546.11 Payment for Services.

(a) Payment for services provided to recipients participating in the EPSDT program shall be made in accordance with rates established by the department in accordance with RSA 161:4, VI(a).

(b) The provider shall submit claims for payment to the department’s fiscal agent.

(d) Payment for transportation services pursuant to He-W 546.05(d) shall be made in accordance with He-W 574.

Source. (See Revision Note at chapter heading He-W 500); ss by #5532, eff 12-17-92, EXPIRED: 12-17-98

New. #6940, eff 1-30-99; ss by #8782, eff 1-1-07; ss by #10829, eff 5-19-15; ss by #14383, eff 9-20-25, EXPIRES: 9-20-35

PART He-W 547 HOME VISIT FOR POSTPARTUM AND NEWBORN ASSESSMENT

He-W 547.01 Definitions.

(a) “Department” means the New Hampshire (NH) department of health and human services.

(b) “Health promotion and anticipatory guidance” means services provided by a registered nurse (RN) to a newborn’s parent or guardian within 60 days of the newborn’s birth in accordance with He-W 547.04(c).

(c) “Home visit for postpartum and newborn assessment (home visit) services” means the services rendered to newborns and their birth mothers, at their residence, within 60 days of the newborn’s birth, in accordance with He-W 547.04.

(d) “Maternal postpartum assessment” means services provided by an RN to a woman within 60 days postpartum, in accordance with He-W 547.04(b).

(e) “Medicaid” means the Title XIX and Title XXI programs administered by the department, which makes medical assistance available to eligible individuals.

(f) “Newborn health assessment” means the services provided by an RN to a newborn within 60 days of birth, which includes a determination of whether or not the newborn’s health is within normal limits, in accordance with He-W 547.04(a).

(g) “Recipient” means an individual who is eligible for and receiving medical assistance under the medicaid program.

(h) “Title XIX” means the joint federal-state program described in Title XIX of the Social Security Act and administered in NH by the department under the medicaid program.

(i) “Title XXI” means the joint federal-state program described in Title XXI of the Social Security Act and administered in NH by the department under the medicaid program.

Source. (See Revision Note at chapter heading He-W 500); ss by #6018, eff 4-1-95, EXPIRED: 4-1-03

New. #8446, eff 10-7-05; amd by #10139, eff 7-1-12; ss by #10428, eff 10-7-13; ss by #14334, eff 8-1-25, EXPIRES: 8-1-35

He-W 547.02 Recipient Eligibility. Recipients who are within 60 days postpartum shall be eligible for home visit services.

Source. (See Revision Note at chapter heading He-W 500); ss by #6018, eff 4-1-95, EXPIRED: 4-1-03

New. #8446, eff 10-7-05; ss by #10428, eff 10-7-13; ss by #14334, eff 8-1-25, EXPIRES: 8-1-35

He-W 547.03 Provider Participation. All providers of home visit services shall:

(a) Be licensed as a home health care provider by the department’s health facilities administration in accordance with RSA 151:2, I(b) and He-P 809;

(b) Be a NH enrolled medicaid provider;

(d) Require the RNs in (c) above to have one year of maternal and child health care experience which may have included community health experience.

Source. (See Revision Note at chapter heading He-W 500); ss by #6018, eff 4-1-95, EXPIRED: 4-1-03

New. #8446, eff 10-7-05; ss by #10428, eff 10-7-13; ss by #14334, eff 8-1-25, EXPIRES: 8-1-35

He-W 547.04 Covered Services. The following services shall be covered when provided during a home visit:

(a) Newborn health assessment of the:

(1) Skin, including color, condition, and birthmarks;

(2) Head, including fontanelles;

(3) Neck, including mobility;

(4) Eyes, including appearance, movement, and evidence of sight;

(5) Ears, including evidence of hearing;

(6) Nose, including patency and septum;

(7) Mouth, including lips, mucosa, palate, and gums;

(8) Chest and lungs, including appearance, respiration, auscultation, and breasts;

(9) Heart, including rate and rhythm;

(10) Abdomen, including appearance, palpation, umbilicus, and femoral pulses;

(11) Skeleton, including upper and lower structure, and range of upper and lower motion;

(12) Genitourinary system, including genitalia, urine stream, and circumcision;

(13) Back, including spine and anus;

(14) Neurological and behavioral systems, including general appearance, cry, motor system, reflexes, and signs and symptoms of neonatal abstinence syndrome; and

(15) Weight;

(b) Maternal postpartum assessment services including:

(1) A determination of whether the following health characteristics and functions are within normal limits:

a. Diet;

b. Rest, activity, and exercise;

c. Breast feeding;

d. Abdominal cramping and tenderness;

e. Urinating and bowels;

f. Emotional response, including postpartum depression screening;

g. Bonding;

h. General appearance;

i. Blood pressure;

j. Temperature;

k. Heart and lungs;

l. Breasts and nipples;

m. Abdomen and fundus;

n. Perineum and episiotomy;

o. Lochia;

p. Wound care and healing; and

q. Substance use, including:

1. Alcohol;

2. Tobacco; and

3. Illicit and illegal drug use;

(2) Postpartum education including, but not limited to:

a. Family planning;

b. Breast care;

c. Hygiene;

d. Sexuality;

e. Perineal care for stitches and hemorrhoids;

f. Psychological adjustment and postpartum depression;

g. Exercising;

h. Sleep safety measures as recommended by the American Academy of Pediatrics; and

i. Reactions to medications and vaccinations;

(3) The provision of referrals to other community agencies as appropriate, including, but not limited to:

a. The special supplemental nutrition program for women, infants, and children (WIC);

b. Mental health services;

c. Domestic violence resources;

d Breastfeeding support;

e. The department’s home visiting programs for continued support;

f. Local family resource centers; and

g. Safe transportation programs to include car seat fitting; and

(4) The discussion of other health, social, or environmental concerns; and

(1) Nutrition, including:

a. Breastfeeding;

b. Preparation and storage of formula;

c. Feeding problems; and

d. Supplements;

(2) Behavioral issues, including:

a. Crying patterns;

b. Colic;

c. Consolability;

d. Sleep patterns;

e. Elimination; and

f. Individuality;

(3) Family relationships and interactions, including:

a. Parent or guardian to child;

b. Sibling rivalry;

c. Parent or guardian to parent or guardian; and

d. Relatives;

(4) Safety and injury prevention, including:

a. Home environment;

b. Use and placement of an appropriate infant car seat;

c. Poison control;

d. Safe water temperature;

e. Drowning;

f. Falling;

g. Crib safety, including safe sleeping environment;

h. Pets;

i. Sleep positioning and current safe sleep practices;

j. Choking;

k. Younger siblings;

l. Abusive head trauma, including shaken baby syndrome; and

m. Sudden infant death syndrome (SIDS) risk prevention and sudden unexplained infant death (SUID) safe sleep initiatives;

(5) Resources, including:

a. The special supplemental nutrition program for women, infants, and children (WIC);

b. Family planning programs;

c. Respite care;

d. Support from family and friends;

e. Mental health services;

f. Domestic violence programs;

g. Breastfeeding support services;

h. Home visiting programs for continued support;

i. Family resource centers, and

j. Programs that assist with car seat selection and fitting;

(6) Health promotion and related concerns, including:

a. Immunizations;

b. Rashes and jaundice;

c. When to call the child’s primary health care provider for advice and concerns;

d. The importance of keeping appointments with the primary health care provider for the child’s health check-ups, in accordance with the recommendations set forth in the American Academy of Pediatrics’, “Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents,” (4th edition, February 2017), available as noted in Appendix A;

e. The medicaid program and the importance of maintaining continued medicaid coverage through the child’s first birthday;

f. Bathing and skin care;

g. Urinary tract infections;

h. Temperature taking;

i. The care of the umbilical cord and circumcision; and

j. Oral health care and the importance of bringing the child for their first dental visit with a dental provider no later than the child’s first birthday, in accordance with the periodicity schedule contained in the American Academy of Pediatric Dentistry’s, “Periodicity of Examination, Preventive Dental Services, Anticipatory Guidance/Counseling, and Oral Treatment for Infants, Children, and Adolescents”, (2022 revision), available as noted in Appendix A;

(7) Identifying if the newborn is at risk for, or has, a nutritional problem or unstable housing;

(8) Ensuring follow-up appointments are scheduled with their primary health care providers; and

(9) Information regarding early and periodic screening, diagnosis, and treatment services, as described in He-W 546.

Source. (See Revision Note at chapter heading He-W 500); ss by #6018, eff 4-1-95, EXPIRED: 4-1-03

New. #8446, eff 10-7-05; ss by #10428, eff 10-7-13; ss by #14334, eff 8-1-25, EXPIRES: 8-1-35

He-W 547.05 Non-Covered Services.

(a) Medical services covered under the NH medicaid program pursuant to He-W 530 through He-W 590 and He-M 400 through He-M 700 shall not be covered as part of a home visit.

(b) If during the home visit a medical necessity for other services is assessed, those services shall be billed separately from the home visit service.

Source. (See Revision Note at chapter heading He-W 500); ss by #6018, eff 4-1-95, EXPIRED: 4-1-03

New. #8446, eff 10-7-05; ss by #10428, eff 10-7-13; ss by #14334, eff 8-1-25, EXPIRES: 8-1-35

He-W 547.06 Required Documentation.

(a) Providers shall document home visit referrals in the recipient’s medical record.

(b) Providers conducting home visits shall document the results of newborn health assessments, health promotion, and anticipatory guidance, describing the assessment results and the provision of the services provided, and report them to the child’s primary health care provider within 5 business days of the home visit.

(c) Providers conducting home visits shall document the results of the maternal postpartum assessments, describing the assessment results, and report the results to the mother’s primary health care provider or obstetrics and gynecology provider within 5 business days of the home visit.

Source. (See Revision Note at chapter heading He-W 500); ss by #6018, eff 4-1-95, EXPIRED: 4-1-03

New. #8446, eff 10-7-05; ss by #10428, eff 10-7-13; ss by #14334, eff 8-1-25, EXPIRES: 8-1-35

He-W 547.07 Utilization Review and Control. The department’s bureau of program integrity shall monitor utilization of home visit services to identify, prevent, and correct potential occurrences of fraud, waste, and abuse in accordance with 42 CFR 455, 42 CFR 456, and He-W 520.

Source. (See Revision Note at chapter heading He-W 500); ss by #6018, eff 4-1-95, EXPIRED: 4-1-03

New. #8446, eff 10-7-05; ss by #10428, eff 10-7-13; ss by #14334, eff 8-1-25, EXPIRES: 8-1-35

He-W 547.08 Third Party Liability.

(a) All third party obligations shall be exhausted before medicaid may be billed, in accordance with 42 CFR 433.139.

(b) Home visit service providers shall request information from the recipient regarding other insurance coverage.

(d) Home visit service providers shall maintain a record of any other insurance verifications in the recipient’s medical record in accordance with He-W 520.

Source. (See Revision Note at chapter heading He-W 500); ss by #6018, eff 4-1-95, EXPIRED: 4-1-03

New. #8446, eff 10-7-05; ss by #10428, eff 10-7-13; ss by #14334, eff 8-1-25, EXPIRES: 8-1-35

He-W 547.09 Payment for Services.

(a) Payment rates of home visit services shall be established by the department in accordance with RSA 161:4, VI(a).

(b) Home visit service providers shall submit claims for payment to the department’s fiscal agent.

(d) The department shall recoup state and federal medicaid payments as permitted by 42 CFR 455, 42 CFR 447, and 42 CFR 456 for a provider’s failure to maintain supporting records of services and screening of all employees in accordance with He-W 547.

Source. (See Revision Note at chapter heading He-W 500); ss by #6018, eff 4-1-95, EXPIRED: 4-1-03

New. #8446, eff 10-7-05; ss by #10428, eff 10-7-13; ss by #14334, eff 8-1-25, EXPIRES: 8-1-35

PART He-W 548 EXTENDED SERVICES TO PREGNANT WOMEN

He-W 548.01 Definitions.

(a) “Department” means the New Hampshire department of health and human services.

(b) “Extended services” means services rendered to pregnant and postpartum women in addition to routine medical prenatal and postpartum care with the purpose of improving birth outcomes and parenting skills.

(c) “Medicaid” means the Title XIX and Title XXI programs administered by the department, which makes medical assistance available to eligible individuals.

(d) “Postpartum period” means the period that begins on the last day of pregnancy and extends through the end of the month in which the 60-day period following termination of pregnancy ends.

(e) “Recipient” means any individual who is eligible for and receiving medical assistance under the medicaid program.

(f) “Title XIX” means the joint federal-state program described in Title XIX of the Social Security Act and administered in New Hampshire by the department under the medicaid program.

(g) “Title XXI” means the joint federal-state program described in Title XXI of the Social Security Act and administered in New Hampshire by the department under the medicaid program.

Source. (See Revision Note at chapter heading He-W 500); ss by #5578, eff 2-11-93; ss by #6939, Interim, eff. 1-30-99, EXPIRED 5-30-99

New. #7036, eff 6-25-99; ss by #8904, eff 6-25-07; amd by #10139, eff 7-1-12; ss by #10914, eff 8-26-15

He-W 548.02 Recipient Eligibility. All medicaid recipients shall be eligible for extended services during pregnancy and through the postpartum period.

Source. (See Revision Note at chapter heading He-W 500); ss by #5578, eff 2-11-93; ss by #6939, Interim, eff. 1-30-99, EXPIRED 5-30-99

New. #7036, eff 6-25-99; ss by #8904, eff 6-25-07; ss by #10914, eff 8-26-15

He-W 548.03 Provider Participation. All providers of extended services shall:

(a) Be under current contract obligation with the maternal and child health section, division of public health services as a prenatal program or as a primary care agency providing prenatal care; and

(b) Be a NH enrolled medicaid provider.

Source. (See Revision Note at chapter heading He-W 500); ss by #5578, eff 2-11-93; ss by #6939, Interim, eff. 1-30-99, EXPIRED 5-30-99

New. #7036, eff 6-25-99; ss by #8904, eff 6-25-07; ss by #10914, eff 8-26-15

He-W 548.04 Covered Services. The following services shall be covered, rendered singularly or in any combination during a calendar month, and in accordance with the recipient’s plan of care:

(a) Social services including:

(1) An initial assessment;

(2) Assisting the recipient in identifying her ongoing needs and referring her to appropriate services; and

(3) Home visits;

(b) Care coordination between a recipient and any other individuals or agencies involved in the recipient’s care, including:

(1) Communicating outcomes or status to appropriate providers;

(2) Providing liaison assistance during the transition process to ongoing health, mental health, or social services;

(3) Assisting with arrangements for transportation, childcare, or community services;

(4) Making referrals to other agencies, programs, and community services, including the federal special supplemental food program for women, infants and children;

(5) Follow-up to ensure the delivery of necessary services, including tracking missed appointments, rescheduling, and the identification and resolution of care barriers; and

(6) Intra-agency consultations concerning the recipient’s care needs;

(1) Education about the health implications of risk behavior, such as smoking, and use of alcohol and other drugs;

(2) Education about infant health, mental health, and development, including positive parenting and its role in infant and child development; and

(3) Individual instruction about the course of pregnancy, delivery and child care; and

(d) Nutritional services including:

(a) An initial assessment of the recipient’s current nutritional status;

(b) Nutritional counseling; and

Source. (See Revision Note at chapter heading He-W 500); ss by #5578, eff 2-11-93; ss by #6939, Interim, eff. 1-30-99, EXPIRED 5-30-99

New. #7036, eff 6-25-99; ss by #8904, eff 6-25-07; ss by #10914, eff 8-26-15

He-W 548.05 Non-Covered Services. Any other medical services that are covered under the NH medicaid program, pursuant to He-W 522 through 577 or He-M 426 through 701 shall not be covered as part of extended services to pregnant women.

Source. (See Revision Note at chapter heading He-W 500); ss by #5578, eff 2-11-93; ss by #6939, Interim, eff. 1-30-99, EXPIRED 5-30-99

New. #7036, eff 6-25-99; ss by #8904, eff 6-25-07; ss by #10914, eff 8-26-15

He-W 548.06 Required Documentation. The provider shall maintain the following documentation for all extended services care provided:

(a) A plan of care containing:

(1) The initial assessment, which shall contain:

a. The recipient’s name and medicaid identification number;

b. The date of entry into clinic service;

c. The number of weeks of gestation at the date of entry;

d. The recipient’s medical, nutritional, and social needs and risks;

e. A listing of services and types of providers to be used, to address the recipient’s needs and risks, as well as the frequency of services;

f. A dated signature on the plan of care by the physician or advanced practice registered nurse, or a physician assistant if so delegated by a physician in accordance with Med 603.01, along with the signature of the recipient, approving the plan of care;

g. A statement signed by the recipient which gives the agency staff permission to discuss the recipient’s needs with other medical and social service caregivers; and

h. The date of, and reason for, discharge from the program;

(2) Ongoing plan of care notes, relating to the original plan of care, containing:

a. Date(s) of service(s); and

b. Description of service(s); and

(3) Changes to the original plan of care described in (1)d. and (1)e. above, to be attached to the original plan of care;

(b) Attendance records for any group education attended by a recipient;

(c) An extended services summary sheet listing the recipient’s name and medicaid identification number, and the date(s) and type(s) of extended service(s) rendered;

(d) Supporting records in accordance with He-W 520 and this part, and failure to maintain records in accordance with He-W 520 and this part shall entitle the department to recoupment of state and federal medicaid payments made as permitted by 42 CFR 455 and 42 CFR 447; and

(e) Documentation required by He-W 520 and this part for a minimum of 6 years or until the resolution of any legal action(s) commenced within the 6 year period, whichever is longer.

Source. (See Revision Note at chapter heading He-W 500); ss by #5578, eff 2-11-93; ss by #6939, Interim, eff. 1-30-99, EXPIRED 5-30-99

New. #7036, eff 6-25-99; ss by #8904, eff 6-25-07; ss by #10914, eff 8-26-15

He-W 548.07 Utilization Review and Control. The department’s provider integrity unit shall monitor utilization of extended services to pregnant women to identify, prevent, and correct potential occurrences of fraud, waste, and abuse, in accordance with 42 CFR 455, 42 CFR 456, and He-W 520.

Source. (See Revision Note at chapter heading He-W 500); ss by #5578, eff 2-11-93; ss by #6939, Interim, eff. 1-30-99, EXPIRED 5-30-99

New. #7036, eff 6-25-99; ss by #8904, eff 6-25-07; ss by #10914, eff 8-26-15

He-W 548.08 Third Party Liability. All third party obligations shall be exhausted before the medicaid program is billed, in accordance with 42 CFR 433.139.

Source. (See Revision Note at chapter heading He-W 500); ss by #5578, eff 2-11-93; ss by #6939, Interim, eff. 1-30-99, EXPIRED 5-30-99

New. #7036, eff 6-25-99; ss by #8904, eff 6-25-07; ss by #10914, eff 8-26-15

He-W 548.09 Payment for Services. Payment for extended services to pregnant women shall be made as follows:

(a) Rates of payment shall be at a monthly rate established by the department in accordance with RSA 161:4, VI(a);

(b) At least one of the services described in He-W 548.04 shall be provided each month, in order for the monthly rate to be billed by the provider;

(d) The provider shall maintain supporting records, in accordance with He-W 520 and He-W 548.06, and the department shall be entitled to recoupment of state and federal medicaid payments made in violation of 42 CFR 455 and 42 CFR 447.

Source. (See Revision Note at chapter heading He-W 500); ss by #5578, eff 2-11-93; ss by #6939, Interim, eff. 1-30-99, EXPIRED 5-30-99

New. #7036, eff 6-25-99; ss by #8904, eff 6-25-07; ss by #10914, eff 8-26-15

PART He-W 549 HOME VISITING NEW HAMPSHIRE AND CHILD/FAMILY HEALTH CARE SUPPORT SERVICES

He-W 549.01 Definitions.

(a) “Caregiver” means a parent, grandparent or any other individual identified as having primary responsibility for the child.

(b) “Child/family health care support” means services that are rehabilitative and preventive in nature and which, in addition to medical care, are rendered to recipients for the purpose of improving their health status and function within the family and community.

(d) “First time mother” means a pregnant woman who has had no previous live births.

(e) “Home Visiting New Hampshire (HVNH)” means the maternal and child health preventive program that provides health education, support and linkages to community services to Title XIX eligible, pregnant women together with their families in their homes.

(f) “Low birth weight” means an infant weighed 2500 grams or less at birth.

(g) “Medicaid” means the Title XIX and Title XXI programs administered by the department which makes medical assistance available to eligible individuals.

(h) “Premature” means an infant born before 37 weeks gestation.

(i) “Recipient” means any individual who is eligible for and receiving medical assistance under the medicaid program.

(j) “Special health care needs” means having or being at risk for chronic physical, developmental, behavioral, or emotional conditions requiring health and related services of a type or amount beyond what is generally required.

(k) “Title V” means the program described in Title V of the Social Security Act, and administered by the maternal and child health section (MCH) of the NH division of public health services or by the special medical services (SMS) section of the NH division of community based care services as part of the health resources and services administration, United States department of health and human services.

(l) “Title XIX” means the joint federal-state program described in Title XIX of the Social Security Act and administered in New Hampshire by the department under the medicaid program.

(m) “Title XXI” means the joint federal-state program described in Title XXI of the Social Security Act and administered in New Hampshire by the department under the medicaid program.

(n) “Unit” means a 15-minute period of time for which a service is rendered.

Source. #7775, eff 10-8-02; ss by #9768, eff 10-8-10; ss by #10092, eff 3-1-12; amd by #10139, eff 7-1-12; amd by #10398, eff 8-20-13

He-W 549.02 Recipient Eligibility.

(a) The following individuals shall be eligible for HVNH, as described in He-W 549.05(a):

(1) A medicaid recipient who:

a. Is a first time mother; and

b. Is under age 21 at the time of enrollment;

(2) An infant, up to one year of age, who is born to a recipient in (1) above; and

(3) An infant, up to one year of age, who:

a. Is no older than 2 weeks of age at the time of enrollment in the program; and

b. Is born to a first time mother who is under the age of 21 at the time of the infant’s enrollment in the program.

(b) All Title XIX recipients who are under age 21 shall be eligible to receive child/family health care support services, as specified in He-W 549.05(b), if any one of the following 4 conditions are met:

(1) At least 2 primary criteria outlined in (c) below;

(2) At least 3 secondary criteria outlined in (d) below;

(3) At least one primary and 2 secondary criteria outlined in (c) and (d) below; or

(4) The recipient is eligible for Title V services through the special medical services section, in accordance with He-M 520.03 and He-M 520.04(b).

(1) The caregiver, child or a household member has:

a. A diagnosed mental illness;

b. Known substance abuse; or

c. A disability or developmental delay, except that a child shall not be a recipient of family-centered early supports and services pursuant to He-M 510;

(2) The caregiver has been referred by a protective services agency or has a finding of child neglect or abuse;

(3) The caregiver or child has special health care needs;

(4) The child’s family is homeless; or

(5) One of the child’s parents or parent’s partner is absent for circumstances including, but not limited to, death, missing, incarceration, military deployment, or as a result of a protective/restraining order.

(d) For child/family health care support services, secondary criteria for eligibility shall include:

(1) The child’s caregiver is under 21 years of age;

(2) The caregiver is a first time parent;

(3) The caregiver has limited English proficiency;

(4) The caregiver is single without any identified social supports;

(5) The caregiver has less than a high school education;

(6) The child was premature or had a low birth weight and is not a recipient of family-centered early supports and services pursuant to He-M 510;

(7) There is documentation of family trauma, including, but not limited to:

a. An unexpected or untimely death in the family;

b. Domestic violence in the family;

c. Caregiver is an adult victim of child abuse or neglect; or

d. The family has been the victim of a crime;

(8) There is documentation of a disrupted or problematic parent-child relationship, such as, but not limited to, insecure attachment;

(9) The family’s income is less than 125% of the most recent federal poverty level as published annually in the Federal Register by the Secretary of the U.S. Department of Health and Human Services; or

(10) One or more grandparents is raising the child.

Source. #7775, eff 10-8-02; ss by #9768, eff 10-8-10; ss by #10092, eff 3-1-12; amd by #10398, eff 8-20-13

He-W 549.03 Amount of Services.

(a) Child/family health care support services shall consist of 12 units of service per state fiscal year, including the units making up the assessment visits in He-W 549.05(a)(2).

(b) Recipients identified in He-W 549.02(b)(4) shall be eligible for 16 units of service per state fiscal year, including the units making up the assessment visits in He-W 549.05(a)(2).

Source. #7775, eff 10-8-02; ss by #9768, eff 10-8-10; ss by #10092, eff 3-1-12

He-W 549.04 Provider Participation.

(a) Each participating provider shall:

(1) Be under current services contract obligation:

a. With the maternal and child health (MCH) section of the NH division of public health services;

b. With the special medical services (SMS) section of the NH division of community based care services, as a Title V agency; or

c. With the department’s division for children, youth, and families (DCYF);

(2) Be a New Hampshire enrolled Title XIX provider; and

(3) Deliver HVNH or child/family health care support services through the following health care providers:

a. Advanced practice registered nurses (APRN) licensed to practice by the states in which they practice;

b. Registered nurses (RN) licensed to practice by the states in which they practice;

c. Licensed practical nurses (LPN) licensed to practice by the states in which they practice;

d. Licensed dietitians who are licensed under RSA 326-H:12;

e. Social workers with a baccalaureate or master’s degree in social services, psychology, education or public health; or

f. Para-professionals who:

1. Have a high school diploma or general equivalency diploma;

2. Have 2 years’ experience working with families in a health care support capacity; and

3. Work in coordination with a licensed multidisciplinary team, including but not limited to APRNs, licensed clinical social workers (LCSW), licensed marriage and family therapists, and/or other licensed health care professionals.

(b) Participating providers under current services contract obligation with SMS in accordance with (a)(1)b. above shall bill only for nutrition-related services identified in He-W 549.05(b)(5)a.

Source. #7775, eff 10-8-02; ss by #9768, eff 10-8-10; ss by #10092, eff 3-1-12 (from He-W 549.03); amd by #11124, eff 6-22-16

He-W 549.05 Covered Services. Covered HVNH and child/family health care support services shall include the following services delivered in accordance with a plan of care as described in He-W 549.07:

(a) HVNH services which shall:

(1) Focus on healthy birth outcomes;

(2) Include initial assessment, not to exceed 2 visits, and subsequent visits;

(3) Be conducted through face-to-face visits at:

a. The pregnant woman’s or child’s home;

b. The participating provider or health care provider agency; or

c. Any other location, as documented in the pregnant woman’s or child’s progress notes; and

(4) Include the following:

a. Prenatal assessment, support and education including, but not limited to:

1. Nutrition assessment and education;

2. Networking with social support services;

3. Accessing and receiving continuous prenatal care; and

4. Health implications of risk behavior, such as smoking;

b. Parenting skills and child development education;

c. Parental assessment, support and education to encourage parental coping and the parent’s ability to develop attachment and nurturing skills;

d. Family planning;

e. Community support guidance for the purpose of securing and maintaining a safe and healthy home;

f. Education and support to assure recipient has access to, and obtains, preventive and acute health care; and

g. Follow-up activities related to any of the above services; and

(b) Child/family health care support services which:

(1) Shall include initial assessment and subsequent visits;

(2) Shall be family-centered and child-focused;

(3) Shall be conducted through a face-to-face visit with the recipient’s parent or guardian at:

a. The recipient’s home;

b. The participating provider or health care provider agency; or

c. Any other location, as documented in the recipient’s progress notes;

(4) May be conducted on a limited basis by telephone or via a video conference in lieu of a face-to-face visit if the service can be provided over the phone or via a video conference and provision of the service over the phone or via a video conference would not compromise the intent or anticipated result of the service; and

(5) Shall include any of the following:

a. Nutrition assessment and education;

b. Family support activities geared towards developing and maintaining family support systems, including, but not limited to, education and consultation;

c. Child-focused, family-centered education to a recipient’s parents or guardians in the areas of physical and behavioral health, social support, parenting education, and household and environmental safety;

d. Child development screening, education, and guidance;

e. Community support guidance for the purpose of securing and maintaining a safe and healthy home;

f. Parental assessment, support and education to encourage parental coping and the parent’s ability to develop attachment and nurturing skills;

g. Education and support to assure recipient has access to, and obtains, preventive and acute health care; and

h. Follow-up activities related to any of the above services.

Source. #7775, eff 10-8-02; ss by #9768, eff 10-8-10; ss by #10092, eff 3-1-12 (from He-W 549.04)

He-W 549.06 Non-Covered Services. The following services shall be non-covered as HVNH and child/family health care support services:

(a) Any covered service listed in He-W 549.05, or component thereof, which duplicates a service already being provided, such as, but not limited to:

(1) Services provided though other Title XIX-funded department programs;

(2) Services provided through private programs such as a health maintenance organization (HMO); and

(3) Services which are free to the public;

(b) Travel;

(d) Administrative services; and

(e) Services that do not meet the documentation requirements in He-W 549.07.

Source. #7775, eff 10-8-02; ss by #9768, eff 10-8-10; ss by #10092, eff 3-1-12 (from He-W 549.05)

He-W 549.07 Required Documentation. Each participating provider shall develop and maintain on file the following documentation for each recipient:

(a) A plan of care which shall be developed following the initial assessment, in accordance with the following:

(1) The plan of care shall include:

a. The recipient’s name, date of birth and Title XIX identification number;

b. The recipient’s identified needs and/or risk factors;

c. The recommended HVNH or child/family health care support services; and

d. The frequency of the recommended HVNH or child/family health care support services;

(2) The plan of care shall be approved, dated, and signed by:

a. A physician or APRN, when the plan of care contains a nursing or SMS nutrition component; or

b. A physician, APRN, LCSW, psychologist, associate psychologist, licensed clinical mental health counselor, or licensed marriage and family therapist, when the plan of care does not contain a nursing component; and

(3) The plan of care shall be reviewed and updated at least annually and as necessary, including being approved, dated, and signed in accordance with (2) above;

(b) A family support plan which shall:

(1) Be required only of participating HVNH providers;

(2) Be developed, in conjunction with the family, based on initial assessment and the plan of care;

(3) Be updated at least quarterly, in conjunction with the family, based on the health care provider’s assessment of progress or lack of progress towards the goals in (4) below; and

(4) Specify family-specific goal information including, but not limited to:

a. Family-specific goals, including the date each goal is identified;

b. Action steps to achieve each family-specific goal;

c. Frequency of services required to achieve each family-specific goal;

d. Sources of support resources for the family to utilize to achieve each family-specific goal;

e. Name and goal-related role of each anticipated and involved health care provider;

f. Dates on which progress toward each goal is to be reviewed, which shall be at least quarterly; and

g. Status of goal at review date;

(c) Progress notes, which shall be prepared at the time of each visit, or at the time of a telephone call made or video conference conducted in lieu of a face-to-face visit, by the health care provider, to include, but not be limited to:

(1) The date of each visit, telephone call or video conference;

(2) The location of each visit, if other than the recipient’s home or the participating provider or health care provider agency, and the reason therefor;

(3) The reason for a telephone call or video conference if in lieu of a visit;

(4) The individuals present at the time of the visit;

(5) The start time and end time of each visit, telephone call or video conference;

(6) For HVNH only, documentation of the service(s) provided at each visit, or via telephone call or video conferencing and how the service(s) provided relates to a specific goal contained in the family support plan;

(7) For MCH providers of child/family health care support services, documentation of which service(s) specified in He-W 549.05(b)(5), as related to the plan of care, were provided at each visit, or via telephone call or video conference;

(8) For participating providers under contract obligation with SMS, documentation of the service(s) provided at each visit or via telephone call or via video conference; and

(9) The dated signature and credentials of the health care provider;

(d) For HVNH only, documentation in the recipient’s chart as follows:

(1) Family/household information, including, but not limited to:

a. Names of family members;

b. Dates of birth of family members; and

c. Relationship of family members to recipient;

(2) Family support team information, including, but not limited to the name and role of each health care provider providing services; and

(3) The names and types of other sources of support being received by the recipient, such as, but not limited to:

a. Primary care, dental, and mental health providers; and

b. Support from such programs as women, infants and children nutrition services, and the division for children, youth and families; and

(e) For child/family health care support services only, documentation verifying that the recipients served met the eligibility criteria in He-W 549.02(b).

Source. #7775, eff 10-8-02; ss by #9768, eff 10-8-10; ss by #10092, eff 3-1-12 (fr5om He-W 549.06); amd by #11124, eff 6-22-16

He-W 549.08 Utilization Review and Control. The department shall monitor utilization of HVNH and child/family health care support services, in accordance with 42 CFR 455, 42 CFR 456, and He-W 520.

Source. #7775, eff 10-8-02; ss by #9768, eff 10-8-10; ss by #10092, eff 3-1-12 (from He-W 549.07)

He-W 549.09 Third Party Liability.

(a) All third party obligations shall be exhausted before Title XIX shall be billed, in accordance with 42 CFR 433.139, with the exception of the following:

(1) Pregnant women and children who are covered by third party liability, enforced by the New Hampshire division of child support services, shall be exempt from third party billing practices; and

(2) All preventive pediatric and prenatal care services shall be exempt from third party billing practices.

(b) Participating providers may bill medicaid directly for (a)(1) and (a)(2) above, and medicaid shall then seek reimbursement from the third party.

Source. #7775, eff 10-8-02; ss by #9768, eff 10-8-10; ss by #10092, eff 3-1-12 (from He-W 549.08)

He-W 549.10 Payment for Services.

(a) Payment for HVNH and child/family health care support services shall be made, per 15 minute unit of service, in accordance with rates established by the department in accordance with RSA 161:4, VI(a).

(b) For billing purposes:

(1) Any period of time that consists of 8 minutes or less shall not be billed; and

(2) Any period of time that consists of more than 8 minutes shall be billed as one unit.

(d) The participating provider shall maintain supporting records, in accordance with He-W 520.

Source. #10092, eff 3-1-12 (from He-W 549.09)

PART He-W 550 ADULT MEDICAL DAY CARE SERVICES - EXPIRED (Now He-E 803)

He-W 550.01 - 550.08 - EXPIRED

Source. (See Revision Note at chapter heading He-W 500); ss by #5889, eff 8-31-94; ss by #7355, INTERIM, eff 8-31-00, EXPIRED: 2-27-01

PART He-W 551 - RESERVED

PART He-W 552 PERSONAL CARE ATTENDANT SERVICES

He-W 552.01 Purpose. The purpose of this chapter is to set forth the procedures and requirements of personal care attendant services provided by personal care attendants to the severely physically disabled pursuant to RSA 161-E.

Source. (See Revision Note at chapter heading He-W 500); ss by #4993, eff 11-30-90, EXPIRED: 11-30-96

New. #6742, eff 4-30-98; ss by #7941, eff 8-23-03; ss by #8597, eff 3-30-06; amd by #10139, eff 7-1-12; ss by #10562, INTERIM, eff 3-30-14, EXPIRES: 9-26-14; ss by #10676, eff 9-26-14

He-W 552.02 Definitions.

(a) “Chronically wheelchair mobile” means the recipient, due to a physical disability, must use a wheelchair for mobility.

(b) “Department” means the New Hampshire department of health and human services.

(c) “Legally responsible relative” means a spouse, or the parent(s) of a minor child, including step-parents, foster parents and legal guardians, who are legally responsible to provide care for another person.

(d) “Medicaid” means the Title XIX and Title XXI programs, administered by the department, which make medical assistance available to eligible individuals.

(e) “Member of the recipient’s family” means an individual related to the recipient within the second degree of kinship, including:

(1) A spouse, parent, step-parent, sister, or brother; or

(2) A grandparent, aunt, or uncle residing in the same household.

(f) “Natural supports” means the help and care that an individual receives from his or her family, friends, significant others, roommates, neighbors, and other community resources, including unpaid voluntary services.

(g) “Personal care attendant (PCA)” means a person who meets the requirements set forth in He-W 552.04(b) and is an employee of or is under contract with a personal care service provider(s) to provide personal care attendant services.

(h) “Personal care attendant services (PCA services)” means medically oriented personal care services as more fully described in He-W 552.05(b) which are provided by a personal care attendant in the recipient’s home, workplace, or other non-institutional setting to gain greater control over his or her life in accordance with RSA 161-E.

(i) “Provider” means an entity that employs or contracts with the personal care attendant to provide PCA services and meets the requirements set forth in He-W 552.04(a).

(j) “Recipient” means any individual who is eligible for and receiving medical assistance under the medicaid program.

(k) “Title XIX” means the joint federal-state program described in Title XIX of the Social Security Act and administered in New Hampshire by the department under the medicaid program.

(l) “Title XXI” means the joint federal-state program described in Title XXI of the Social Security Act and administered in New Hampshire by the department under the medicaid program.

Source. (See Revision Note at chapter heading He-W 500); ss by #4993, eff 11-30-90, EXPIRED: 11-30-96

New. #6742, eff 4-30-98; ss by #8597, eff 3-30-06; ss by #10562, INTERIM, eff 3-30-14, EXPIRES: 9-26-14; ss by #10676, eff 9-26-14 (from He-W 552.01)

He-W 552.03 Recipient Eligibility.

(a) Medicaid recipients shall be eligible for PCA services when the recipient:

(1) Is at least 18 years of age;

(2) Is his/her own legal guardian;

(3) Is chronically wheelchair-mobile;

(4) Is approved to participate in an independent living program by provider of PCA services;

(5) Is able to participate fully in activities of daily living (ADLs), which are the basic self-care tasks of everyday life, such as eating, bathing, dressing, toileting, and transferring;

(6) Is able to self direct, which means the recipient is capable of:

a. Making informed choices about his or her PCA services; and

b. Selecting, directing, supervising and managing the personal care attendant in the implementation of a plan of care;

(7) Is living in a non-institutional environment, but requires a minimum of 2 hours of medically oriented PCA services per day; and

(8) Has a demonstrated need for PCA services as required by (c) below.

(b) The requirements in (a)(6) above shall not preclude the recipient from obtaining assistance with the task of selecting and directing the personal care attendant.

(1) Documentation from the recipient’s physician that includes:

a. A statement certifying that, based on the physician’s assessment of the recipient’s abilities and of the frequency and scope of the acute medical interventions needed by the recipient, PCA services are necessary and appropriate;

b. A description of the specific PCA services and tasks that the recipient needs assistance with; and

c. The number of hours of PCA services needed on a daily or weekly basis; and

(2) Documentation signed by the recipient indicating that the recipient’s needs cannot be fully met with natural supports, and includes:

a. A statement attesting that the PCA services are intended to assist, not replace or supplant the help already available to the recipient from family members, community resources, or other natural supports; and

b. Information detailing why the legally responsible relative is not able to provide the care that is needed, such as physical limitations or a work schedule that limits their availability.

Source. (See Revision Note at chapter heading He-W 500); ss by #4993, eff 11-30-90, EXPIRED: 11-30-96

New. #6742, eff 4-30-98; ss by #8597, eff 3-30-06; ss by #10562, INTERIM, eff 3-30-14, EXPIRES: 9-26-14; ss by #10676, eff 9-26-14 (from He-W 552.02)

He-W 552.04 Provider Participation.

(a) All providers of PCA services shall be enrolled as a New Hampshire medicaid provider to provide PCA services.

(b) All personal care attendants shall:

(1) Be employed by or under contract with a New Hampshire medicaid provider in (a) above;

(2) Meet the training and experience requirements specified in He-W 552.07; and

(3) Not be a member of the recipient’s family, per 42 CFR 440.167(a)(2).

Source. (See Revision Note at chapter heading He-W 500); ss by #4993, eff 11-30-90, EXPIRED: 11-30-96

New. #6742, eff 4-30-98; ss by #7941, eff 8-23-03; ss by #8597, eff 3-30-06; ss by #10562, INTERIM, eff 3-30-14, EXPIRES: 9-26-14; ss by #10676, eff 9-26-14 (from He-W 552.03)

He-W 552.05 Covered Services.

(a) PCA services shall be covered when they are:

(1) PCA services as defined by He-W 552.02(h) and as further described in (b) below;

(2) Documented by the recipient’s physician who certifies to the necessity of the PCA services in accordance with He-W 552.03(c);

(3) Part of a plan of care developed by a registered nurse as provided for in He-W 552.09(b);

(4) Provided in the home or in locations other than the home, such as school and work, if the PCA services would have otherwise been provided in the home;

(5) Of a type, frequency, and duration that is consistent with the recipient’s demonstrated needs for PCA services as documented in the plan of care; and

(6) Provided in accordance with the requirements of this part.

(b) PCA services, provided in accordance with the plan of care, shall include, as applicable:

(1) Personal hygiene, such as providing or assisting an individual with bathing, washing hair, grooming, shaving, nail care, foot care, skin care, mouth care, and oral hygiene, including special mouth care;

(2) Assistance with toileting, or a bowel and bladder care program, such as assisting the recipient getting to and from the bathroom, on and off the toilet, or assistive device used for toileting, changing incontinence supplies, following a toileting schedule, cleansing an individual or adjusting clothing relate to toileting, emptying a catheter drainage bag or assistive device, ostomy care, and bowel care;

(3) Assistance with movement and mobility, transfers or repositioning, such as transferring a recipient from a bed to a wheelchair, turning an individual or adjusting padding for physical comfort or pressure relief, and assisting with range-of-motion exercises;

(4) Under the direction of the recipient, assistance with medications to the extent allowable under RSA 326-B;

(5) Assistance with dressing;

(6) Meal preparation and clean-up when such activities are not otherwise being provided, and may include preparing meals for modified diets, assisting with eating, and monitoring to prevent choking or aspiration; and

(7) The performance of light household tasks related to the recipient’s needs, such as but not limited to, changing and washing the recipient’s bed linens, doing the recipient’s laundry, cleaning of recipient occupied space, or moving furniture to remove obstacles and hazards to enable the recipient to move easily in the home.

(c) The recipient shall be responsible for informing the personal care attendant about his or her preferences regarding the PCA services, and how they are to be performed.

Source. (See Revision Note at chapter heading He-W 500); ss by #4993, eff 11-30-90, EXPIRED: 11-30-96

New. #6742, eff 4-30-98; ss by #8597, eff 3-30-06; ss by #10562, INTERIM, eff 3-30-14, EXPIRES: 9-26-14; ss by #10676, eff 9-26-14 (from He-W 552.04)

He-W 552.06 Non-covered Services.

(a) Non-covered services shall be those services for which the NH Medicaid program shall make no payment.

(b) The following activities shall not be considered PCA services:

(1) Services that are not medically oriented, including:

a. Shopping, except for grocery shopping;

b. Managing finances;

c. Care, grooming, or feeding of pets or other animals, with the exception of service animals as defined by the Americans with Disabilities Act (ADA), Title III Subpart A 36.104, or assistance animals as defined by the Fair Housing Act Section 504; and

d. Social integration activities, such as accompanying the recipient to a restaurant, to the movies, to a ball game or to any other community or social activity;

(2) Chore services, which are tasks that exceed light housekeeping and include:

a. Cleaning of floors, shampooing carpets, cleaning walls, and cleaning furniture in areas not occupied by the recipient, such as cleaning the entire home rather than the area the recipient occupies;

b. Doing laundry, other than the recipient’s personal laundry, such as doing laundry for the household as opposed to just the recipient’s personal laundry;

c. Cleaning windows; and

d. Doing yard work, gardening, home repairs, or shoveling snow unless needed to ensure the recipient’s and the PCA’s safe access to and from the recipient’s home when the recipient has no natural supports;

(3) Services provided outside the recipient’s home for the convenience of the personal care attendant, such as care provided at the personal care attendant’s home, or any other location where the recipient would not normally go within the community;

(4) Services performed for the convenience of the recipient, or the recipient’s family member(s), or intended to otherwise replace assistance available through the recipient’s natural supports system;

(5) Time spent with the recipient when no actual hands on care or other covered services are being provided, including but not limited to supervision, companion care, baby-sitting the recipient’s dependents, or social visits;

(6) Services provided to a recipient while the recipient is:

a. An inpatient or resident of a hospital, nursing facility, intermediate care facility for the mentally retarded, or institution for mental disease, in accordance with 42 CFR 440.167;

b. An inmate of a public institution in accordance with 1905(a)(27)(A) of the Social Security Act; or

c. Attending a program for which personal care services are already provided, such as adult medical day care;

(7) Services provided to the recipient outside the United States;

(8) Duplicative PCA services;

(9) Any services not listed as covered under He-W 552.05;

(10) Services which are not included in the approved plan of care;

(11) Services provided to someone other than the recipient; and

(12) Care requiring the technical or professional skill that a state statute or regulation mandates must be performed by a health care professional licensed or certified by the state.

Source. (See Revision Note at chapter heading He-W 500); ss by #4993, eff 11-30-90, EXPIRED: 11-30-96

New. #6742, eff 4-30-98; ss by #8597, eff 3-30-06; ss by #10562, INTERIM, eff 3-30-14, EXPIRES: 9-26-14; ss by #10676, eff 9-26-14 (from He-W 553.06)

He-W 552.07 Training Requirements.

(a) The provider shall ensure that, within 30 days of the date of hire, the personal care attendant has, through training or experience, the skills required to perform the PCA services including competency in the following areas:

(1) Roles, responsibilities and expectations of a personal care attendant, including knowledge of activities that do and do not qualify as PCA services;

(2) Personal care and nutrition;

(3) Infection control and universal precautions designed to prevent the transmission of infectious diseases;

(4) Safety and emergency procedures, including basic first aid and 911 protocols;

(5) Proper lifting techniques;

(6) Recipient rights, and reporting of abuse and neglect; and

(7) Record-keeping and documentation, including the penalties associated with improper recordkeeping and documentation.

(b) The provider shall maintain documentation in the personnel file indicating that the personal care attendant meets the requirements of (a) above, including the name and signature of the person making the competency determination.

Source. (See Revision Note at chapter heading He-W 500); ss by #4993, eff 11-30-90, EXPIRED: 11-30-96

New. #6742, eff 4-30-98; ss by #8597, eff 3-30-06; ss by #10562, INTERIM, eff 3-30-14, EXPIRES: 9-26-14; ss by #10676, eff 9-26-14

He-W 552.08 Provider and PCA Responsibilities.

(a) The provider shall:

(1) Ensure that the recipient receives independent living skills training as stated in the recipient’s individualized independent living plan of care;

(2) Coordinate independent living resources and supports; and

(3) Perform on-going assessments to evaluate the recipient’s psychosocial, physical, and environmental status to prevent hospitalization and to promote wellness.

(b) The personal care attendant shall document a detailed written daily record to include:

(1) Specific tasks performed;

(2) Condition and changes in condition or status of the recipient, such as a reported change in sleep patterns, an injury, or development of a decubitus ulcer; and

(3) The dates worked, total number of hours and/or 15 minute units worked for each day, including the in and out times.

(1) Raise the concerns with the recipient;

(2) Note the concerns in their daily report; and

(3) If raising the issue with the recipient does not alleviate the concern, bring the concern to the attention of the registered nurse employed by the provider to oversee the recipient’s care.

(d) When the personal care attendant brings a concern to the nurse’s attention in accordance with (c)(3), the nurse shall follow-up and document the outcome in the provider’s record for the recipient.

Source. #10676, eff 9-26-14 (from He-W 552.03)

He-W 552.09 Personal Care Assessments and the Plan of Care.

(a) A personal care assessment shall be conducted by the provider’s licensed registered nurse and used to develop the plan of care.

(b) The personal care assessment shall include the following:

(1) The recipient’s functional level;

(2) The adaptability of the recipient’s place of residence to the provision of PCA services;

(3) The capability of the recipient to participate in his or her own care and to determine the degree of support needed; and

(4) The extent of, and need for, any natural supports taking into account the potential contributions of natural supports.

(1) Be based on the recipient’s physician’s documentation described in He-W 552.03(c) and the personal care assessment as described in (a) above;

(2) Include the information from the personal case assessment as well as the following:

a. Diagnosis;

b. Recipient status, including:

1. Behavioral health status;

2. Physical health status;

3. Functional limitations; and

4. Rehabilitative prognosis;

c. PCA services needed, including:

1. The type, frequency, and number of hours and/or 15 minute units per day or week;

2. Any equipment requirements;

3. Any nutritional requirements; and

4. Medications;

d. Discharge planning or referral; and

e. Other identified appropriate PCA services;

(3) Be signed by the licensed registered nurse responsible for the oversight of the recipient’s care, and incorporated in the provider’s record for the recipient; and

(4) Be reviewed by the provider’s licensed registered nurse who is responsible for the oversight of the recipient’s care every 3 months, and the prescribing physician every 6-months, or more often if warranted by the severity of the recipient’s functional limitations.

(d) The provider’s licensed registered nurse who is responsible for the oversight of the recipient’s PCA services shall make a face-to-face visit to the recipient’s residence at least once every 3-months to:

(1) Reassess the PCA services in light of the recipient’s needs as described in the plan of care, and note any need for changes to the plan of care;

(2) Confirm that the recipient is satisfied with the PCA services being provided;

(3) Verify that the PCA services being provided in accordance with the recipient’s needs, preferences and the plan of care; and

(4) Ensure that documentation and recordkeeping are being performed in an accurate and appropriate manner.

(e) All assessments required in (a) and (d) above shall be conducted using a standardized assessment tool of the provider’s choice, which has been reviewed by the department.

(f) Any revisions to the plan of care as a result of a review as described in (d) above, shall be in writing, and approved by the recipient’s physician.

Source. #10676, eff 9-26-14

He-W 552.10 Utilization Review and Control. The department’s provider program integrity unit shall monitor utilization of the PCA services to identify, prevent, and correct potential occurrences of fraud, waste and abuse, in accordance with 42 CFR 455 and 42 CFR 456 and He-W 520.

Source. #10676, eff 9-26-14 (from He-W 552.05)

He-W 552.11 Third Party Liability. All third party obligations shall be exhausted before medicaid may be billed, in accordance with 42 CFR 433.139.

Source. #10676, eff 9-26-14 (from He-W 552.06)

He-W 552.12 Payment for Services. Payment for PCA services shall be made as follows:

(a) Payment for PCA services shall be made in accordance with fee schedules established by the department in accordance with RSA 161:4, VI(a); and

(b) The provider shall submit claims for payment to the department’s fiscal agent.

Source. #10676, eff 9-26-14 (from He-W 552.07)

He-W 552.13 Documentation.

(a) The provider shall maintain supporting records, in accordance with He-W 520.

(b) The supporting records described in (a) above shall include, but not be limited to:

(1) Documentation from the recipient’s physician that includes documentation of the need for PCA services in accordance with He-W 552.03(c);

(2) Results of the personal care assessment completed in accordance with He-W 552.09;

(3) The plan of care, as described in He-W 552.09(b);

(4) Documentation describing any changes in either the type of PCA services to be provided or the number of hours of PCA services provided, including an explanation of the basis for the change;

(5) Documentation of the time during which PCA services were provided to each recipient, including the date of service, number of hours and/or units worked, including specific in and out times, and confirmed by the recipient in writing, verbally, or electronically that PCA services were performed;

(6) Documentation of the PCA services for which reimbursement has been requested, including a detailed description of the specific PCA services provided;

(7) Documentation of the face-to-face visits conducted in accordance with He-W 552.09(c), including any related notes and outcomes; and

(8) Documentation of oversight measures taken by the provider to ensure PCA services are being provided when they are being provided outside the state of New Hampshire for longer than a 30-day period of time.

(c) All electronic or written documentation submitted in accordance with (b) above shall be legible and written in English.

(d) The provider shall provide such documentation to the department upon request.

Source. #10676, eff 9-26-14 (from He-W 553.04)

PART He-W 553 HOME HEALTH SERVICES

REVISION NOTE:

Document # 11127, effective 7-1-16, contained Part He-W 553 on home health agencies, comprising rules He-W 553.01 through He-W 553.07. Document #11127 adopted He-W 553.01 and readopted with amendments and renumbered the former He-W 553.01 through 553.06 as He-W 553.02 through He-W 553.07. Most of the former He-W 553.01 and all of the former He-W 553.02 through He-W 553.06 were scheduled to expire 9-11-15 but were extended pursuant to RSA 541-A:14-a until replaced by the rules He-W 553.02 through He-W 553.07 in Document #11127.

The former He-W 553.07 on payment for services had originally been adopted by Document #8972, effective 9-11-07, until superseded by Document #9105, effective 3-18-08. The former He-W 553.08 on rate setting methodology had originally been adopted by Document #9105, effective 3-18-08. The former He-W 553.07 and He-W 553.08 were both “suspended for the biennium ending June 30, 2017” as rules relative to rate setting pursuant to 2015, 276:145, effective 7-1-15. But the rules were allowed by the Department of Health and Human Services to expire on 3-18-16. The former He-W 553.09 on third party liability and former He-W 553.10 on utilization review and control had also originally been adopted by Document #8972, effective 9-11-07, until superseded by Document #9105, effective 3-18-08. These rules were also allowed by the Department of Health and Human Services to expire on 3-18-16.

He-W 553.01 Purpose. The purpose of this part is to prescribe the requirements of home health services under the New Hampshire medicaid state plan.

Source. (See Revision Note at part heading for He-W 553) #11127, eff 7-1-16

He-W 553.02 Definitions.

(a) “Department” means the New Hampshire department of health and human services.

(b) “Direct care time” means the time a licensed nursing assistant (LNA), registered nurse (RN), or licensed practical nurse (LPN) spends with one recipient during which home health services are provided only to that individual recipient during a visit.

(d) “Home health aide services” means services provided to a recipient which constitute hands-on care and are required to maintain the recipient’s health, facilitate treatment of the recipient’s medical condition, illness, or injury, and when performed by a LNA, provided under the supervision of a RN or LPN.

(e) “Home health care provider” means any organization or business entity engaged in arranging for or providing home health services as described in RSA 151:2-b(I) and 42 CFR 440.70(d) and which is a NH enrolled medicaid provider in accordance with He-W 553.04.

(f) “Home health services” means skilled nursing services, home health aide services, and physical therapy, occupational therapy, speech pathology, and audiology services provided by a licensed therapy provider in accordance with He-W 568.

(g) “Independent nurse” means an RN who is not an employee with or an independent contractor of a home health care provider and is qualified to provide skilled nursing services.

(h) “Light housekeeping” means preparing meals for the recipient, cleaning the recipient’s bedroom and bathroom, and changing the recipient’s bed linens.

(i) “Medicaid” means the Title XIX and Title XXI programs administered by the department, which makes medical assistance available to eligible individuals.

(j) “Non-routine supplies” means those supplies necessary to complete specific medical treatments ordered by a physician, such as ostomy supplies, IV supplies, catheters and catheter supplies, syringes and needles, sterile dressings, and wound care supplies, and does not include routine supplies.

(k) “Recipient” means an individual who is eligible for and receiving medical assistance under the medicaid program.

(l) “Routine supplies” means those supplies used incidentally in the course of a visit and include gloves, alcohol wipes, blood drawing supplies, adhesive and paper tape, and non-sterile dressings.

(m) “Skilled nursing services” means services that must be provided by an RN or a LPN because the nature of the service is inherently complex or the recipient’s condition is such that the service can be safely and effectively provided only by a RN or LPN.

(n) “Title XIX” means the joint federal-state program described in Title XIX of the Social Security Act and administered in New Hampshire by the department under the medicaid program.

(o) “Title XXI” means the joint federal-state program described in Title XXI of the Social Security Act and administered in New Hampshire by the department under the medicaid program.

(p) “Unit” means 15 minutes.

(q) “Visit” means a personal encounter with the recipient by staff of a home health care provider for the purpose of providing a covered service(s).

Source. (See Revision Note at chapter heading He-W 500); ss by #5342, eff 3-3-92, EXPIRED: 3-3-98

New. #8972, eff 9-11-07; amd by #9105, eff 3-18-08; amd by #10139, eff 7-1-12; ss by #11127, eff 7-1-16 (formerly He-W 553.01) (See Revision Note at part heading for He-W 553)

He-W 553.03 Recipient Eligibility. A recipient shall be eligible to receive home health services in accordance with 42 CFR 441.15(c) if all of the following criteria are met:

(a) The recipient is under the care of a physician;

(b) The recipient requires home health services as ordered by his or her physician and documented in a written plan of care; and

(c) The recipient resides in his or her primary or temporary residence, excluding a hospital, nursing facility, or intermediate care facility for individuals with intellectual disabilities (ICF/IID), in accordance with 42 CFR 440.70(c).

Source. #8972, eff 9-11-07; ss by #11127, eff 7-1-16 (formerly He-W 553.02) (See Revision Note at part heading for He-W 553)

He-W 553.04 Provider Participation.

(a) All home health care providers shall:

(1) Hold a current New Hampshire state license as a home health care provider, in accordance with RSA 151:2-b, I, and He-P 809;

(2) Be certified to participate in the medicare program; and

(3) Be a New Hampshire enrolled medicaid provider.

(b) When there is no licensed and certified home health care provider in the area, an independent nurse may provide skilled nursing services if the independent nurse:

(1) Is currently licensed to practice in the state in which he or she practices;

(2) Receives written orders from the recipient’s physician;

(3) Documents the care and services provided in accordance with He-W 553.05; and

(4) Is a NH enrolled medicaid provider.

Source. #8972, eff 9-11-07; ss by #11127, eff 7-1-16 (formerly He-W 553.03) (See Revision Note at part heading for He-W 553)

He-W 553.05 Required Documentation.

(a) Home health care providers and independent nurses shall maintain complete and timely records for each recipient receiving services in accordance with He-W 520, and this part.

(b) Where a home health care provider or independent nurse has failed to maintain records pursuant to (a) above , the department shall be entitled to recoupment of state or federal medicaid payments made, as permitted by 42 CFR 455, 42 CFR 456 and 42 CFR 447.

(c) In addition to the requirement set forth in (a) above, home health care providers and independent nurses shall maintain the documentation required by this part and He-W 520 to support claims submitted for reimbursement for a minimum of 6 years or until the resolution of any legal action(s) commenced within the 6 year period, whichever is longer.

(d) Recipient records shall include all of the following:

(1) Written orders for initial home health services and certification of the need for home health services signed by the recipient’s physician specifying:

a. The frequency of medication and treatment to be administered; and

b. The period of time to be covered by the orders;

(2) Documentation of the occurrence of a face-to-face encounter which is related to the primary reason the recipient requires home health services indicating the time frame the encounter took place, the date, the practitioner who conducted the encounter, and the practitioner’s findings in accordance with He-W 553.06(a) below;

(3) For recipients under the age of 21, a recipient history and a health assessment with an appropriate pediatric tool completed upon admission by the RN or appropriate rehabilitation skilled professional in accordance with 42 CFR 484.55;

(4) For recipients over the age of 21, a recipient history and a health assessment, completed upon admission by the RN or appropriate rehabilitation skilled professional in accordance with 42 CFR 484.55, except that the homebound assessment of 42 CFR 484.55 is not required;

(5) Documentation at least every 60 days to indicate review of the recipient’s health assessment by the RN or appropriate rehabilitation skilled professional in accordance with 42 CFR 484.55;

(6) A written individualized plan of care which shall include the following:

a. The diagnosis related to the recipient’s need for home health services;

b. Other diagnoses;

c. An assessment of the recipient’s mental alertness and cognitive level;

d. Measurable recipient goals;

e. Types of services and equipment required;

f. Frequency of home health services;

g. Anticipated length of treatment;

h. General prognosis;

i. Rehabilitation potential;

j. Functional limitations including activities of daily living;

k. Activities permitted;

l. Nutritional requirements;

m. Medications;

n. Treatments;

o. Safety measures required to protect the recipient from potential injury;

p. Services being provided by non-paid caregivers involved in the recipient’s treatment and any related education or training needs of the caregivers; and

q. Discharge plans;

(7) Documentation at least every 60 days, to indicate review of the written plan of care by the recipient’s physician;

(8) Documentation at least every 60 days that indicates the locations of service delivery other than the recipient’s home for services already provided;

(9) Auditable, paper, or electronic service notes for each service provided to the recipient identifying:

a. Name of recipient;

b. Date of service;

c. Location(s) where service was provided, if other than the recipient’s primary residence;

d. Primary purpose of the home health services;

e. Description of services provided;

f. Amount of direct care time spent providing each home health service;

g. Condition of the recipient at the time the service was provided, and any significant change in recipient’s mental or physical condition;

h. Any progress the recipient has made towards goals identified on the written plan of care;

i. An explanation of any variation from the written plan of care; and

j. Name, title, and written or electronic signature of the individual providing the home health service; and

(10) Documentation of any consults or meetings regarding the recipient’s care, which also indicates the results of the consult or meeting.

(e) Home health care providers and independent nurses shall make the documentation required by this part and He-W 520 available for review to the department upon the request of the department.

Source. #8972, eff 9-11-07; ss by #11127, eff 7-1-16 (formerly He-W 553.04) (See Revision Note at part heading for He-W 553)

He-W 553.06 Covered Services.

(a) Services shall be covered when:

(1) A physician orders services as part of a written plan of care; and

(2) A face-to-face encounter with the recipient, which may occur within 90 days before the initial start of the home health services or within 30 days after the start of services, is documented in compliance with He-W 553.05(d)(2) above, and is performed by one of the following medicaid enrolled providers:

a. The recipient’s physician; or

b. The following non-physician practitioners when the requirements in (b) below are met:

(i) A nurse practitioner or clinical nurse specialist working in collaboration with the recipient’s physician;

(ii) A certified nurse midwife; or

(iii) A physician assistant under the supervision of the recipient’s physician.

(b) Non-physician practitioners in (a)(2)b. above who perform the face-to-face encounter shall communicate the clinical findings of the face-to-face encounter to the recipient’s physician who shall incorporate the clinical findings into the recipient’s medical record.

(c) Covered services shall be those home health services, regardless of diagnosis, the need for which is consistent with the nature of the recipient’s condition and accepted standards of medical and nursing practice.

(d) Covered home health services shall include:

(1) Skilled nursing services in accordance with the written plan of care including:

a. Skilled observation and assessment of the recipient’s status, including available support system and physical environment;

b. Administration of medications, including intramuscular and intravenous medications;

c. Insertion and irrigation of indwelling urinary catheters;

d. Administration of enemas, providing ostomy care, and other related procedures to provide assistance with bowel evacuation;

e. Skilled respiratory care including suctioning, tracheostomy care, administration of inhalation therapies, and chest physiotherapy;

f. Wound care, care of decubitus ulcers, and treatment of other extensive skin disorders;

g. Administration of enteral feedings;

h. Rehabilitative nursing procedures such as the initiation and supervision of bowel and bladder training programs;

i. Education, specific to the recipient’s condition, provided to the recipient and significant others involved with the recipient;

j. Pre-filling of medication administration devices such as pill planners;

k. Medication reconciliation; and

l. Education about medication therapeutic effects, side effects, and adherence to prescribed regimen;

(2) Home health aide services, in accordance with the written plan of care, including assistance provided to a recipient for the following:

a. Personal hygiene, including bathing, grooming, dressing, and changing bed linens, when there is a medical need and it is documented in the care plan;

b. Ambulation and movement, including range of motion exercises, turning, positioning, and transferring;

c. Nutritional care, including feeding and hydration;

d. Elimination, including toileting and bowel or bladder training;

e. Assistance with the use of adaptive prosthetic and orthotic devices;

f. Assistance with self-administering medications, when the assistance provided by the aide does not require the skill of a licensed nurse;

g. Administration of medications by a medication LNA or by an LNA if delegated by a RN in accordance with RSA 326-B:14, II-a;

h. Activities that are directly supportive of skilled therapy services;

i. Other medically related activities which can safely and effectively be provided by a LNA, including simple dressing changes;

j. Light housekeeping when there is documentation that no other support in the home exists at the time of the visit, and when such services are directly related to the recipient’s medical condition and care needs and is documented in the written plan of care; and

k. Tasks properly delegated to the LNA by the supervising RN pursuant to RSA 326-B:28;

(3) Physical therapy, speech therapy, occupational therapy, speech pathology and audiology services provided a licensed therapy provider and subject to the limits specified in He-W 530;

(4) Durable medical equipment, medical supplies, prosthetics, and orthotic devices, when prescribed by the attending physician and in accordance with the requirements in He-W 571; and

(5) Office visits, when the recipient receives services provided by an advanced practice registered nurse (APRN) at the location of the home health care provider as an alternative to visiting a physician’s office for treatment.

Source. #8972, eff 9-11-07; ss by #11127, eff 7-1-16 (formerly He-W 553.05) (See Revision Note at part heading for He-W 553)

He-W 553.07 Non-Covered Services. Non-covered home health services shall include:

(a) Physician services;

(b) Social worker services;

(d) Visits provided solely for the purpose of supervising the LNA;

(e) Services provided by an LNA, RN, or LPN or other licensed therapy provider which are not medically related and which constitute routine household activities, day care, or recreational services;

(f) Services rendered without a physician’s signed order;

(g) Any service whose primary purpose is providing emotional support;

(h) Any service whose primary purpose is the care or supervision that would be required by any individual of the recipient’s chronological age;

(i) Drugs and biologicals;

(j) Meals delivered to the home; and

(k) Homemaker services considered to be general household activities, except as described in He-W 553.06(d)(2)j., including:

(1) Keeping a safe environment in areas of the home used by the recipient;

(2) Performing house cleaning;

(3) Rearranging furniture to assure that the recipient can safely reach necessary supplies or medication;

(4) Completing laundry tasks; and

(5) Assisting the recipient with purchasing food and helping with the preparation of meals and special diets.

Source. #8972, eff 9-11-07; ss by #11127, eff 7-1-16 (formerly He-W 553.06) (See Revision Note at part heading for He-W 553)

PARTS He-W 554 and He-W 555 - RESERVED

PART He-W 556 SUPPORTED RESIDENTIAL HEALTH CARE FACILITY SERVICES - EXPIRED AND RESERVED

Source. (See Revision Note at chapter heading He-W 500); ss by #5676, eff 8-1-93, EXPIRED: 8-1-99

PART He-W 557 - RESERVED

PART He-W 558 HOME AND COMMUNITY-BASED SERVICES FOR THE ELDERLY AND CHRONICALLY ILL - EXPIRED

He-W 558.01 – 558.09

Source. (See Revision Note at chapter heading He-W 500); ss by #5890, eff 8-31-94; ss by #7356, INTERIM, eff 8-31-00, EXPIRED: 2-27-01

PART He-W 559 CASE MANAGEMENT OF ADVANCE CARE PLANNING AND DIRECTIVES - EXPIRED

He-W 559.01 - 559.02

Source. (See Revision Note at chapter heading He-W 500); ss by #5891, eff 8-31-94, EXPIRED: 8-31-00

New. #7700, eff 7-1-02, EXPIRED: 7-1-10

He-W 559.03 - 559.08

Source. #7700, eff 7-1-02, EXPIRED: 7-1-10

PARTS He-W 560 through He-W 564 - RESERVED

PART He-W 565 VISION CARE SERVICES

He-W 565.01 Definitions.

(a) “Department” means the New Hampshire department of health and human services.

(b) “Medicaid” means the Title XIX and Title XXI programs administered by the department, which makes medical assistance available to eligible individuals.

(d) “Optometrist” means a doctor of optometry (OD), a primary health care provider who diagnoses, manages, and treats conditions and diseases of the eye.

(e) “Optician” means “ophthalmic dispenser/optician” as defined in RSA 327-A:1,VII, namely “anyone who sells or dispenses, upon prescription, spectacles, eyeglasses or contact lenses.”

(f) “Recipient” means any individual who is eligible for and receiving medical assistance under the medicaid program.

(g) “Title XIX” means the joint federal-state program described in Title XIX of the Social Security Act and administered in New Hampshire under the medicaid program.

(h) “Title XXI” means the joint federal-state program described in Title XXI of the Social Security Act and administered in New Hampshire by the department under the medicaid program.

Source. (See Revision Note at chapter heading He-W 500); ss by #4819, eff 6-1-90, EXPIRED: 6-1-96

New. #6705, eff 3-3-98, EXPIRED: 3-3-06

New. #8603, eff 4-10-06; amd by #10139, eff 7-1-12; ss by #10638, eff 7-12-14; ss by #14080, eff 9-25-24

He-W 565.02 Recipient Eligibility. All medicaid recipients shall be eligible to receive vision care services, in accordance with He-W 565.

Source. (See Revision Note at chapter heading He-W 500); ss by #4819, eff 6-1-90, EXPIRED: 6-1-96

New. #6705, eff 3-3-98, EXPIRED: 3-3-06

New. #8603, eff 4-10-06; ss by #10638, eff 7-12-14; ss by #14080, eff 9-25-24

He-W 565.03 Provider Participation. Vision care providers shall meet the criteria specified below:

(a) Ophthalmologists and optometrists shall be licensed by the state in which they practice;

(b) Opticians practicing in New Hampshire (NH) shall be registered in accordance with RSA 327-A:2, or, if practicing in another state, meet the requirements of the state in which they practice;

(c) Opticians who fit contact lenses shall have a statement of delegation from an ophthalmologist or optometrist in accordance with RSA 327-A:2;

(d) Ophthalmologists, optometrists, and opticians shall be NH-enrolled medicaid providers; and

(e) Ophthalmologists, optometrists, and opticians shall request and obtain prior authorization from the department before providing services which require prior authorization.

Source. (See Revision Note at chapter heading He-W 500); ss by #4819, eff 6-1-90, EXPIRED: 6-1-96

New. #6705, eff 3-3-98, EXPIRED: 3-3-06

New. #8603, eff 4-10-06; ss by #10638, eff 7-12-14; ss by #14080, eff 9-25-24

He-W 565.04 Service Limits. Vision care services shall be subject to the limits described in He-W 565 and He-W 530.

Source. (See Revision Note at chapter heading He-W 500); ss by #4819, eff 6-1-90, EXPIRED: 6-1-96

New. #6705, eff 3-3-98, EXPIRED: 3-3-06

New. #8603, eff 4-10-06; ss by #10638, eff 7-12-14; ss by #14080, eff 9-25-24

He-W 565.05 Covered Services. Covered services shall include:

(a) Eye examination procedures to diagnose and monitor medical conditions of the eye, including:

(1) Complete eye examinations including:

a. Visual acuity testing;

b. Gross visual fields;

c. Muscle balance;

d. Slit lamp examinations; and

e. Ophthalmoscopy and tonometry;

(2) Interior extended testing of visual fields only;

(3) Ophthalmoscopy, fundoscopy only; and

(4) Routine tonometry;

(b) Eye examinations, performed in:

(1) A provider’s office;

(2) A recipient’s home; or

(3) A nursing facility in which the recipient resides;

(d) One pair of single vision lenses with frames, following an eye examination as described in (a) and (b) above, provided that the refractive error is at least plus or minus .50 diopter according to the type of refractive error, which may be calculated as a combined total of the spherical and cylindrical errors, in each eye;

(e) One pair of eyeglasses with bifocal corrective lenses or one pair of eyeglasses with corrective lenses for close vision and one pair of eyeglasses with corrective lenses for distant vision if there is a refractive error of at least .50 diopter for both close and distant vision;

(f) Transition lenses for recipients with ocular albinism;

(g) Contact lenses for ocular pathology in cases where the visual acuity is not correctable to 20/70 or better without contact lenses, or when required to correct aphakia or to treat corneal disease;

(h) Replacement of the component eyeglasses parts due to breakage or damage, subject to the following:

(1) Replacements may be in the form of a single lens, both lenses, frame only, or a complete pair of corrective lenses;

(2) Each component part or complete pair of corrective lenses may only be replaced one time within a 12-month period; and

(3) When the recipients has 2 pairs of eyeglasses in lieu of bifocals as allowed in (e) above, each pair of eyeglasses is subject to replacement in accordance with (1) and (2) above;

(i) Only one replacement of lost eyeglasses per lifetime for recipients under 21 years of age;

(j) Trifocal lenses provided that the recipient:

(1) Is employed and the trifocal lenses are required for the work involved in the recipient’s employment;

(2) Is a full time student and the trifocal lenses are required for the work involved in the recipient’s education; or

(3) Currently has trifocals;

(k) Progressive lenses;

(l) Ocular prostheses including:

(1) Artificial eyes; and

(2) Replacing the lens of an eye; and

(m) Replacement of nickel frames after 12 months, if the recipient has a documented allergy to nickel demonstrated by skin irritation and wearing down of the frame in the effected area.

Source. (See Revision Note at chapter heading He-W 500); ss by #4819, eff 6-1-90, EXPIRED: 6-1-96

New. #6705, eff 3-3-98, EXPIRED: 3-3-06

New. #8603, eff 4-10-06; amd by #10342, eff 6-1-13; ss by #10638, eff 7-12-14; ss by #14080, eff 9-25-24

He-W 565.06 Non-Covered Services. Non-covered services shall include:

(a) Replacement of lost eyeglasses, as follows:

(1) For recipients age 21 and over; and

(2) More than once per lifetime for recipients under age 21, except in accordance with He-W 546.06;

(b) Photochromatic lenses, including transition lenses, except for recipients diagnosed with ocular albinism or for other recipients with prior authorization;

(d) Orthoptics and vision therapy, such as muscle training;

(e) Low vision aids, such as magnifying glasses;

(f) Sunglasses and eyeglass tinting, except with prior authorization;

(g) Polarized lenses and anti-reflective coatings, except with prior authorization;

(h) Titanium frames;

(i) High-index lenses, except with prior authorization;

(j) LASIK surgery;

(k) Low vision aids;

(l) Items or services for which a less costly alternative is available; and

(m) Any other item or service not listed in He-W 565.05.

Source. (See Revision Note at chapter heading He-W 500); ss by #4819, eff 6-1-90, EXPIRED: 6-1-96

New. #6705, eff 3-3-98, EXPIRED: 3-3-06

New. #8603, eff 4-10-06; ss by #10342, eff 6-1-13; ss by #10638, eff 7-12-14; ss by #14080, eff 9-25-24

He-W 565.07 Utilization Review and Control.

(a) The department’s bureau of program integrity shall monitor utilization of vision care services to identify, prevent, and correct potential occurrences of fraud, waste, and abuse in accordance with 42 CFR 455, 42 CFR 456, and He-W 520.

Source. (See Revision Note at chapter heading He-W 500); ss by #4819, eff 6-1-90, EXPIRED: 6-1-96

New. #6705, eff 3-3-98, EXPIRED: 3-3-06

New. #8603, eff 4-10-06; ss by #10638, eff 7-12-14; ss by #14080, eff 9-25-24

He-W 565.08 Third Party Liability.

(a) All third party obligations shall be exhausted before NH medicaid may be billed, in accordance with 42 CFR 433.139.

(b) Vision care service providers shall request information from the recipient regarding other insurance coverage.

(c) If other insurance coverage is available, providers shall contact the insurer to verify benefits initially and at least annually thereafter or when the insurance carrier changes.

(d) Vision care service providers shall maintain a record of any other insurance verifications in the recipient’s medical record in accordance with He-W 520.

Source. (See Revision Note at chapter heading He-W 500); ss by #4819, eff 6-1-90, EXPIRED: 6-1-96

New. #6705, eff 3-3-98, EXPIRED: 3-3-06

New. #8603, eff 4-10-06; ss by #10638, eff 7-12-14; ss by #14080, eff 9-25-24

He-W 565.09 Payment for Services.

(a) Payment for vision care services shall be made in accordance with rates established by the department in accordance with RSA 161:4, VI(a).

(b) The vision care provider shall submit claims for payment to the department’s fiscal agent.

(d) The provider shall maintain supporting records, in accordance with He-W 520.

Source. (See Revision Note at chapter heading He-W 500); ss by #4819, eff 6-1-90, EXPIRED: 6-1-96

New. #6705, eff 3-3-98, EXPIRED: 3-3-06

New. #8603, eff 4-10-06; ss by #10638, eff 7-12-14; ss by #14080, eff 9-25-24

PART He-W 566 DENTAL SERVICES

He-W 566.01 Definitions.

(a) “By report” means a written description of the service provided and the medical necessity of same as required by the department to be submitted with certain claims for payment of such claims.

(b) “Comprehensive orthodontic treatment” means diagnosis, long-term treatment, periodic evaluations, and retention, leading to improvement of a recipient’s malocclusion.

(c) “Deciduous teeth”, also known as primary teeth, means the 20 teeth that erupt first and are normally shed and replaced by secondary teeth.

(d) “Department” means the New Hampshire department of health and human services.

(e) “Destruction of tissue” means demonstrable, traumatic alteration of soft or hard tissue architecture with history of treatment of pain.

(f) “Diagnostic model” means a model or representation that demonstrates all erupted teeth, the gingival tissue surrounding the anterior and posterior arches, and the true occlusal relationships of the teeth and tissues.

(g) “Differential diagnosis” means a condition or disorder consistent with and reasonably thought to be the cause of the history, signs, and symptoms presented by the recipient which is determined by a process that differentiates it from other conditions or disorders with similar signs or symptoms.

(h) “Early and Periodic Screening, Diagnosis and Treatment (EPSDT) services” means a program, pursuant to 42 CFR 440.40, designed to provide preventative health care, diagnostic services, and early detection and treatment of disease or abnormalities to Title XIX eligible individuals under age 21.

(i) “Interceptive orthodontic treatment” means an intervention in the initial stages of a developing problem related to the dentition, to lessen severity of the malformation and to eliminate its cause.

(j) “Limited orthodontic treatment” means orthodontic treatment not involving the entire dentition.

(k) “Malocclusion” means improper alignment of the biting or chewing surfaces of upper and lower teeth that results from a deviation of the alignment of the teeth from the ideal alignment.

(l) “Medicaid” means the Title XIX and Title XXI programs administered by the department which makes medical assistance available to eligible individuals.

(m) “Medically necessary” means:

(1) For individuals under age 21, reasonably calculated to prevent, diagnose, correct, cure, alleviate, or prevent the worsening of conditions that endanger life, cause pain, result in illness or infirmity, threaten to cause or aggravate a handicap, or cause physical deformity or malfunction, and no other equally effective course of treatment is available or suitable for the EPSDT recipient requesting a medically necessary service; and

a. Clinically appropriate in terms of type, frequency of use, extent, site, and duration, and consistent with the established diagnosis or treatment of the recipient’s illness, injury, disease, or its symptoms;

b. Not primarily for the convenience of the recipient or the recipient’s family, caregiver, or health care provider;

d. Not experimental, investigative, cosmetic, or duplicative in nature.

(n) “Palliative treatment” means minor treatment to reduce the pain of a disease, illness, or injury of the tooth or teeth excluding non-treatment activities such as writing a prescription, dispensing a drug or medication, or telephone consultation with or about a recipient.

(o) “Radiograph” means an image or picture produced by exposure to ionizing radiation of a radiation-sensitive film, phosphorous plate, emulsion, or digital sensor.

(p) “Recipient” means any individual who is eligible for and receiving medical assistance under the medicaid program.

(q) “Severe handicapping malocclusion” means a malocclusion resulting from severe skeletal discrepancies that can be objectively documented as causing the following:

(1) Tissue injury;

(2) Significantly impaired speech, mastication, breathing or swallowing; or

(3) Severe psychological trauma or severe antisocial behavior.

(r) “Title XIX” means the joint federal-state program described in Title XIX of the Social Security Act and administered in New Hampshire by the department under the medicaid program.

(s) “Title XXI” means the joint federal-state program described in Title XXI of the Social Security Act and administered in New Hampshire by the department under the medicaid program.

Source. (See Revision Note at chapter heading He-W 500); ss by #5639, eff 6-17-93; ss by #7012, eff 6-15-99; ss by #7912, eff 7-1-03; ss by #9902, eff 6-1-11; amd by #10139, eff 7-1-12; ss by #12782, INTERIM, eff 5-21-19, EXPIRED: 11-18-19

New. #12937, eff 12-7-19

He-W 566.02 Recipient Eligibility. All Title XIX recipients shall be eligible to receive dental services, in accordance with He-W 566.

Source. (See Revision Note at chapter heading He-W 500); ss by #5639, eff 6-17-93; ss by #7012, eff 6-15-99; ss by #7912, eff 7-1-03; ss by #9902, eff 6-1-11; ss by #12782, INTERIM, eff 5-21-19, EXPIRED: 11-18-19

New. #12937, eff 12-7-19

He-W 566.03 Provider Participation. Each participating dental provider shall:

(a) Hold an active license to practice dentistry in the state in which he or she practices;

(b) Be a New Hampshire enrolled Title XIX provider; and

New. #12937, eff 12-7-19

He-W 566.04 Covered Services.

(a) The following dental services shall be covered for recipients who are under 21 years of age:

(1) Prophylaxis, no more frequently than every 150 days;

(2) Restorative treatment;

(3) Periodic examinations, no more frequently than every 150 days, unless they are medically necessary to diagnose an illness or condition;

(4) Vital pulpotomy, which consists of removal of diseased or involved pulp in an effort to retain the remaining pulp in a healthy, vital condition;

(5) Extractions of symptomatic teeth associated with diagnosed pathology, such as tumor, cyst, or infection, except third molars as described in (7) below;

(6) Extractions of asymptomatic teeth, except third molars as described in (7) below, subject to prior authorization in accordance with He-W 566.07, as follows:

a. When associated with diagnosed pathology, such as tumor, cyst, or infection; or

b. When extraction is part of an orthodontic treatment plan that has been approved through prior authorization by the department in accordance with He-W 566.07;

(7) Third molar extraction, subject to prior authorization in accordance with He-W 566.07;

(8) General anesthesia when medically necessary and documented in the recipient’s dental records;

(9) Nitrous oxide analgesia and intravenous therapy sedation;

(10) Comprehensive orthodontic treatment for severe handicapping malocclusion in accordance with He-W 566.05(a), subject to prior authorization in accordance with He-W 566.07;

(11) Interceptive orthodontic treatment in accordance with He-W 566.05(b), subject to prior authorization in accordance with He-W 566.07;

(12) Space maintainers when medically necessary to replace a prematurely lost deciduous or permanent molar or bicuspid;

(13) Limited orthodontic treatment in accordance with He-W 566.05(c);

(14) Radiographs as follows:

a. Complete series or panographic survey, once every 5 years;

b. Bitewings every 12 months if medically necessary; and

c. All types of dental radiographs regardless of limits in a. and b. above, as may be required to complete a differential diagnosis;

(15) Palliative treatment when the claim is submitted in accordance with He-W 566.10(f);

(16) Removable prosthetic replacement of permanent teeth subject to prior authorization in accordance with He-W 566.07;

(17) Topical fluoride treatment applied twice per year until age 21;

(18) If moderate or high risk of caries is documented, 2 applications of silver diamine per tooth, provided that no more than 18 total silver diamine treatments shall be administered per year and no application of silver diamine shall be administered after the recipient reaches the age of 21;

(19) Endodontia, including root canal therapy, excluding third molars, when the claim is accompanied by a radiograph, and the endodontia treatment is deemed complete when all radiographs demonstrate that the canals are completely filled to the apex of the root(s) of the tooth in accordance with He-W 566.10(e);

(20) Crowns;

(21) Periodontal treatment limited to prophylaxis, scaling, and root planing;

(22) Surgical periodontal treatment subject to prior authorization in accordance with He-W 566.07;

(23) Sealants for permanent and deciduous molars every 5 years, until age 21;

(24) Diagnostic and preventive dental services, with the exception of orthodontic treatment as allowed in (b) below, available for EPSDT-eligible children in accordance with He-W 546.05; and

(25) Other services determined by the department to be medically necessary, in accordance with He-W 546.06.

(b) Orthodontic treatment for malocclusions that do not meet the criteria set forth in He-W 566.05(b) shall be considered for orthodontic treatment under the EPSDT prior authorization for coverage based on medical necessity provisions at He-W 546 when documentation of the following is submitted to the department:

(1) Principal diagnosis;

(2) Prognosis with and without treatment;

(3) Date of onset of the illness or condition and etiology, if known;

(4) Clinical significance or functional impairment or pathology caused by the illness or condition resulting from the malocclusion;

(5) Demonstration of evidence of the degree to which the malocclusion contributes to the illness or condition;

(6) Specific types of services to be rendered by each discipline associated with the total treatment plan;

(7) Therapeutic goals to be achieved by each discipline and anticipated time for achievement of goals;

(8) Explanation of any existing conditions that are likely to limit efficacy of treatment;

(9) Extent to which health care services have been previously provided to address the illness or condition and summary of results demonstrated by prior care;

(10) Orthodontic records as described in He-W 566.05(g)(1), (2) and (4); and

(11) Any additional documentation in accordance with He-W 546.06(b) or any other documentation available which might assist in making a determination of medical necessity of the proposed orthodontic treatment.

(c) The documentation submitted in accordance with (b) above shall be completed by health professionals who are sufficiently trained and duly licensed to diagnose and treat the illness or condition arising from the malocclusion and creating the medical necessity for treatment.

(d) The documentation described in (b) and (c) above shall be submitted to the department by the medicaid enrolled provider who will complete the orthodontic treatment along with a request for prior authorization in accordance with He-W 546.06.

(e) The following dental services shall be covered for recipients 21 years of age or over for relief of acute pain or elimination of acute infection or diagnosed pathology:

(1) Palliative treatment when the claim is submitted in accordance with He-W 566.10(f);

(2) Extraction of the causative tooth or teeth and biopsy of the tooth or teeth;

(3) Treatment of severe trauma, when a determination is made by the attending clinician using standard medical parameters for emergency conditions, which shall include, but not be limited to:

a. Hemorrhage;

b. Laceration requiring suturing;

c. Abrasion requiring debridement; or

d. Bone fracture requiring reduction; and

(4) Radiographs and examinations as necessary to assess conditions described in (1)-(3) above.

New. #12937, eff 12-7-19

He-W 566.05 Orthodontic Treatment.

(a) Comprehensive orthodontic treatment shall be covered for recipients under 21 years of age who demonstrate severe handicapping malocclusion, which limits function and if left untreated would result in damage to the dental structures or surrounding tissue, due to one or more of the following conditions:

(1) Crowding of teeth greater than 12 mm in a single arch;

(2) Deep impinging overbite with destruction of tissue;

(3) Crossbite of anterior teeth with destruction of tissue;

(4) Overjet greater than 9 mm;

(5) Reverse overjet greater than 3.5 mm; or

(6) Severe traumatic deviations demonstrated by gross pathology.

(b) Interceptive orthodontic treatment shall be covered for recipients under 21 years of age who have at least one of the following conditions:

(1) Constricted palate;

(2) Deep impinging overbite with demonstration of destruction of tissue;

(3) Anterior crossbite; or

(4) Dentition exhibiting results of harmful habits.

(c) Limited orthodontic treatment shall be covered for recipients under 21 years of age, by report, and no more than once per arch per recipient per lifetime.

(d) Comprehensive and interceptive orthodontic treatment shall:

(1) Each be covered once per recipient per lifetime; and

(2) Require prior authorization in accordance with He-W 566.07.

(e) Sealants shall be present on all permanent molars prior to the provider requesting prior authorization in (d)(2) above.

(f) Any dental provider who undertakes orthodontic treatment for children with severe handicapping malocclusions shall be qualified by training and experience in accordance with Den 302.04.

(g) In addition to the information required at He-W 566.07, prior authorization requests for comprehensive and interceptive orthodontic treatment shall include the following:

(1) A treatment plan, which shall address and include the following:

a. Diagnosis and explanation describing the nature of the severe handicapping malocclusion or functional limitation associated with the malocclusion with sufficient detail and documentation to support and demonstrate the existence of conditions described in (a)-(b) above or He-W 546.05;

b. Justification for early treatment if the request is for comprehensive treatment and deciduous teeth are present or not all of the permanent teeth have erupted;

c. Name of the referring dentist;

d. Description of the chief complaint expressed by the referring dentist or the recipient or legal representative;

e. Specific treatment objectives;

f. Description of the plan for comprehensive oral care during orthodontic treatment;

g. Signed statement from the provider attesting that:

1. The recipient has received an oral examination and was found to be free of untreated oral disease;

2. The recipient demonstrates oral hygiene habits consistent with being able to prevent inflammation and dental decay during orthodontic treatment; and

3. Sealants are in place on all of the recipient’s unrestored erupted molars; and

h. Signed statement from the recipient or legal representative acknowledging the recipient’s understanding and acceptance:

1. Of the provider’s treatment plan including, but not limited to, the recipient’s willingness to adhere to an oral hygiene regimen necessary to prevent inflammation and decay, to attend any scheduled appointments, and to properly wear and maintain the appliance;

2. Of the provider’s right to discontinue treatment for non-compliance, including, but not limited to, the recipient’s failure to adhere to oral hygiene expectations, missed appointments, and failure to properly wear or maintain appliances;

3. That the Title XIX program will not pay for the cost of orthodontic treatment beyond the recipient’s 21st birthday; and

4. That the Title XIX program will not pay for the cost of orthodontic treatment more than once per recipient per lifetime if treatment is terminated due to non-compliance with the treatment plan as documented by the provider;

(2) Diagnostic model taken within 30 days of submitting the prior authorization request;

(3) Treatment cost estimate;

(4) Except as allowed by (h) below, radiographs that are current and of adequate quality to allow for an accurate diagnosis of the malocclusion; and

(5) Assurance that the requested treatment is the least restrictive, most cost-effective treatment for the malocclusion.

(h) When requesting interceptive treatment, photographs may be submitted in lieu of radiographs, provided the photographs clearly demonstrate the criteria being considered for approval.

(i) Banding shall occur within 60 days of the receipt of the prior authorization approval.

(j) Comprehensive orthodontic treatment shall be covered only if the recipient adheres to the treatment plan of care specified at (g)(1) above.

(k) Treatment may be terminated by the provider for non-compliance, including, but not limited to, the recipient’s failure to adhere to oral hygiene expectations, missed appointments, and failure to properly wear or maintain appliances.

(l) Providers shall supply the department with treatment progress reports at the following intervals:

(1) A progress report immediately following the 12th month of treatment, including a description of recipient compliance with the provider’s treatment plan and a report of objectives achieved to date;

(2) A final treatment report, including diagnostic models or post treatment photographs of the dentition in centric relation from center, right and left sides, submitted at the conclusion of treatment which demonstrate that the treatment goals have been met; and

(3) Immediate report of any patterns of non-compliance, if applicable.

New. #12937, eff 12-7-19

He-W 566.06 Non-Covered Services. Non-covered services shall include:

(a) A dental procedure, which is attempted but cannot be completed;

(b) Behavior management or the administration of psychotropic medication to modify the recipient’s behavior in the dental office;

(d) Dental and orthodontic treatment or surgery for the purpose of preserving or improving appearance, except when required for the prompt repair of accidental injury;

(e) Services that have not been proven to be safe or effective, as documented in dental peer review literature;

(f) Fixed prostheses of more than one unit;

(g) Implants and procedures associated with implants such as bone grafting;

(h) Dental services rendered in locations other than the dental office, such as in outpatient hospital settings or ambulatory surgical centers, when such services could be performed in a dentist’s office and there is no medical need for the use of an acute care, outpatient hospital, or ambulatory facility;

(i) Orthodontic treatment for recipients who have failed to comply with a prescribed treatment plan that has been approved through prior authorization by the department, including non-compliance with appointments, hygiene, or care of appliances, with such failure documented by the provider;

(j) Periodic examinations for recipients age 21 or over;

(k) Services that are not dental in nature;

(l) Services that are more costly than other services but are expected to provide the recipient with the same functional outcome;

(m) Replacement or repair of dental appliances required as a result of recipient neglect, wrongful disposition, intentional misuse or abuse;

(n) Extractions of asymptomatic teeth and third molars, unless prior authorized in accordance with He-W 566.07;

(o) Periodontal treatment consisting of subgingival placement of biological materials or chemotherapeutic agents;

(p) Periodontal surgery, unless prior authorized in accordance with He-W 566.07;

(q) The portion of the orthodontic treatment plan carried out after the recipient reaches 21 years of age;

(r) Any treatment, such as extractions, radiographs, examinations, and other services, that are ancillary to an orthodontic treatment plan that has not been prior authorized for medicaid coverage;

(s) Dental records, including casts and radiographs, when such records do not meet the criteria set forth in He-W 566.05(a)-(b) above or He-W 546.05; and

(t) Endodontics, including root canal therapy, that has not been deemed complete in accordance with He-W 566.04(a)(18) and He-W 566.10(e).

New. #12937, eff 12-7-19

He-W 566.07 Prior Authorization.

(a) The following dental services and procedures, as described in He-W 566.04, shall require prior authorization from the department:

(1) Comprehensive and interceptive orthodontic treatment;

(2) Dental orthotic device;

(3) Surgical periodontal treatment;

(4) Extraction of asymptomatic teeth and third molars; and

(5) Removable prosthesis.

(b) Procedures for prior authorization shall be as follows:

(1) The prior authorization shall be for the item or treatment requested and be obtained prior to providing the item or treatment;

(2) Notwithstanding (1) above, for extractions that warrant immediate action, both the prior authorization request and the claim for payment shall be submitted to the address in (4) below after the extraction is performed;

(3) The recipient shall have the primary responsibility for obtaining prior authorization and may do this with the assistance of the provider, who requests authorization on behalf of the recipient; and

(4) Requests for dental prior authorizations shall be addressed to:

New Hampshire Department of Health and Human Services

Office of Medicaid Business and Policy

Dental Director’s Office

Attn: Dental Consultant

129 Pleasant Street

Concord, NH 03301

(c) Requests for prior authorization shall include sufficient, current medical information to enable the department to evaluate the request.

(d) Prior authorization requests for services in (a) above, shall include:

(1) An explanation describing the illness, special care, or specific condition, to enable the department to understand the physical and/or emotional problem of the recipient and the specified goal for which the item or treatment is being requested;

(2) Assurance that the required treatment is the least restrictive, most cost-effective alternative;

(3) Cost of the treatment, if known;

(4) Diagnosis;

(5) Expected outcome and recommended timetable of the prescribed item or treatment;

(6) Name and address of the intended provider;

(7) Name and address of person or agency making the request;

(8) Radiographs;

(9) Periodontal charting when surgical periodontal treatment is requested; and

(10) Recipient name, address, date of birth, and medicaid identification number (MID).

(e) In addition to (d) above, prior authorization requests for the extraction of third molars and asymptomatic teeth shall also include an explanation describing the specific conditions or illness that requires tooth removal and a radiograph supporting the rationale for removal, and shall include the diagnosed pathology, if present, for each tooth requested.

(f) Prior authorization requests for comprehensive and interceptive orthodontic treatment shall include, in addition to the information specified in (c) and (d) above, information specified in He-W 566.05(g).

(g) Prior authorizations shall be approved by the department upon determination that the treatment requested is appropriate, cost effective and supported by the documentation submitted in accordance with (b) through (f) above.

(h) If the department approves the prior authorization request, the state’s fiscal agent shall send written notification of the approval to the provider.

(i) Prior authorization requests for comprehensive and interceptive orthodontic treatment that do not have enough information as required in accordance with He-W 566.05(g) and (c) through (f) above for an approval or denial decision shall be returned to the provider.

(j) All prior authorizations approved shall be provider-specific and shall be non-transferable between providers.

(k) Prior authorization requests for services and procedures specified in (a)(2)-(5) above that do not have enough information as required in accordance with (c) through (e) above for an approval or denial decision shall be returned to the provider.

(l) Providers shall be responsible for determining that the recipient is medicaid eligible on the date of service.

(m) If the department denies the prior authorization request, the department shall forward a notice of denial to the recipient and the provider on the department’s Form 272a, “Medical Assistance Program Denial for Prior Authorized Services,” which includes the following information:

(1) The reason for, and legal basis of, the denial; and

(2) Information that a fair hearing on the denial may be requested within 30 calendar days of the date on the notice of the denial, in accordance with He-C 200.

(n) Decisions made by the department in accordance with (g)-(i) and (k) above shall not be superseded by the treating or consultative health care professional’s prescription, orders, or recommendations.

Source. (See Revision Note at chapter heading He-W 500); ss by #5639, eff 6-17-93; ss by #7012, eff 6-15-99; ss by #7912, eff 7-1-03; ss by #9902, eff 6-1-11; amd by #10031, eff
11-19-11; ss by #12782, INTERIM, eff 5-21-19, EXPIRED: 11-18-19

New. #12937, eff 12-7-19

He-W 566.08 Utilization Review and Control.

(a) The department’s program integrity unit shall monitor utilization of dental services to identify, prevent, and correct potential occurrences of fraud, waste, and abuse in accordance with 42 CFR 455, 42 CFR 456, 42 CFR 1001, and He-W 520.

New. #12937, eff 12-7-19

He-W 566.09 Third Party Liability. All third party obligations shall be exhausted before the Title XIX program shall be billed, in accordance with 42 CFR 433.139, except that if the recipient is under age 21 and is an EPSDT participant or has other medical insurance provided by an absent parent, the Title XIX program shall pay the provider for the service rendered and pursue reimbursement from the other medical insurance.

New. #12937, eff 12-7-19

He-W 566.10 Payment for Services.

(a) Payment for dental services shall be made in accordance with rates established by the department in accordance with RSA 161:4, VI(a).

(b) Dental providers shall submit claims for payment to the department’s fiscal agent.

(c) Pursuant to He-W 566.07(b)(2), for extractions that warrant immediate action, both the prior authorization request and the claim for payment shall be submitted to the address in He-W 566.07(b)(4).

(d) Dental providers shall maintain supporting records, in accordance with He-W 520 and this part.

(e) Payments for endodontic treatments, including root canal treatment, shall be made only when the provider submits a radiograph that demonstrates that the endodontic therapy was successful, effective, and complete when completely filled to the apex of the root(s) of the tooth.

(f) Payment for palliative treatments shall be made only when the provider submits documentation by report that demonstrates that the treatment was completed and the services provided were consistent with palliative treatment as defined in He-W 566.01(n).

(g) Payment for comprehensive orthodontic treatment shall be inclusive of, but not limited to:

(1) All examinations associated with the orthodontic treatment including periodic and emergency examinations;

(2) All periodic adjustments associated with the orthodontic treatment;

(3) All radiographs, diagnostic models, images, and other records associated with the orthodontic treatment;

(4) Space maintenance, when performed by the orthodontic provider within 2 years of the banding;

(5) Appliances as applied;

(6) Application and removal of appliances;

(7) Replacement and repair of brackets, bands, and arch wires;

(8) Retainers and follow-up examinations;

(9) Treatment ancillary to the orthodontia, including, but not limited to, separators and radiographs;

(10) Orthodontically related palliative treatment; and

(11) Closing records.

(h) Payment for interceptive orthodontic treatment shall be inclusive of, but not limited to:

(1) All examinations associated with the orthodontic treatment including periodic and emergency examinations;

(2) All periodic adjustments associated with the orthodontic treatment;

(3) All radiographs, diagnostic models, images, and other records associated with the orthodontic treatment;

(4) Space maintenance, if applicable;

(5) Appliances as applied;

(6) Application and removal of appliances;

(7) Replacement and repair of brackets, bands, and arch wires;

(8) Retainers and follow-up examinations, if applicable;

(9) Treatment ancillary to the orthodontia, including but not limited to separators and radiographs;

(10) Orthodontically related palliative treatment; and

(11) Closing records.

(i) Payments for comprehensive orthodontic treatment for services prior authorized shall be made to the provider in 3 equal installments upon the department’s receipt of an orthodontic claim and as follows:

(1) A payment shall be made following the application of appliances;

(2) A payment shall be made following the completion of the 12th month of treatment and the submission of a progress report as described in He-W 566.05(l)(1); and

(3) A payment shall be made following case completion and the submission of the final treatment report and photographs as described in He-W 566.05(l)(2).

(j) In the event of termination, provider payment for comprehensive treatment shall be prorated as follows:

(1) If the appliances have been applied and the recipient is terminated or transferred before completing 12 months of treatment, the provider shall receive payment in accordance with (i)(1) above plus a payment equal to the reimbursement rate for each periodic adjustment the recipient received; and

(2) If the recipient has completed 12 months of treatment and is terminated prior to case completion, the provider shall receive payment in accordance with (i)(1)-(2) above plus a payment equal to the reimbursement rate for each periodic adjustment the recipient received following the 12th month of treatment, up to 10 adjustments.

(k) If treatment of the recipient is transferred to another provider, the new provider shall:

(1) Request prior authorization for treatment in accordance with He-W 566.07; and

(2) Receive payment based on the terms of the treatment plan that has been approved through prior authorization by the department in accordance with He-W 566.07.

(l) Prior to terminating orthodontic treatment of a recipient, the provider shall remove the appliances and provide retention.

Source. #7012, eff 6-15-99; ss by #7912, eff 7-1-03; ss by #9902, eff 6-1-11; ss by #12782, INTERIM, eff 5-21-19, EXPIRED: 11-18-19

New. #12937, eff 12-7-19

PART He-W 567 HEARING AID SERVICES

He-W 567.01 Definitions.

(a) “Audiogram” means a specific hearing test which charts a person’s hearing sensitivity utilizing an audiometer or other specialized equipment, such as:

(1) Pure tone air audiometry;

(2) Bone conduction testing;

(3) Speech audiometry, including speech reception threshold and speech recognition; and

(4) Auditory brainstem response (ABR) testing which includes measurements of frequency specific thresholds.

(b) “Department” means the New Hampshire department of health and human services.

(c) “Hearing aid” means “hearing aid” as defined in RSA 137-F:2, IV, namely “any wearable instrument or device designed for or offered for the purpose of or represented as aiding or compensating for impaired human hearing and any parts or attachments, including ear molds, but excluding batteries and cords or accessories thereto, or equipment, devices, and attachments used in conjunction with services provided by a public utility company.”

(d) “Hearing aid consultation” means discussion with an audiologist of hearing aid options regarding degree, type, and configuration of hearing loss to determine an appropriate make and model of hearing aid.

(e) “Hearing aid evaluation” means real ear evaluation of the current aids to determine if the aids are adequate to meet the recipient’s needs, or sound field evaluation for devices that cannot be measured via real ear, such as cochlear implants, bone anchored or bone conduction hearing aids.

(f) “Medicaid” means the Title XIX and Title XXI programs administered by the department which makes medical assistance available to eligible individuals.

(g) “Pocket talker” means a portable, personal amplification device that is used to amplify sound and speech or to adjust tone to enhance comprehension of speech, including, but not limited to, a generic device or a device with the brand name “Pocketalker”, “Riezen”, “Listen Up”, or “Super Ear”.

(h) “Recipient” means any individual who is eligible for and receiving medical assistance under the medicaid program.

(i) “Statutory blindness” means “blindness” as defined in Sections 216(i)(1) and 1614(a)(2) of the Social Security Act, 42 USC 416, and 42 USC 1382c.

(j) “Title XIX” means the joint federal-state program described in Title XIX of the Social Security Act and administered in New Hampshire by the department under the medicaid program.

(k) “Title XXI” means the joint federal-state program described in Title XXI of the Social Security Act and administered in New Hampshire by the department under the medicaid program.

Source. (See Revision Note at chapter heading He-W 500); ss by #6157, eff 12-29-95, EXPIRED: 12-29-03

New. #9480, eff 5-23-09, amd by #10139, eff 7-1-12; paras (a)-(e), (g), and (i); EXPIRED 5-23-17; ss by #12538, eff
5-25-18

He-W 567.02 Recipient Eligibility. All medicaid recipients shall be eligible for hearing aid services, in accordance with He-W 567.

Source. (See Revision Note at chapter heading He-W 500); ss by #6157, eff 12-29-95, EXPIRED: 12-29-03

New. #9480, eff 5-23-09, EXPIRED: 5-23-17

New. #12538, eff 5-25-18

He-W 567.03 Provider Participation. Each participating hearing aid services provider shall be:

(a) One of the following:

(1) An audiologist licensed in accordance with RSA 137-F:11 or licensed by the state in which he or she practices; or

(2) A hearing aid dealer registered in accordance with RSA 137-F:8 or credentialed in accordance with applicable law in the state in which he or she practices; and

(b) A New Hampshire enrolled medicaid provider.

Source. (See Revision Note at chapter heading He-W 500); ss by #6157, eff 12-29-95, EXPIRED: 12-29-03

New. #9480, eff 5-23-09, EXPIRED: 5-23-17

New. #12538, eff 5-25-18

He-W 567.04 Service Limits. All hearing aid services shall be subject to the limits set forth in He-W 567 and He-W 530.03.

Source. (See Revision Note at chapter heading He-W 500); ss by #6157, eff 12-29-95, EXPIRED: 12-29-03

New. #9480, eff 5-23-09, EXPIRED: 5-23-17

New. #12538, eff 5-25-18

He-W 567.05 Covered Services. With the exception of those items specified in He-W 567.06, the following hearing aid services and items shall be covered:

(a) When provided by an audiologist or hearing aid dealer:

(1) The hearing aid evaluation or a hearing aid consultation, which shall be limited to one service every 2 years since the last date of service for recipients age 21 or over and as needed for recipients under age 21;

(2) The ear mold(s);

(3) The least costly hearing aid(s) or pocket talker as determined by the audiologist or hearing aid dealer to achieve appropriate access to speech in all of the recipient’s communication settings;

(4) The dispensing or fitting of the hearing aid(s) or pocket talker, including real ear verification for conventional hearing aids, adjustment, and instruction;

(5) Follow-up to include verification of hearing aid or pocket talker performance, if not completed at the fitting, and monitoring of hearing thresholds, as needed; and

(6) The audiogram;

(b) Monaural hearing aids:

(1) For recipients under 21 years of age when:

a. The audiogram indicates a unilateral hearing loss of one or more thresholds of 25 decibels (dB) hearing level (HL) or poorer at any frequency from 1000 hertz (Hz) to 4000 Hz; and

b. The audiologist or hearing aid dispenser deems the loss communicatively significant; and

(2) For recipients 21 years of age or over when the audiogram indicates a bilateral hearing loss with an average threshold of 35 dBHL or poorer for 1000 Hz, 2000 Hz, 3000 Hz, and 4000 Hz by pure tone air conduction;

(1) For recipients under 21 years of age when:

a. The audiogram indicates a bilateral hearing loss of one or more thresholds of 25 dBHL or poorer at any frequency from 1000 Hz to 4000 Hz; and

b. The audiologist or hearing aid dispenser deems the loss communicatively significant; and

(2) For recipients 21 years of age or over, when:

a. A prior authorization has been requested and obtained from the department in accordance with He-W 567.07 in advance of the hearing aid(s) being rendered; and

b. One of the following applies:

1. The coverage criteria for monaural hearing aids per He-W 567.05(b), and one of the following criteria have been met:

(i) The recipient is attending post-secondary school at any educational level for the purpose of obtaining employment or is receiving vocational training, as documented in accordance with He-W 567.08(d); or

(ii) The recipient is employed and is likely to be determined as unable to meet the audiometric requirements of the job without the use of binaural hearing aids, as documented in accordance with He-W 567.08(c); or

2. The recipient meets the definition of statutory blindness per He-W 567.01(i) and as documented in accordance with He-W 567.08(b), and an audiogram indicates a unilateral hearing loss with an average threshold of 35 dBHL or poorer for 1000 Hz, 2000 Hz, 3000 Hz, and 4000 Hz by pure tone air conduction;

(d) Hearing aid batteries for the life span of the hearing aid(s);

(e) Replacement of hearing aids:

(1) If there is an increase in the recipient’s hearing loss, as established by the most recent audiogram, which makes the existing hearing aid ineffective;

(2) If an audiologist or hearing aid dealer determines that the hearing aid can no longer be repaired, or that it is not cost effective to do so; or

(3) If the replacement is due to loss and is coverable under He-W 546 for recipients under age 21;

(f) Hearing aid repairs, which shall not require:

(1) A physician referral; or

(2) An initial purchase by medicaid;

(g) Frequency modulation (FM) systems for recipients under age 21, when a hearing aid on its own does not meet the recipient’s personal amplification needs, or when a traditional hearing aid is not an appropriate option, as determined by an audiologist;

(h) Pocket talkers, to accommodate hearing loss and enhance communications, when:

(1) The audiogram indicates that a recipient has a bilateral hearing loss with an average threshold of 35 dBHL or poorer for 1000 Hz, 2000 Hz, 3000 Hz, and 4000 Hz by pure tone air conduction; and

(2) A hearing aid is not already covered by medicaid;

(i) Replacement of a pocket talker:

(1) With hearing aid(s) or a more effective pocket talker if there is an increase in the recipient’s hearing loss, as established by the most recent audiogram, which makes the existing pocket talker ineffective; or

(2) Once every 5 years; and

(j) Replacement of a headset, earbuds, or neckloop for a pocket talker once every year if an audiologist determines that such accessories are malfunctioning.

Source. (See Revision Note at chapter heading He-W 500); ss by #6157, eff 12-29-95, EXPIRED: 12-29-03

New. #9480, eff 5-23-09; ss by #9739, eff 6-25-10; amd by #10342, eff 6-1-13; ss by #12538, eff 5-25-18

He-W 567.06 Non-Covered Services. Non-covered services shall include, but not be limited to:

(a) Replacement of hearing aids due to loss, misuse, or abuse, except as noted in He-W 567.05(e)(3);

(b) FM systems, if the systems are for the sole purpose of recipient use in an educational setting and are coverable under He-M 1301;

(d) Pocket talker repairs, batteries, accessories, except those listed in He-W 567.05(j) above, and optional telelinks;

(e) A pocket talker if a hearing aid is already covered by medicaid;

(f) A hearing aid if a pocket talker is already covered by medicaid, unless the criterion in He-W 567.05(i)(1) is met; and

(g) Binaural hearing aids for recipients 21 years of age or over when the requirements set forth in He-W 567.05(c)(2) or He-W 567.07 have not been met.

Source. (See Revision Note at chapter heading He-W 500); ss by #6157, eff 12-29-95, EXPIRED: 12-29-03

New. #9480, eff 5-23-09; amd by #10342, eff 6-1-13; ss by #12538, eff 5-25-18

He-W 567.07 Prior Authorization of Binaural Hearing Aids for Recipients 21 Years of Age or Older.

(a) Providers shall direct requests for prior authorization, as required in He-W 567.05(c)(2)a. above, to the department.

(b) Requests for prior authorization shall be submitted in writing and include, at a minimum:

(1) The recipient’s name;

(2) The recipient’s medicaid program identification number;

(3) The recipient’s diagnosis;

(4) The provider’s medicaid ID number;

(5) Clinical documentation that addresses how the request for binaural hearing aids meets the criteria outlined in He-W 567.05(c)(2)b.; and

(6) The signature of the provider.

(c) Prior authorization requested in accordance with (b) above shall be approved by the department if the department determines that the request demonstrates the criteria outlined in He-W 567.05(c)(2)b. have been met.

(d) If the department approves the prior authorization request in accordance with (c) above, the state’s fiscal agent shall send written confirmation of the approval to the provider.

(e) If the department denies the prior authorization request, the department shall forward a notice of denial to the recipient and the provider on the department’s Form 272a, “Medical Assistance Program Denial for Prior Authorized Services,” which includes the following information:

(1) The reason for, and legal basis of, the denial; and

(2) Information that an appeal of the denial may be requested, in accordance with He-C 200, within 30 calendar days of the date on the notice of the denial.

(f) The provider shall be responsible for determining that the recipient is medicaid eligible on the date of service.

Source. #10342, eff 6-1-13; ss by #12538, eff 5-25-18

He-W 567.08 Documentation. The hearing aid services provider shall maintain supporting records, including:

(a) An audiogram;

(b) Audiological and medical data, documenting the required criteria, as established in accordance with He-W 567, to support the request for the hearing aid(s) or pocket talker;

(c) For those recipients 21 years of age or over requesting binaural hearing aids in accordance with He-W 567.05(c)(2)b.1.(ii):

(1) A statement from the recipient’s employer verifying the recipient’s employment status, and including the employer's audiometric requirements for the particular position in which the recipient is employed;

(2) A statement from the audiologist that the recipient cannot meet the employer’s audiometric requirements in (1) without the use of binaural hearing aids; and

(3) An audiogram which supports the audiologist's statement in (2) above; and

(d) A letter from the recipient’s school verifying attendance or documentation confirming the recipient is receiving vocational training, if applicable.

Source. (See Revision Note at chapter heading He-W 500); ss by #6157, eff 12-29-95, EXPIRED: 12-29-03

New. #9480, eff 5-23-09; ss by #9739, eff 6-25-10; renumbered by #10342 (from He-W 567.07); ss by #12538, eff 5-25-18

He-W 567.09 Utilization Review and Control. The department’s program integrity unit shall monitor utilization of hearing aid services to identify, prevent, and correct potential occurences of fraud, waste, and abuse, in accordance with 42 CFR 455, 42 CFR 456, and He-W 520.

Source. (See Revision Note at chapter heading He-W 500); ss by #6157, eff 12-29-95, EXPIRED: 12-29-03

New. #9480, eff 5-23-09, EXPIRED: 5-23-17; renumbered by #10342 (from He-W 567.08); ss by #12538, eff 5-25-18

He-W 567.10 Third Party Liability. All third party obligations shall be exhausted before medicaid shall be billed, in accordance with 42 CFR 433.139.

Source. (See Revision Note at chapter heading He-W 500); ss by #6157, eff 12-29-95, EXPIRED: 12-29-03

New. #9480, eff 5-23-09, EXPIRED: 5-23-17; renumbered by #10342 (from He-W 567.09); ss by #12538, eff 5-25-18

He-W 567.11 Payment for Services.

(a) Payment for hearing aid services shall be made in accordance with rates established by the department in accordance with RSA 161:4, VI(a).

(b) The hearing aid services provider shall submit claims for payment to the department’s fiscal agent.

Source. (See Revision Note at chapter heading He-W 500); ss by #6157, eff 12-29-95, EXPIRED: 12-29-03

New. #9480, eff 5-23-09, EXPIRED: 5-23-17; renumbered by #10342 (from He-W 567.10); ss by #12538, eff 5-25-18

PART He-W 568 PHYSICAL THERAPY, OCCUPATIONAL THERAPY AND SERVICES FOR INDIVIDUALS WITH SPEECH, HEARING AND LANGUAGE DISORDERS

He-W 568.01 Definitions.

(a) “Department” means the New Hampshire department of health and human services.

(b) “Medicaid” means the Title XIX and Title XXI programs administered by the department which makes medical assistance available to eligible individuals.

(d) “Occupational therapy (OT)” means “occupational therapy” as defined in RSA 326-C:1, III.

(e) “Occupational therapy assistant” means “occupational therapy assistant” as defined in RSA 326-C:1, IV.

(f) “Physical therapy (PT)” means the “practice of physical therapy” as defined in RSA 328-A:2, XI.

(g) “Physical therapy assistant” means “physical therapy assistant” as defined in RSA 328-A:2, VIII.

(h) “Recipient” means any individual who is eligible for and receiving medical assistance under the medicaid program.

(i) “Services for speech, hearing and language disorders” means diagnostic, screening, preventive, or corrective speech-language pathology.

(j) “Speech-language pathology (SLP)” means “speech-language pathology” as defined in RSA 326-F:1, IV.

(k) “Speech-language assistant” means “speech-language assistant” as defined in RSA 326-F:1, II-a.

(l) “Title XIX” means the joint federal-state program described in Title XIX of the Social Security Act and administered in New Hampshire by the department under the medicaid program.

(m) “Title XXI” means the joint federal-state program described in Title XXI of the Social Security Act and administered in New Hampshire by the department under the medicaid program.

(n) “Visits” are defined as a meeting scheduled by an individual to see an occupational therapist, physical therapist, or a speech-language pathologist for evaluation, treatment, or advice.

Source. (See Revision Note at chapter heading He-W 500); ss by #4995, eff 11-30-90, EXPIRED: 11-30-96

New. #7909, eff 6-24-03; ss by #9929, INTERIM, eff 6-19-11, EXPIRES: 12-16-11; ss by #10042, eff 12-16-11; amd by #10139, eff 7-1-12; ss by #13355, eff 3-19-22

He-W 568.02 Recipient Eligibility. All Title XIX recipients shall be eligible for physical therapy, occupational therapy, and services for speech, hearing and language disorders, in accordance with He-W 568.

Source. (See Revision Note at chapter heading He-W 500); ss by #4995, eff 11-30-90, EXPIRED: 11-30-96

New. #7909, eff 6-24-03; ss by #9929, INTERIM, eff 6-19-11, EXPIRES: 12-16-11; ss by #10042, eff 12-16-11; ss by #13355, eff 3-19-22

He-W 568.03 Provider Participation.

(a) Each participating physical therapist, occupational therapist, and speech-language pathologist shall:

(1) Be licensed by the state in which they practice; and

(2) Be a NH enrolled Title XIX provider.

(b) Occupational therapy assistants, physical therapy assistants, and speech-language assistants shall not be eligible to enroll as a Title XIX provider but may provide services to Title XIX recipients in accordance with He-W 568.05 below.

Source. (See Revision Note at chapter heading He-W 500); ss by #4995, eff 11-30-90, EXPIRED: 11-30-96

New. #7909, eff 6-24-03; ss by #9929, INTERIM, eff 6-19-11, EXPIRES: 12-16-11; ss by #10042, eff 12-16-11; ss by #13355, eff 3-19-22

He-W 568.04 Service Limits.

(a) The service limits for physical therapy, occupational therapy, and services for speech, hearing and language disorders shall apply to all such services, regardless of whether these services are provided through a hospital outpatient department, another provider, such as a home health agency, or by the individual therapists.

(b) Physical therapy, occupational therapy, and services for speech, hearing and language disorders shall be limited to 20 visits per recipient per state fiscal year.

(c) The 20 visits described in (b) above may be used for physical therapy, occupational therapy, services for speech, hearing and language disorders, or any combination of these services.

Source. (See Revision Note at chapter heading He-W 500); ss by #4995, eff 11-30-90, EXPIRED: 11-30-96

New. #7909, eff 6-24-03; ss by #9929, INTERIM, eff 6-19-11, EXPIRES: 12-16-11; ss by #10042, eff 12-16-11; ss by #13355, eff 3-19-22

He-W 568.05 Covered Services.

(a) Physical therapy, occupational therapy and services for individuals with speech, hearing and language disorders shall be covered when prescribed, in writing, by a physician or other licensed practitioner, for each recipient treated.

(b) Services in (a) above shall be covered:

(1) When performed by the physical therapist, occupational therapist, or speech-language pathologist; or

(2) When performed by a physical therapy assistant, an occupational therapy assistant, or a speech-language assistant working under the direction of a physical therapist, occupational therapist, or a speech-language pathologist, as applicable and in accordance with applicable requirements in Phy 400, Occ 400, or Spe 600.

(c) When services are provided in accordance with (b)(2) above, the individual responsible for the oversight of the assistant shall, in addition to any applicable requirements in Phy 400, Occ 400, or Spe 600:

(1) See the recipient first to conduct the initial assessment and develop a plan of care;

(2) See the recipient periodically thereafter;

(3) Specify the type of care to be provided by the physical therapy assistant, occupational therapy assistant, or speech-language assistant;

(4) Review the need for continued services;

(5) Assume professional responsibility for services provided by the physical therapy assistant, occupational therapy assistant, or speech-language assistant; and

(6) Ensure that services provided are within the scope of the prescribed services.

(d) Hearing aid services and related auditory devices shall be covered subject to the requirements and limits in He-W 567.

Source. (See Revision Note at chapter heading He-W 500); ss by #4995, eff 11-30-90, EXPIRED: 11-30-96

New. #7909, eff 6-24-03; ss by #9929, INTERIM, eff 6-19-11, EXPIRES: 12-16-11; ss by #10042, eff 12-16-11; ss by #13355, eff 3-19-22

He-W 568.06 Prior Authorization.

(a) The provider shall request prior authorization, as specified in He-W 530, for therapy services prescribed in excess of the limits described in He-W 568.04.

(b) Providers of hearing aid services and devices shall request prior authorization in accordance with He-W 567.

Source. (See Revision Note at chapter heading He-W 500); ss by #4995, eff 11-30-90, EXPIRED: 11-30-96

New. #7909, eff 6-24-03; ss by #9929, INTERIM, eff 6-19-11, EXPIRES: 12-16-11; ss by #10042, eff 12-16-11; ss by #13355, eff 3-19-22

He-W 568.07 Utilization Review and Control. The department’s program integrity unit shall monitor utilization of physical therapy, occupational therapy and services for individuals with speech, hearing and language disorders, in accordance with 42 CFR 455, 42 CFR 456, 42 CFR 1001, and He-W 520.

Source. (See Revision Note at chapter heading He-W 500); ss by #4995, eff 11-30-90, EXPIRED: 11-30-96

New. #7909, eff 6-24-03; ss by #9929, INTERIM, eff 6-19-11, EXPIRES: 12-16-11; ss by #10042, eff 12-16-11; ss by #13355, eff 3-19-22

He-W 568.08 Documentation.

(a) Therapy service described in He-W 568.05 above shall be documented, including:

(1) The date of each therapy service provided;

(2) The amount of time spent rendering each therapy service;

(3) A description of the therapeutic modality used during the therapy service;

(4) Measurable short-term and long-term goals;

(5) Objectives of the therapy service provided;

(6) Modalities to be utilized during the therapy service;

(7) Frequency of therapy services prescribed;

(8) An estimation of the duration of treatment;

(9) Ongoing progress notes evaluating the recipient’s progress in relation to the established goals and estimated duration of treatment; and

(10) An indication as to whether the services provided were for individual or group therapy.

(b) The provider shall maintain records to support claims submitted for reimbursement for a period of at least 6 years from the date of service, or until the resolution of any legal action(s) commenced in the 6-year period, whichever is longer.

Source. (See Revision Note at chapter heading He-W 500); ss by #4995, eff 11-30-90, EXPIRED: 11-30-96

New. #7909, eff 6-24-03; ss by #9929, INTERIM, eff 6-19-11, EXPIRES: 12-16-11; ss by #10042, eff 12-16-11; ss by #13355, eff 3-19-22

He-W 568.09 Third Party Liability. All third party obligations shall be exhausted before Title XIX shall be billed in accordance with 42 CFR 433.139.

Source. (See Revision Note at chapter heading He-W 500); ss by #4995, eff 11-30-90, EXPIRED: 11-30-96

New. #7909, eff 6-24-03; ss by #9929, INTERIM, eff 6-19-11, EXPIRES: 12-16-11; ss by #10042, eff 12-16-11; ss by #13355, eff 3-19-22

He-W 568.10 Payment for Services.

(a) Reimbursement to providers of physical therapy, occupational therapy and services for individuals with speech, hearing and language disorders shall be made in accordance with fee schedules established by the department, in accordance with RSA 161:4, VI(a).

(b) The provider shall bill with a therapy procedure code as defined by the American Medicaid Association’s “Current Procedural Terminology (CPT) 2022 Professional Edition” available as noted in Appendix A, and submit claims for payment to the department’s fiscal agent.

(d) Providers shall submit claims for payment for services in accordance with the following:

(1) Only direct treatment by a therapist or a physical therapy assistant, occupational therapy assistant, or speech-language assistant shall be billed, meaning the time the therapist or physical therapy assistant, occupational therapy assistant, or speech-language assistant spends providing direct treatment to one recipient;

(2) Therapists working as a team to treat one or more recipients shall not each bill separately for the same or different service provided at the same time to the same recipient; and

(3) If a recipient requires co-treatment simultaneously by 2 therapists, visits shall be billed separately by each provider for the total time the recipient was receiving actual therapy services.

(e) The time a recipient spends not being treated, for any reason, shall not be billed.

(f) Services provided by a physical therapy assistant, occupational therapy assistant, or speech-language assistant, in accordance with He-W 568.05(b) and (c) above, shall be billed by the enrolled therapist providing oversight of the physical therapy assistant, occupational therapy assistant, or speech-language assistant.

Source. (See Revision Note at chapter heading He-W 500); ss by #4995, eff 11-30-90, EXPIRED: 11-30-96

New. #7909, eff 6-24-03; ss by #9929, INTERIM, eff 6-19-11, EXPIRES: 12-16-11; ss by #10042, eff 12-16-11; ss by #13355, eff 3-19-22

PART He-W 569 RADIOLOGICAL SERVICES

He-W 569.01 Definitions.

(a) “Current procedural terminology (CPT) code” means a unique identifying code in the field of medical nomenclature and designed by US Department of Health and Human Services as the national coding standard utilized in government and private health insurance programs for reporting medical services and procedures.

(b) “Department” means the New Hampshire (NH) department of health and human services, unless otherwise specified.

(c) “Medicaid” means the Title XIX and Title XXI programs administered by the department, which makes medical assistance available to eligible individuals.

d) “Recipient” means an individual who is eligible for and receiving medical assistance under the medicaid program.

(e) “Title XIX” means the joint federal-state program described in Title XIX of the Social Security Act and administered in NH by the department under the medicaid program.

(f) “Title XXI” means the joint federal-state program described in Title XXI of the Social Security Act and administered in NH by the department under the medicaid program.

Source. (See Revision Note at chapter heading He-W 500); ss by #6575, eff 9-12-97; ss by #8400, INTERIM, eff 8-20-05, EXPIRES: 2-16-06; ss by #8562, eff 2-7-06; amd by #10139, eff 7-1-12; ss by #10517, eff 2-7-14, EXPIRED: 2-7-24

New. 14277, eff 6-24-25, EXPIRES: 6-24-35

He-W 569.02 Recipient Eligibility. All medicaid recipients shall be eligible for radiological services, in accordance with He-W 569.

Source. (See Revision Note at chapter heading He-W 500); ss by #6575, eff 9-12-97; ss by #8400, INTERIM, eff 8-20-05, EXPIRES: 2-16-06; ss by #8562, eff 2-7-06; ss by #10517, eff 2-7-14, EXPIRED: 2-7-24

New. #14277, eff 6-24-25; EXPIRES: 6-24-35

He-W 569.03 Provider Participation. All participating radiological service providers shall:

(a) Be licensed by the states in which they practice;

(b) Provide radiological services under the direction of a physician in accordance with 42 CFR 440.30; and

New. 14277, eff 6-24-25, EXPIRES: 6-24-35

He-W 569.04 Service Limits. Radiological services shall be subject to the limits set forth in He-W 530.

New. #14277, eff 6-24-25, EXPIRES: 6-24-35

He-W 569.05 Covered Services. The following radiological services shall be covered when ordered by a physician or other licensed practitioner within the scope of their practice:

(a) Therapeutic radiological services, such as radiation therapy; and

(b) Diagnostic radiological services in accordance with the prior authorization requirements of He-W 569.06.

New. #14277, eff 6-24-25, EXPIRES: 6-24-35

He-W 569.06 Prior Authorization and Review.

(a) The following diagnostic radiological services shall require prior authorization:

(1) Computerized tomography (CT);

(2) Magnetic resonance imaging (MRI);

(3) Magnetic resonance angiography (MRA);

(4) Positive emission tomography (PET); and

(5) Nuclear cardiology.

(b) Diagnostic radiological services specified in (a) above shall be exempt from prior authorization requirements when services are provided:

(1) As part of a hospital emergency department visit;

(2) As part of a recipient’s inpatient hospitalization; or

(3) Concurrently with, or on the same day as, an urgent care facility visit.

(1) Completing and submitting Form 272X, “Request for Service Authorization for Diagnostic Imaging” (June 2025) and certifying that they have obtained and attached a physician’s order and a letter of medical necessity (LMN) in addition to attaching medical records to support the medical necessity of the diagnostic imaging; and

(2) Submitting the clinical information supporting the medical necessity for the request, including, but not limited to, the medical care plan, relevant diagnostic tests, and progress notes, to the department by mail, fax, or e-mail.

(d) When a completed prior authorization request is submitted in accordance with (c) above, the department shall send a written notice of decision to the recipient and the ordering practitioner within 2 business days of the decision being made.

(e) If the department denies the prior authorization request, the written denial notice, provided in accordance with (d) above shall include the following:

(1) The reason for, and the legal basis of, the denial;

(2) A copy of the clinical guidelines used to make the decision; and

(3) Information that a fair hearing on the denial may be requested within 30 calendar days of the date on the notice of the denial, in accordance with He-C 200.

Source. (See Revision Note at chapter heading He-W 500); ss by #6575, eff 9-12-97; ss by #8400, INTERIM, eff 8-20-05, EXPIRES: 2-16-06; ss by #8562, eff 2-7-06; amd by #10342, eff 6-1-13; ss by #10517, eff 2-7-14, EXPIRED: 2-7-24

New. #14277, eff 6-24-25, EXPIRES: 6-24-35

He-W 569.07 Utilization Review and Control.

(a) The department’s bureau of program integrity shall monitor utilization of radiological services, to identify, prevent, and correct potential occurrences of fraud, waste, and abuse, in accordance with 42 CFR 455, 42 CFR 456, He-W 520, and He-W 521.

Source. (See Revision Note at chapter heading He-W 500); ss by #6575, eff 9-12-97; ss by #8400, INTERIM, eff 8-20-05, EXPIRES: 2-16-06; #8562, eff 2-7-06; ss by #10517, eff 2-7-14, EXPIRED: 2-7-24

New. #14277, eff 6-24-25, EXPIRES: 6-24-35

He-W 569.08 Third Party Liability.

(a) All third party obligations shall be exhausted before medicaid may be billed, in accordance with 42 CFR 433.139.

(b) Radiological service providers shall request information from the recipient regarding other insurance coverage.

(c) If other insurance coverage is available, providers shall contact the insurer to verify benefits initially and at least annually thereafter or when the insurance carrier changes.

(d) Radiological service providers shall maintain a record of any other insurance verifications in the recipient’s medical record in accordance with He-W 520 and He-W 521.

Source. (See Revision Note at chapter heading He-W 500); ss by #6575, eff 9-12-97; ss by #8400, INTERIM, eff 8-20-05, EXPIRES: 2-16-06; #8562, eff 2-7-06; ss by #10517, eff 2-7-14, EXPIRED: 2-7-24

New. #14277, eff 6-24-25, EXPIRES: 6-24-35

He-W 569.09 Payment for Services.

(a) Radiological services providers shall bill utilizing the complete radiological examination CPT code to include the following modifiers as described below:

(1) The radiological professional CPT code modifier, which shall include supervision, interpretation, and written report of the radiological examination only;

(2) The technical CPT code modifier which shall include the taking of the radiological examination film only; and

(3) Informational modifiers, if more than one procedure code is billed per day.

(b) Payments to radiological services providers shall be made in accordance with rates established by the department pursuant to RSA 161:4, VI.

(d) Radiological services providers shall maintain supporting documentation, in accordance with He-W 520 and He-W 521.

Source. #8562, eff 2-7-06; ss by #10517, eff 2-7-14; ss by #10517, eff 2-7-14, EXPIRED: 2-7-24

New. #14277, eff 6-24-25, EXPIRES: 6-24-35

PART He-W 570 PHARMACEUTICAL SERVICES

He-W 570.01 Definitions.

(a) “Actual acquisition cost (AAC)” means actual acquisition cost as defined at 42 CFR 447.502, namely, the agency’s determination of the pharmacy providers’ actual prices paid to acquire drug products marketed or sold by specific manufacturers.

(b) “Compound drug” means a drug product prepared by the pharmacist using more than one ingredient.

(d) “Co-payment” means the amount paid by a recipient to a NH medicaid enrolled pharmacy provider for each prescription filled.

(e) “Department” means the New Hampshire department of health and human services.

(f) “Dispensing fee” means a payment for the pharmacist’s service of dispensing drugs.

(g) “Drug efficacy study implementation (DESI) drugs” means drugs found to lack substantial evidence of effectiveness as determined by the Food and Drug Administration (FDA) and also includes identical, related, or similar (IRS) drugs.

(h) “Federal upper limit (FUL)” means the maximum cost allowed by the federal government for certain multiple source drugs.

(i) “General public” means individuals purchasing drugs at the usual and customary retail price.

(j) “Generic equivalent” means an equivalent AB rated drug product that is suitable for drug interchange, approved by the FDA as safe and effective, with the same established generic name, active ingredient, strength, quantity, and dosage form as the drug product identified in the prescription.

(k) “Healthcare common procedure coding system (HCPCS)” means a uniform method for health care providers and medical suppliers to report professional services, procedures, and supplies.

(l) “Identical, related, or similar (IRS) drugs” means a drug interchange or substitution as it applies to DESI drugs.

(m) “Legend drug” means a drug which is dispensed only with a prescription from a licensed practitioner.

(n) “Licensed practitioner” means any person who is lawfully entitled to prescribe, administer, dispense, or distribute legend drugs to patients.

(o) “Maintenance medication” means a drug prescribed for routine continuous daily therapy for at least 120 days.

(p) “Medicaid” means the Title XIX and Title XXI programs administered by the department which makes medical assistance available to eligible individuals.

(q) “National average drug acquisition cost (NADAC)” means a national price benchmark that represents the national average invoice price derived from retail community pharmacies for drug products based on invoices from wholesalers and manufacturers, and which is updated and published weekly by the Centers for Medicare and Medicaid Services (CMS) and available at https://www.medicaid.gov/medicaid/prescription-drugs/pharmacy-pricing/index.html.

(r) “National drug code (NDC)” means the unique 11-digit code number assigned to any drug by the manufacturer identifying drug manufacturer or distributor, drug name, and package size.

(s) “New Hampshire maximum allowable cost (NHMAC)” means the maximum cost allowed by the department for certain multiple source drugs.

(t) “Non-legend drug” means a drug prescribed by a licensed practitioner which is normally purchased over the counter.

(u) “Non-preferred prescription drug” means a drug that has been determined to have an alternative drug available that is clinically equivalent and more cost effective, and which has been clinically reviewed and approved by the NH drug use review board established in He-C 5010 and has been included on the department’s preferred drug list as non-preferred.

(v) “Parenteral” means drug administration other than by the mouth or rectum, such as by injection, infusion, or implantation.

(w) “Patient profile” means a record, whether paper or electronic, of each recipient’s drug history.

(x) “Pharmacist” means “pharmacist” as defined in RSA 318:1, VII.

(y) “Pharmacy benefit manager (PBM)” means the representative designated by the department to administer the drug plan for the medicaid population.

(z) “Pharmacy lock-in program” means a program established to prevent recipients from obtaining excessive quantities of, or from inappropriately using, prescription drugs through multiple pharmacies.

(aa) “Preferred drug list (PDL)” means a formal published list of specific prescription drug products by brand and generic name divided into 2 separate categories as either preferred or non-preferred.

(ab) “Preferred prescription drug” means a drug that has been clinically reviewed and approved by the NH drug use review board established in He-C 5010 and has been included on the department’s preferred drug list based on its proven clinical and cost effectiveness.

(ac) “Prescription” means “prescription” as defined in RSA 318:1, XVI.

(ad) “Primary pharmacy” means the sole pharmacy that is responsible for dispensing and, in accordance with Ph 706, monitoring the drug utilization of a recipient assigned to the pharmacy lock-in program.

(ae) “Prior authorization” means the process by which a prescriber seeks approval from the department, through its designated agent, to make payments for drugs which are considered to have a high potential for misuse or abuse, are high cost, or should be monitored for correct adherence to clinical protocols.

(af) “Recipient” means any individual who is eligible for and receiving medical assistance under the medicaid program.

(ag) “Title XIX” means the joint federal-state program described in Title XIX of the Social Security Act and administered in New Hampshire by the department under the medicaid program.

(ah) “Title XXI” means the joint federal-state program described in Title XXI of the Social Security Act and administered in New Hampshire by the department under the medicaid program.

(ai) “Unit dose drug” means the individually packaged dosage form of a drug.

(aj) “Usual and customary” means “usual and customary” as defined in RSA 126-A:3 III(b).

(ak) “Wholesale acquisition cost (WAC)” means the drug manufacturer’s list price to wholesale distributors or direct purchasers, not including prompt pay or other discounts, rebates, or reductions in price, as reported in wholesale price guides or other publications of drug or biological pricing data.

Source. (See Revision Note at chapter heading He-W 500); ss by #5742, eff 12-1-93, EXPIRED: 12-1-99

New. #7392, eff 10-28-00; ss by #7680, eff 4-20-02; ss by #7712, INTERIM, eff 6-22-02, EXPIRED: 12-19-02

New. #7805, eff 12-21-02; ss by #9831, eff 12-21-10; amd by #10139, eff 7-1-12; amd by #11101, eff 5-25-16; amd by #12140, eff 4-1-17; ss by #12529, eff 5-22-18

He-W 570.02 Recipient Eligibility. All medicaid recipients shall be eligible for pharmaceutical services, in accordance with He-W 570.

Source. (See Revision Note at chapter heading He-W 500); ss by #5742, eff 12-1-93, EXPIRED: 12-1-99

New. #7392, eff 10-28-00; ss by #7680, eff 4-20-02; ss by #7712, INTERIM, eff 6-22-02, EXPIRED: 12-19-02

New. #7805, eff 12-21-02; ss by #9831, eff 12-21-10; ss by #12529, eff 5-22-18

He-W 570.03 Provider Participation. Each participating pharmacy provider shall be:

(a) One of the following:

(1) A registered or licensed pharmacy in the state in which the pharmacy is located; or

(2) A mail-order pharmacy registered or licensed in a state outside New Hampshire that is registered in New Hampshire and has been issued a permit by the NH pharmacy board pursuant to RSA 318:37, II;

(b) A licensed practitioner authorized to dispense drugs, pursuant to RSA 318 or applicable state law in which the pharmacy is located; and

Source. (See Revision Note at chapter heading He-W 500); ss by #5742, eff 12-1-93, EXPIRED: 12-1-99

New. #7392, eff 10-28-00; ss by #7680, eff 4-20-02; ss by #7712, INTERIM, eff 6-22-02, EXPIRED: 12-19-02

New. #7805, eff 12-21-02; ss by #9831, eff 12-21-10; ss by #12529, eff 5-22-18

He-W 570.04 Covered Items. With the exception of those items specified in He-W 570.05, the following FDA approved drugs, if rated effective, and if produced by manufacturers who are participating in the United States Department of Health and Human Services' (USDHHS) drug rebate agreement, shall be covered when prescribed by a licensed practitioner and subject to the prior authorization requirements in He-W 570.06:

(a) Legend drugs, only when prescribed as part of the course of medical treatment for a specific illness, injury, or disease for use specified by the FDA, or for non-experimental purposes, as supported by accepted medical practice, and in accordance with He-W 570.08;

(b) Select non-legend drugs, with the exception of those specified in He-W 570.05 and, only when prescribed as part of the course of medical treatment for a specific illness, injury, or disease for use specified by the FDA, or for non-experimental purposes, as supported by accepted medical practice, and in accordance with (c) below and He-W 570.08;

(1) Antihistamines;

(2) Antacids and H2-Receptor Agonists;

(3) Analgesics, salicylates, and antipyretics;

(4) Magnesium, iron, niacin, and calcium;

(5) Ganglionic stimulants;

(6) Laxatives and cathartics;

(7) Hyperglycemics;

(8) Topical steroids;

(9) Vaginal and topical antifungals;

(10) Topical antimicrobials;

(11) Lice treatments; and

(12) Oral contraceptives;

(d) Opioid rescue, both brand and generic;

(e) Compound drugs when at least one ingredient can be identified by a rebatable NDC; and

(f) Nutritional supplements when needed to sustain life.

Source. (See Revision Note at chapter heading He-W 500); ss by #5742, eff 12-1-93, EXPIRED: 12-1-99

New. #7392, eff 10-28-00; ss by #7680, eff 4-20-02; ss by #7712, INTERIM, eff 6-22-02, EXPIRED: 12-19-02

New. #7805, eff 12-21-02; ss by #8372, eff 8-1-05; ss by #9586, eff 11-4-09, EXPIRED: 11-4-17

New. #12421, INTERIM, eff 11-21-17, EXPIRED: 5-20-18

New. #12529, eff 5-22-18; ss by #13880, eff 2-21-24

He-W 570.05 Non-Covered Items. Non-covered items shall include:

(a) Experimental or investigational drugs not approved by the FDA;

(b) Drugs listed by the FDA as being DESI drugs or IRS drugs;

(d) Non-legend drugs when:

(1) A legend drug effecting the same health outcome is available and:

a. Is more clinically effective; or

b. Is therapeutically equivalent and more cost effective; or

(2) The non-legend drug is being used to primarily treat discomfort or to maintain comfort, including, but not limited to:

a. Antidiarrheals;

b. Antiflatulants;

c. Nasal decongestants;

d. Eye and ear preparations; and

e. Topical antipruitics;

(e) Non-legend drugs and supplies, which are household and medicine chest items, including, but not limited to:

(1) Band-aids;

(2) Corn plasters;

(3) Contact lens products;

(4) Cough drops and lozenges;

(5) Mouthwash;

(6) Nursery supplies;

(7) Nutritional supplements when not needed to sustain life;

(8) Odor barrier products;

(9) Personal hygiene items;

(10) Sunscreen;

(11) Soaps and cleansers;

(12) Acne products;

(13) Products to mitigate seborrheic dermatitis; and

(14) Fluoride preparations;

(f) Legend and non-legend drugs used for the symptomatic relief of cough and colds, pursuant to Section 1396r-8(d)(2)(D) of the Social Security Act;

(g) Legend and non-legend drugs used for cosmetic purposes or hair growth, pursuant to Section 1396r-8(d)(2)(C) of the Social Security Act;

(h) Legend and non-legend drugs which enhance or promote fertility or procreation, or for which the labeled use is ovulation stimulation, pursuant to Section 1396r-8(d)(2)(B) of the Social Security Act;

(i) Legend and non-legend drugs without a prescription from a licensed practitioner;

(j) Legend and non-legend drugs when used for the treatment of sexual or erectile dysfunction, unless such agents are used to treat a condition, other than sexual or erectile dysfunction, for which the agents have been approved by the FDA, pursuant to Section 1396r-8(d)(2)(k); and

(k) Items which are free to the general public.

Source. (See Revision Note at chapter heading He-W 500); ss by #5742, eff 12-1-93; amd by #5874, eff 8-1-94; ss by #7392, eff 10-28-00; ss by #7680, eff 4-20-02; ss by #7712, INTERIM, eff 6-22-02, EXPIRED: 12-19-02

New. #7805, eff 12-21-02; ss by #8372, eff 8-1-05; ss by 8628, eff 5-6-06; ss by #9831, eff 12-21-10; ss by #12529, eff 5-22-18

He-W 570.06 Prior Authorization.

(a) Coverage of drugs subject to prior authorization shall be in accordance with this section.

(b) Drugs shall be subject to prior authorization based on the following:

(1) The recommendations of the NH drug use review board made pursuant to He-C 5010.07;

(2) The abuse potential of the drug;

(3) Whether the drug is new to the market;

(4) The possibility for off-label use of the drug;

(5) The cost of the drug; and

(6) Any other safety or efficacy concerns.

(d) Prior authorization requests for a drug shall be approved or denied based on the following:

(1) Diagnosis;

(2) Whether or not the drug is prescribed for on or off label use;

(3) Dosage;

(4) The recipient’s age;

(5) The drug class; and

(6) Any other factor concerning safety, efficacy, or individual recipient medical concerns.

(e) The criteria in (d) above shall be posted on the department’s website.

(f) The procedure for requesting prior authorization shall be as follows:

(1) The licensed practitioner or their designated agent shall initiate the prior authorization process on behalf of the recipient by contacting the PBM by telephone or other telecommunication device;

(2) The certified pharmacy technician at the PBM shall collect information from the requestor in (f)(1) above regarding the drug prescribed, to determine whether the criteria for approval have been met;

(3) The certified pharmacy technician at the PBM shall then either:

a. Grant immediate approval when all criteria, as approved by the department, in accordance with (d) above have been met; or

b. Transfer the request to a pharmacist at the PBM when the information furnished does not satisfy the criteria approved by the department in (d) above or when it cannot be determined whether the criteria approved by the department in (d) above have been met; and

(4) If the request or caller is transferred to the pharmacist at the PBM pursuant to (f)(3)b. above, the pharmacist shall further discuss the recipient’s specific needs with the requestor in (f)(1) above and either:

a. Grant immediate approval when all criteria approved by the department in (d) above have been met; or

b. Issue a denial in accordance with (i) below.

(g) The PBM shall respond to prior authorization requests by telephone or other telecommunication device within 24 hours of the initial request, in accordance with Section 1927(d)(5) of the Social Security Act.

(h) While the prior authorization is being considered, a 72-hour supply of medication shall be provided to the recipient in an emergency, in accordance with Section 1927(d)(5) of the Social Security Act.

(i) When a prior authorization request is denied, the department shall forward a written letter of denial to the recipient and the licensed practitioner that states the following:

(1) The drug being denied;

(2) The reason for the denial;

(3) The legal basis for the denial;

(4) Information on how the recipient can file an appeal in accordance with He-C 200; and

(5) That a denial may be appealed by the recipient within 30 calendar days from the date the denial was issued.

(j) When a subsequent prior authorization request is denied for a drug for which a prior authorization was granted in accordance with (g)(1) above, the department shall forward a written notice of denial to the recipient and the prescribing, licensed practitioner that states the following:

(1) The drug being denied;

(2) The reason for the denial;

(3) The legal basis for the denial;

(4) Information on how the recipient can file an appeal in accordance with He-C 200;

(5) That a denial may be appealed by the recipient within 30 calendar days from the date the denial was issued; and

(6) That the recipient has 10 days from the date of the written notification to request the continuation of the original drug for which an initial prior authorization request was granted, pending the completion of the appeal process.

Source. (See Revision Note at chapter heading He-W 500); ss by #5742, eff 12-1-93; ss by #5875, eff 7-27-94, EXPIRED: 7-27-00

New. #7392, eff 10-28-00; ss by #7680, eff 4-20-02; ss by #7712, INTERIM, eff 6-22-02, EXPIRED: 12-19-02

New. #7805, eff 12-21-02; ss by #9586, eff 11-4-09, EXPIRED: 11-4-17

New. #12421, INTERIM, eff 11-21-17, EXPIRED: 5-20-18

New. #12529, eff 5-22-18

He-W 570.07 Pharmacy Lock-In Program.

(a) The department shall conduct recipient utilization reviews in accordance with He-W 520.04 and in consideration of the recommendations of the DUR board pursuant to He-C 5010.07(j) to determine if prescribed drugs are being utilized at a frequency or amount that results in a demonstrated pattern of excessive or inappropriate utilization of services.

(b) If it is determined from the utilization review in (a) above that the recipient utilized excessive or inappropriate pharmaceutical services, the recipient shall be enrolled into the pharmacy lock-in program pursuant to 42 CFR 431.54(e), for a 12-month period.

(c) Recipients shall be notified by the department in writing of their enrollment into the pharmacy lock-in program at least 30 days prior to the effective date of their enrollment.

(d) The written notification to the recipient shall include:

(1) The date of their enrollment into the pharmacy lock-in program;

(2) Instructions for the recipient to choose a primary pharmacy, within 21 days of the date of the written notification, as their only source for obtaining all prescribed drugs;

(3) Notification that if the recipient fails to choose a primary pharmacy in accordance with (d)(2) above, or if the pharmacy is unwilling or unable to be the primary pharmacy, the department shall select a primary pharmacy for the recipient based on the recipient’s previous pharmacy use and geographical location; and

(4) The recipient's rights to appeal pharmacy lock-in and request a fair hearing within 30 days of the date on the written notification, pursuant to 42 CFR 431.54(e), and in accordance with He-C 200, if the recipient disagrees with the department’s decision.

(e) If the primary pharmacy is selected by the recipient pursuant to (d)(2) above, the department shall notify the primary pharmacy in writing of its selection at least 7 business days prior to the effective date of the recipient's enrollment into the pharmacy lock-in program.

(f) If the primary pharmacy is selected by the department pursuant to (d)(3) above, the department shall notify the recipient and the primary pharmacy in writing of its selection at least 7 business days prior to the effective date of the recipient's enrollment into the pharmacy lock-in program.

(g) Recipients enrolled in the pharmacy lock-in program shall have the following service restrictions:

(1) Recipients shall be identified through a claims transaction from the PBM to the non-primary pharmacy as having a service restriction that states “Medication Control. Recipient Restricted to Primary Pharmacy”;

(2) Except as set forth in (g)(3) below, only the recipient’s primary pharmacy may receive payment from the department for drugs dispensed to a recipient with the restriction set forth in (g)(1) above; and

(3) If a pharmacy other than the primary pharmacy determines that a recipient is unable to access his or her primary pharmacy due to the recipient being out of area, or due to the primary pharmacy not being open or not having the prescribed drug available, the non-primary pharmacy may contact the PBM to request permission to dispense a 72-hour emergency supply of a drug to a restricted recipient in accordance with 42 CFR 431.54(e)(3).

(h) Recipients enrolled in the pharmacy lock-in program may change their primary pharmacy only:

(1) Upon the request of the primary pharmacy;

(2) If the recipient moves; or

(3) If the primary pharmacy disenrolls from the medicaid program.

(i) If the department implements a change pursuant to (h) above, the department shall notify the new primary pharmacy and the recipient, in writing, of the effective date of the change.

(j) Eligible recipients who become ineligible for medicaid services during their 12-month pharmacy lock-in enrollment period, shall be reinstated into the pharmacy lock-in program for the balance of the enrollment period, lasting until the originally calculated ending date, should they again become eligible for medicaid services prior to the originally calculated lock-in end date.

(k) Within the last 3 months of the 12 month lock-in period, the department shall conduct a review of the recipient's prior 6 months of utilization of pharmaceutical services pursuant to (a) above and in consideration of the recommendations of the DUR board pursuant to He-C 5010.07(j), to determine whether the recipient has continued to utilize excessive or inappropriate pharmaceutical services.

(l) If the utilization review in (k) above no longer shows a demonstrated pattern of excessive or inappropriate utilization of pharmacy services, the recipient shall be released from the lock-in.

(m) Recipients shall be notified by the department in writing of their release from the pharmacy lock-in program within 30 days after the end date of their lock-in.

(n) The written notification to the recipient shall include:

(1) The date that the recipient’s lock-in ended; and

(2) Notification that the recipient may utilize any medicaid enrolled pharmacy.

(o) If the utilization review in (k) above shows no improvement in the recipient’s pattern of excessive or inappropriate utilization of pharmacy services, the recipient shall continue to be enrolled in the lock-in program for an additional 24 months.

(p) Recipients shall be notified by the department in writing of of their continued enrollment into the pharmacy lock-in program in accordance with He-W 570.07(c) and (d).

(q) Within the last 3 months of the 24 month lock-in period, the department shall conduct a review in accordance with (k) above.

(r) If the utilization review in (k) above shows some improvement in the recipient’s pattern of excessive or inappropriate utilization of pharmacy services, the recipient shall continue to be enrolled in the lock-in program for an additional 12 months after completion of the prior 12-month lock-in.

(s) Recipients shall be notified by the department in writing of their continued enrollment into the pharmacy lock-in program in accordance with He-W 570.07(c) and (d).

(t) Within the last 3 months of the 12 month lock-in period, the department shall conduct a review in accordance with (k) above.

Source. (See Revision Note at chapter heading He-W 500); ss by #5742, eff 12-1-93, EXPIRED: 12-1-99

New. #7392, eff 10-28-00; ss by #7680, eff 4-20-02; ss by #7712, INTERIM, eff 6-22-02, EXPIRED: 12-19-02

New. #7805, eff 12-21-02; ss by #8636, eff 5-26-06; ss by #9586, eff 11-4-09, EXPIRED: 11-4-09

New. #12421, INTERIM, eff 11-21-17, EXPIRED: 5-20-18

New. #12529, eff 5-22-18

He-W 570.08 Prescription Drug Dispensing Limitations. The following dispensing limitations shall apply to prescriptions drugs:

(a) Pharmacists shall follow current standards of practice in accordance with Ph 501.01;

(b) Non-controlled drug prescriptions shall be refilled pursuant to Ph 704.14;

(d) Controlled drug substances shall follow refill requirements pursuant to 21 CFR 1306.22;

(e) Refill extensions authorized by the prescribing, licensed practitioner shall be treated as a new prescription; and

(f) Maintenance drugs shall be dispensed in a quantity sufficient to treat the recipient as follows:

(1) Solid oral drugs shall be dispensed as:

a. A minimum supply of 28 days and a maximum supply of 12 months for oral contraceptives; and

b. A minimum supply of 30 days and a maximum supply of 90 days for solid oral drugs with the exception of oral contraceptives, as described in (f)(1)a. above;

(2) If the prescribing, licensed practitioner’s professional judgment indicates possession of the minimum supply of solid oral drugs, as described in (f)(1) above, would not be in the patient’s best medical interest, the prescribing, licensed practitioner shall clearly indicate, on the prescription, that an exception to the minimum supply is being made; and

(3) For non-solid drugs, such as ointments, aerosols, injectables, and liquids, the drug shall be dispensed in the most commonly dispensed sized container to cover a minimum of 7 days of therapy.

Source. (See Revision Note at chapter heading He-W 500); ss by #5742, eff 12-1-93, EXPIRED: 12-1-99

New. #7392, eff 10-28-00; ss by #7680, eff 4-20-02; ss by #7712, INTERIM, eff 6-22-02, EXPIRED: 12-19-02

New. #7805, eff 12-21-02; ss by #9831, eff 12-21-10; ss by #12529, eff 5-22-18; amd by #12698, eff 12-28-18

He-W 570.09 Certification of Prescriptions. Certification for specific brand, NHMAC, and FUL drugs, shall conform to the following:

(a) The certification shall be in the licensed practitioner’s own handwriting, or the pharmacist’s own handwriting if a telephone order;

(b) The hand-written certification shall state the term “brand necessary” or “brand medically necessary”;

(d) Drugs certified as “brand necessary” or “brand medically necessary” shall be subject to prior authorization in accordance with He-W 570.06.

Source. (See Revision Note at chapter heading He-W 500); ss by #5742, eff 12-1-93, EXPIRED: 12-1-99

New. #7392, eff 10-28-00; ss by #7680, eff 4-20-02; ss by #7712, INTERIM, eff 6-22-02, EXPIRED: 12-19-02

New. #7805, eff 12-21-02; ss by #9831, eff 12-21-10; ss by #12529, eff 5-22-18

He-W 570.10 Documentation and Retention. The following requirements shall apply to documentation maintained for pharmaceutical services pursuant to RSA 318:47:

(a) The pharmacy provider shall maintain supporting records for all drugs dispensed, in accordance with He-W 520, including specific refill orders documented at the time of original fill; and

(b) Prescription documentation and retention shall meet the requirements of RSA 318:47-c, except that such records shall be retained for at least 6 years.

Source. (See Revision Note at chapter heading He-W 500); ss by #5742, eff 12-1-93, EXPIRED: 12-1-99

New. #7392, eff 10-28-00; ss by #7680, eff 4-20-02; ss by #7712, INTERIM, eff 6-22-02, EXPIRED: 12-19-02

New. #7805, eff 12-21-02; ss by #9831, eff 12-21-10; ss by #12529, eff 5-22-18

He-W 570.11 Utilization Review and Control. The department’s provider integrity unit shall monitor utilization of pharmaceutical services to identify, prevent, and correct potential occurrences of fraud, waste, and abuse in accordance with 42 CFR 455, 42 CFR 456, and He-W 520.

Source. (See Revision Note at chapter heading He-W 500); ss by #5742, eff 12-1-93, EXPIRED: 12-1-99

New. #7392, eff 10-28-00; ss by #7680, eff 4-20-02; ss by #7712, INTERIM, eff 6-22-02, EXPIRES: 12-19-02

New. #7805, eff 12-21-02; ss by #9831, eff 12-21-10; ss by #12529, eff 5-22-18

He-W 570.12 Third Party Liability. All third party obligations shall be exhausted before claims shall be submitted to the department’s PBM or its fiscal agent.

Source. (See Revision Note at chapter heading He-W 500); ss by #5742, eff 12-1-93, EXPIRED: 12-1-99

New. #7392, eff 10-28-00; ss by #7680, eff 4-20-02; ss by #7712, INTERIM, eff 6-22-02, EXPIRED: 12-19-02

New. #7805, eff 12-21-02; ss by #9831, eff 12-21-10; ss by #12529, eff 5-22-18

He-W 570.13 Prescription Co-payment. Recipients shall make co-payments to the pharmacy provider for drug products as follows:

(a) A co-payment in the amount of $1.00 shall be required for each preferred prescription drug and each refill of a preferred prescription drug dispensed;

(b) A co-payment in the amount of $2.00 shall be required for each non-preferred prescription drug and each refill of a non-preferred prescription drug dispensed unless the prescribing provider determines that a preferred prescription drug will be less effective for the recipient, will have adverse effects for the recipient, or both, in which case the co-payment shall be $1.00;

(c) A co-payment in the amount of $1.00 shall be required for a prescription drug that is not identified as either a preferred or non-preferred prescription drug; and

(d) Co-payments for drug products shall not be required:

(1) Of recipients with income at or below 100% of the federal poverty level (FPL);

(2) Of recipients in a nursing facility, hospital, intermediate care facility for individuals with intellectual disabilities, or other medical institution;

(3) Of recipients participating in the home and community based care (HCBC) waiver programs;

(4) Of recipients receiving services that relate to pregnancy in accordance with 42 CFR 447.53 (b)(2), or any other medical condition that might complicate the pregnancy;

(5) Of recipients under the age of 18;

(6) For family planning products;

(7) For clozaril or clozapine prescriptions;

(8) Of women eligible through the Breast and Cervical Cancer Treatment Program, pursuant to 42 CFR 435.213;

(9) Of recipients receiving hospice care pursuant to He-W 544; and

(10) Of individuals who are members of a federally recognized Indian tribe or Alaskan natives who have ever been served through the Indian Health Services Program, pursuant to 42 CFR 447.56(a)(x).

Source. (See Revision Note at chapter heading He-W 500); ss by #5742, eff 12-1-93, EXPIRED: 12-1-99

New. #7392, eff 10-28-00; ss by #7680, eff 4-20-02; ss by #7712, INTERIM, eff 6-22-02, EXPIRED: 12-19-02

New. #7805, eff 12-21-02; ss by #7976, eff 10-22-03; ss by #9831, eff 12-21-10; ss by #10716, eff 11-18-14; ss by #11101, eff 5-25-16; ss by #12529, eff 5-22-18; ss by #12698, eff 12-28-18

He-W 570.14 Payment for Drugs.

(a) Payment for drugs shall be:

(1) Made for products whose manufacturer has a signed rebate agreement with the USDHHS, or for single or innovator multiple-source products exempt from such agreements, pursuant to Section 4401 of P.L. 101-508, OBRA ‘90;

(2) Reimbursed at the lesser of the following:

a. The AAC using NADAC files when available, plus the dispensing fee;

b. The WAC, when a NADAC is not available, plus the dispensing fee;

c. The usual and customary charge to the general public;

d. The NHMAC plus the dispensing fee; or

e. The FUL plus the dispensing fee; and

(3) Subject to the following conditions and restrictions:

a. The payment for multiple source drugs, listed as having a FUL by the USDHHS, shall be reimbursed at a rate which does not exceed the FUL plus the dispensing fee, except as determined by the CMS of the USDHHS;

b. The payment for multiple source drugs, listed as having a NHMAC by the department, shall be reimbursed at a rate which does not exceed the maximum allowable cost plus the dispensing fee;

c. The NHMAC and FUL shall not apply when a licensed practitioner certifies on the face of the prescription in his or her own handwriting, pursuant to He-W 570.09, that a specific brand of drug, which is a NHMAC or FUL drug, is medically necessary for a particular recipient;

d. The payment for any refill prescriptions for the same recipient for solid oral maintenance drugs within a time period that does not allow for usage of 75% of the supply of the drug shall be only for the cost of the drug unless the reason for the exception is documented on the prescription or the licensed practitioner’s order; and

e. The payment for compound drugs and sterile preparations for parenteral use shall be at the rate established by the department in accordance with RSA 161:4, VI(a).

(b) For a unit dose drug:

(1) The unit dose form of tablets and capsules shall be reimbursable only for medicaid recipients residing in nursing facilities and other facilities licensed under RSA 151;

(2) Unused portions of unit dose drugs shall be returned by the licensed facility in (b)(1) above to the pharmacy provider when allowed in accordance with 21 CFR 1306 or applicable state law;

(3) Unit dose credit shall be submitted by the pharmacy provider to the department, within 90 days of such return;

(4) The original claim shall be voided by the pharmacy provider and a new claim submitted for the actual amount used;

(5) A pharmacy provider shall use the manufacturer’s unit dose package or his or her own unit dose package which meets the requirements of US pharmacopoeia dispensing information (USPDI) unit dose packages; and

(6) Claims for unit dose packages shall be submitted only at the end of any monthly period.

(d) The pharmacy provider shall submit medical supply and equipment claims with NDCs for payment to the PBM.

(e) The pharmacy provider shall submit medical supply and equipment claims with HCPCS codes for payment to the department’s fiscal agent.

(f) The pharmacy provider shall make available to the department the following documents for utilization and review purposes:

(1) All prescriptions for both medicaid recipients and non-medicaid recipients filled during the time period specified by the department, with all identifying information blocked out;

(2) All price lists that were in effect for such time period; and

(3) Invoices showing the actual acquisition cost of the drugs and supplies.

Source. #7680, eff 4-20-02; ss by #7712, INTERIM, eff 6-22-02, EXPIRED: 12-19-02

New. #7805, eff 12-21-02; ss by #9831, eff 12-21-10; amd by #12140, eff 4-1-17; ss by #12529, eff 5-22-18

PART He-W 571 DURABLE MEDICAL EQUIPMENT, PROSTHETIC AND ORTHOTIC DEVICES, AND MEDICAL SUPPLIES

He-W 571.01 Definitions.

(a) “Apnea of prematurity” means that one of the following has occurred to an infant:

(1) The sudden cessation of breathing that lasts for at least 20 seconds;

(2) The sudden cessation of breathing for any length of time, which is accompanied by bradycardia, which means a heart rate less than 80 beats per minute;

(3) O₂ desaturation, which means O₂ saturation of less than 90% with cyanosis or pallor in an infant younger than 37 weeks gestation; or

(4) The presence of marked hypotonia.

(b) “Apparent life-threatening event (ALTE)” means one or more of the following conditions affecting an infant:

(1) Apnea;

(2) Change in skin color;

(3) Marked change in muscle tone, usually marked limpness; or

(4) Choking and gagging.

(c) “Clean claim(s)” means a claim that can be processed without obtaining additional information from the dispensing provider or from a third party, including a claim with errors originating in the state’s claims system, and not including a claim from a dispensing provider who is under investigation for fraud or abuse or a claim under review for medical necessity.

(d) “Date of service” means the date that the item is delivered to or received by the recipient except:

(1) For custom wheelchairs, the date the custom wheelchair is ordered;

(2) For custom fabricated prosthetic and orthotic devices, the date of fabrication;

(3) For frame and seating systems to pediatric and adult wheelchairs, the date of the order; or

(4) For medical supplies that are dropped shipped, the date of shipment.

(e) “Department” means the New Hampshire department of health and human services.

(f) “Dispensing provider” means the company or the company’s authorized representative providing the item to the recipient.

(g) “Durable medical equipment (DME)” means a type of item that is:

(1) Non-disposable and able to withstand repeated use;

(2) Primarily used to serve a medical purpose for the treatment of an acute or chronic medically diagnosed health condition, illness, or injury; and

(3) Not useful to an individual in the absence of an acute or chronic medically diagnosed health condition, illness, or injury.

(h) “Item(s)” means any DME, prosthetic devices, mobility devices, orthotic devices, or medical supplies.

(i) “Letter of medical necessity (LMN)” means a letter, signed by the ordering physician, physician assistant, or advanced practice registered nurse (APRN) certifying the need for the item being requested.

(j) “Life sustaining” means medical interventions that utilize mechanical or other artificial means to sustain, restore, or supplant a vital function, which serve only or primarily to prolong the moment of death, and where, in the judgment of the attending and consulting physicians, as reflected in the recipient’s medical records, death is imminent if such interventions are not utilized.

(k) “Medicaid” means the Title XIX and Title XXI programs administered by the department, which makes medical assistance available to eligible individuals.

(l) “Medical supplies” means a type of consumable or disposable item appropriate for relief or treatment of a specific medically diagnosed health condition, illness, or injury.

(m) “Mobility devices” means a type of item specifically designed for use by individuals with a mobility-related injury, illness, or disability that helps the individual walk or move from place to place, and includes manual and power wheelchairs, strollers, scooters, walkers, gait trainers, crutches, canes, or similar devices.

(n) “Monthly quantity” means the amount of medical supplies allowed per month.

(o) “Orthotic devices” means a type of orthopedic item that is applied externally to the limb or body to:

(1) Protect against injury;

(2) Support a weak or deformed portion of the body; or

(3) Prevent or correct a physical deformity or malfunction.

(p) “Prosthetic devices” means a non-dental, artificial type of replacement, corrective or supportive device or part of a device used to:

(1) Replace a missing portion of the body; or

(2) Replace a missing function of the body.

(q) “Provider” means a New Hampshire licensed ordering physician, APRN, physician assistant, or an ordering occupational or physical therapist specializing in rehabilitation medicine.

(r) “Recipient” means any individual who is eligible for and receiving medical assistance under the medicaid program.

(s) “Title XIX” means the joint federal-state program described in Title XIX of the Social Security Act and administered in New Hampshire by the department under the medicaid program.

(t) “Title XXI” means the joint federal-state program described in Title XXI of the Social Security Act and administered in New Hampshire by the department under the medicaid program.

Source. (See Revision Note at chapter heading He-W 500); ss by #6158, eff 12-29-95, EXPIRED: 12-29-03

New. #8961, eff 8-20-07; amd by, INTERIM, #8983, eff 9-21-07, EXPIRES: 3-19-08 (deletion of former paras. (d) & (h) and renumbering remaining paragraphs); amd by #10139, eff 7-1-12; ss by #11046, eff 2-27-16

He-W 571.02 Recipient Eligibility.

(a) Except as specified in (b) below, all NH medicaid recipients shall be eligible to receive items in accordance with and subject to the limitations set forth in this part.

(b) Medicaid recipients residing in nursing facilities shall be eligible to receive only customized items not already included in the nursing facility rate, which is determined in accordance with He-E 806.

Source. (See Revision Note at chapter heading He-W 500); ss by #6158, eff 12-29-95, EXPIRED: 12-29-03

New. #8961, eff 8-20-07; ss by #11046, eff 2-27-16

He-W 571.03 Dispensing Provider Participation. Each dispensing provider shall be enrolled with NH medicaid.

Source. (See Revision Note at chapter heading He-W 500); ss by #6158, eff 12-29-95, EXPIRED: 12-29-03

New. #8961, eff 8-20-07; ss by #11046, eff 2-27-16

He-W 571.04 Covered Services.

(a) The purchase of medical supplies, except incontinence supplies, for continuous use or on an as-needed basis, shall not require prior authorization and shall be covered when prescribed, except as follows:

(1) Specialty formulas and food products shall only be covered in accordance with (b)(3)a. and b. below;

(2) Enteral formulas and supplies shall only be covered in accordance with (b)(3)c. below; and

(3) Medical supplies that are listed as non-covered services in He-W 571.06 shall not be covered.

(b) The following items shall be covered when prescribed and supported by an LMN:

(1) The purchase of, or repairs to, prosthetic devices, including prosthetic fingers, thumbs, and toes when they are part of a covered prostheses except as prohibited in He-W 571.06(v);

(2) The purchase of, or repairs to, orthotic devices;

(3) The purchase of the following medical supplies:

a. Specialty formulas prescribed for life-sustaining purposes;

b. Specialty formulas and food products prescribed for metabolic diseases described in RSA 415:6-c;

c. Enteral formulas and supplies when oral feeds are contraindicated; and

d. Disposable incontinence products for recipients between 3 and 20 years of age;

(4) The purchase of one standard manual breast pump per pregnancy;

(5) Bed cradle when necessary to prevent contact with the bed covering for conditions such as burns, decubitis, diabetic ulcers, and gout; and

(6) Except as specified in (c)(5) below, repairs to a purchased, non-rental, wheelchair when such repairs do not exceed a total of $800 within a given state fiscal year, which begins July 1st and ends June 30th.

(c) Unless a requested item is considered non-covered as specified in He-W 571.06, all items that are not otherwise indicated as covered in (a)-(b) above, shall be covered when prescribed, supported by an LMN, and prior authorized in accordance with He-W 571.05, and as follows:

(1) Infant home apnea monitors shall be covered when at least one of the following criteria is met:

a. Within the past 30 days from the date the completed PA request is submitted to the department, the infant has experienced an ALTE; and

b. The infant has one or more of the following conditions:

1. Tracheostomy or anatomic abnormalities of the face, tongue, jaw, or airway that make the infant vulnerable to airway compromise;

2. Neurologic or metabolic disorders affecting respiratory control;

3. Chronic lung disease, such as bronchopulmonary dysplasia, which requires supplemental oxygen (O₂), continuous positive airway pressure, or mechanical ventilation;

4. Apnea of prematurity;

5. Bradycardia on caffeine, theophylline, or similar agents;

6. Diagnosis of pertussis, with positive laboratory results;

7. Diagnosis of gastroesophageal reflux disease (GERD) that results in apnea of at least 20 seconds, bradycardia, or O₂ saturation; or

8. Discharged home on a schedule of weaning narcotics;

(2) A PA approved for an infant home apnea monitor shall be issued as follows:

a. The initial approval shall be valid for 3 months;

b. PA requests for additional coverage beyond the initial 3-month period shall be granted until the infant is ALTE-free for 2 months or until the child reaches 12 months of age, whichever comes first; and

c. PA requests for coverage after the infant reaches 12 months of age shall be granted when supported by physician documentation recommending the continuation of monitoring based on the child’s condition;

(3) An external insulin pump for the treatment of insulin-dependent diabetes (Type 1) shall be limited to one pump per recipient every 4 years or more frequently if technology evolves so that the pump can no longer be used, and shall be approved when the following criteria are met:

a. The recipient has received 3 or more daily insulin injections for at least 6 consecutive months;

b. The recipient has self-monitored his or her own blood sugar at least 4 times per day for the past 2 consecutive months;

c. The recipient and the recipient’s family demonstrate to the recipient’s physician or to the recipient’s diabetic educator the ability to carbohydrate count using insulin-to-carbohydrate ratios as well as insulin correction factors;

d. The recipient has a documented history of recurrent hypoglycemia with wide fluctuations in blood glucose, despite recipient compliance;

e. The recipient has dawn phenomenon with fasting sugars frequently exceeding 200 mg/dl;

f. The recipient has a history of severe glycemic excursions; and

g. An endocrinologist, or a physician with similar skills and training as an endocrinologist in the management of external insulin pumps, prescribes the pump and is involved with the medical care of the recipient;

(4) The purchase of a wig shall be covered with approval being subject to RSA 415:18-d;

(5) The purchase of any wheelchair or wheelchair accessory, as well as all repairs and modifications made to purchased wheelchairs that exceed the $800 limit set forth in (b)(6) above, shall be covered when the following criteria are met:

a. The need for a wheelchair, accessory, repair, or modification has been evaluated by a physical therapist (PT) or occupational therapist (OT), in consultation with the ordering physician;

b. The recipient has a condition for which there is a disease process, injury, or disability:

1. That would contraindicate weight bearing or ambulation; and

2. Where there is a decrease in neuromuscular function that prevents the recipient from being able to ambulate without assistance;

c. When the PA request is for a power wheelchair, the recipient:

1. Is unable to propel a manual wheelchair because of a disease process, injury, or disability; and

2. Is able to safely and independently operate a power wheelchair;

d. The wheelchair is not solely for the convenience of the recipient, or the recipient’s family or caregivers;

e. The recipient does not already have another mobility device that meets the recipient’s mobility needs; and

f. When the PA request is to replace an existing wheelchair, the following criteria are met:

1. It is not possible to repair or modify the existing wheelchair or replacement of the existing wheelchair is found to be the least costly alternative;

2. The current wheelchair no longer meets the recipient’s mobility needs; and

3. The request is not being made solely as a result of changing technology, age of the current wheelchair, or a desire for a new wheelchair;

(6) Customized strollers shall be covered only for recipients who:

a. Are non-ambulatory;

b. Meet the criteria for wheelchair approval as set forth in (5) above;

c. Do not already have a wheelchair or customized stroller, and are not expected to be prescribed a wheelchair within 24 months; and

d. Have mobility needs that will not be met by a commercially available stroller with adaptations;

(7) Gait trainers shall be covered only for recipients who:

a. Are able to stand upright with assistance and have some lower-extremity and trunk strength to be supported in the gait trainer;

b. Are not able to ambulate independently due to a condition such as, but not limited to, neuromuscular or congenital disorders, including acquired skeletal abnormalities;

c. Do not have lower-extremity contractures that would preclude ambulation, and have adequate range of motion to support mobility;

d. Have alignment of the lower extremities such that the foot and ankle can tolerate a standing or upright position as well as reciprocal movement;

e. Do not have complete paralysis of the lower extremities;

f. Have demonstrated improved mobility, ambulation, function, or physiologic symptoms, or have maintained status with the use of the selected gait trainer, and are able to follow a home therapy program incorporating the use of the gait trainer, as documented by a clinical program or home trial with the requested gait trainer; and

g. Have a written home therapy plan outlining the use of the requested gait trainer and for whom there is a caretaker who can appropriately supervise use of the gait trainer;

(8) Standers shall be covered only for recipients who:

a. Do not already have a stander or gait trainer;

b. Are unable to stand or ambulate independently due to a condition such as, but not limited to, a neuromuscular or congenital disorder, including acquired skeletal abnormalities;

c. Are at high risk for lower extremity contractures that cannot be appropriately managed by other treatment modalities, such as stretching, active therapy, and home programs;

d. Have an alignment of the lower extremities such that they can tolerate a standing or upright position;

e. Do not have complete paralysis of the lower extremities;

f. Do not have orthostatic hypotension, postural tachycardia syndrome, osteogenesis imperfecta, osteoporosis or other brittle bone diseases, or hip and knee flexion contractures of more than 20°;

g. Have demonstrated improved mobility, function, and physiologic symptoms, or have maintained status with the use of the requested stander, when other alternatives have failed, and are able to follow a home standing program incorporating the use of the stander, as documented by clinical standing program or home trial with the requested stander;

h. Are unable to stand or ambulate with caregiver assistance or an ambulatory assistive device at sufficient duration or distance to achieve a medical benefit;

i. Have a home therapy plan outlining the use of the requested stander; and

j. Have a request for a stander using code E0642, and are able to self-propel the stander;

(9) Cranial remolding helmets shall be covered when the following criteria are met:

a. The recipient is at least 3 months of age, but not older than 18 months of age;

b. The recipient has marked asymmetry that has not been substantially improved following conservative therapy of at least 2 months duration with cranial repositioning therapy and/or physical therapy; and

c. The asymmetry of the cranial base is documented by one of the following:

1. Skull base asymmetry of at least 6 mm right or left discrepancy, measured subnasally to the tragus, which is the cartilaginous projection of the auricle at the front of the ear; or

2. Cranial vault asymmetry of at least 10 mm right or left discrepancy, measured obliquely from the supraorbital point to the parietooccipital scalp at the midpoint of maximal convexity and from the supraorbital point to the parietooccipital scalp at the midpoint of the flattened area, or a ratio of these 2 measurements is greater than 1:1;

(10) A continuous positive air pressure (CPAP) machine to treat obstructive sleep apnea (OSA) in recipients up to the age of 21 shall be covered when all of the following criteria are met:

a. Adenotonsillectomy is contraindicated, delayed, or unsuccessful in relieving symptoms of OSA;

b. There is an OSA diagnosis established by polysomnography (PSG) performed by a medicare certified sleep study center, or a children’s hospital; and

c. The recipient is 7 years of age or older and weighs 40 pounds or more;

(11) A CPAP machine to treat OSA in a recipient 21 years of age or older shall be covered when all of the following criteria are met:

a. The recipient has a diagnosis of OSA established by PSG performed by a medicare certified sleep study center; and

b. At least one of the following clinical criteria has been met:

1. The apnea-hypopnea index (AHI), which assesses the severity of sleep apnea, is moderate to severe, which is defined as 15 or more events per hour; or

2. The AHI is from 5 to 14 events per hour with documentation of symptoms of daytime sleepiness, impaired cognition, mood disorders, or insomnia that impairs the recipient’s ability to carry out activities of daily living, and one of the following conditions is met:

(i) A diagnosis of hypertension, ischemic heart disease, or a history of stroke; or

(ii) More than 20 episodes of O₂ desaturation, measuring less than 85%, or any one episode of O₂ desaturation, measuring less than 70%, during a full-night sleep study;

(12) A CPAP machine covered in accordance with (10) or (11) above shall be prior authorized as follows:

a. The initial authorization shall be limited to a 2-month trial rental of the CPAP machine to ensure the recipient uses the machine daily and will receive a sufficient benefit from use of the machine;

b. The recipient’s daily use shall be documented by a compliance report indicating that the recipient is gaining sufficient benefit from the CPAP machine, as evidenced by a downloaded recording from the machine showing usage of a daily minimum of 4 hours per night;

c. Following the 2-month trial period, if the recipient demonstrates daily use as described in b. above during the 2-month trial rental period, the requesting dispensing provider may submit a subsequent PA request, which shall include the documentation described in b. above, for the purchase of the CPAP machine;

d. If the recipient does not use the machine as required in b. above during the trial period, but the non-compliance is correctable, such as by adjusting the fit of the mask, the requesting dispensing provider may submit a subsequent PA request for an additional rental period; and

e. Following the trial rental period, if it is demonstrated that the CPAP machine is not providing a sufficient benefit to the recipient, and the failure is not due to non-compliance, abuse, or neglect, the requesting dispensing provider may submit a PA request for a bi-level positive airway pressure (BiPAP) machine;

(13) The department shall approve a request for a BiPAP machine when it has been determined, in accordance with (12) above, that a CPAP machine is not effective in treating the recipient’s OSA;

(14) A BiPAP machine shall be covered as follows:

a. The initial authorization shall be limited to a 2-month trial rental of the BiPAP machine to ensure the recipient uses the machine daily and will receive a sufficient benefit from use of the machine;

b. The recipient’s daily use shall be documented by a compliance report indicating that the recipient is gaining sufficient benefit from the BiPAP machine, as evidenced by a downloaded recording from the machine showing usage of a daily minimum of 4 hours per night; and

c. Following the 2-month trial period, if the recipient demonstrates daily use during the trial rental period as required in b. above, the requesting item provider may submit a subsequent PA request, which shall include the documentation described in b. above, for the purchase of the BiPAP machine;

(15) High-frequency chest compression (HFCC) devices shall be covered when the following criteria are met:

a. The recipient is at least 2 years of age at the time the device is being used;

b. The recipient has a documented need of airway clearance;

c. The recipient has one of the following documented diagnoses:

1. Cystic fibrosis;

2. Chronic bronchiectasis that:

(i) Is characterized by a daily productive cough that has been confirmed by high resolution, spiral, or a standard CT scan;

(ii) Lasts for at least 6 consecutive months; or

(iii) Results in exacerbation, at least 2 times in a one year period, that requires antibiotic therapy; or

3. Chronic neuromuscular disorder affecting the ability to cough or clear respiratory secretions with a prior history of pneumonia or other significant worsening of pulmonary function, which exists when at least 2 of the following criteria are met:

(i) Forced expiration capacity (FEC) of 80% predicted;

(ii) Forced vital capacity (FVC) of less than 50% predicted;

(iii) Small airway score (FEP 25-75%) decrease in one year of 25% or more;

(iv) Pattern of annual or more hospitalizations for acute pulmonary exacerbations; or

(v) Demonstration of reduction of pulmonary function while on steroids for a year;

d. The recipient’s physician provides documentation demonstrating that standard treatments have failed to adequately mobilize retained secretions, as indicated by one of the following:

1. Other airway clearance therapies, including chest physical therapy or the use of a flutter device, cannot be performed at least twice daily, or as would be appropriate for the recipient’s age, because:

(i) There are no available parental or partner resources to perform chest physical therapy;

(ii) The caregiver is physically or mentally incapable of performing chest physical therapy at the required frequency; or

(iii) There are 2 or more individuals with cystic fibrosis, chronic bronchiectasis, or chronic neuromuscular disorder in the same household; or

2. There is a significant deterioration of the recipient’s clinical conditions, as described in c.3. above; and

e. The recipient is under the care of a pulmonologist;

(16) A HFCC device covered in accordance with (15) above shall be prior authorized as follows:

a. The initial authorization shall be limited to a 2-month trial rental of the HFCC device to ensure the recipient uses the device daily and will receive a sufficient benefit from use of the device;

b. The recipient’s daily use and sufficient benefit from usage during the 2-month trial rental period shall be documented by:

1. A report completed by a pulmonologist documenting the recipient’s comfort, tolerance, and willingness to use the device;

2. A report completed by a pulmonologist demonstrating that the recipient has sufficiently benefited from the use of the HFCC device as evidenced by clinical indications, including:

(i) Improvement in forced expiratory volume (FEV1); or

(ii) A reduction in the number of hospitalizations per year;

3. A statement signed by the pulmonologist, which may be part of the report in 2. above, stating that the recipient has sufficiently benefited from the use of the HFCC device, and that the pulmonologist recommends continued usage of the HFCC device; and

4. A usage meter report generated by the dispensing provider documenting usage at least 67% of the prescribed time;

c. Following the 2-month trial rental period specified in a. above, the requesting dispensing provider may submit a prior authorization request for an additional rental period, not to exceed one year, by submitting a prior authorization request along with documentation demonstrating the recipient’s use as described in b. above;

d. A request for an additional rental period or to purchase the device through a rent-to-own arrangement, submitted in accordance with c. above, shall be approved by the department when the clinical evidence of the recipient’s use and sufficient benefit supports continued use of the HFCC device; and

e. Approvals shall be limited to only one HFCC device and one vest per size per family;

(17) Oximeters shall be covered when the recipient has been assessed by his or her physician or pulmonary specialist to determine if supplemental O₂ is required, and either:

a. The recipient has been on supplemental O₂ and an oximeter is requested to determine if he or she can be weaned from the supplemental O₂; or

b. The recipient is receiving supplemental O₂ and is experiencing widely fluctuating O₂ saturation levels and an oximeter is required to assist in determining the cause, frequency, and duration of the fluctuation to properly determine the O₂ flow rate;

(18) Disposable incontinence supplies, including chux underpads, incontinence briefs, pull-ups, diapers, pads or liners, and gloves and toileting wipes used for this condition, for recipients 21 years of age or older shall be covered in accordance with the following:

a. The PA shall be approved for a period of one year if the recipient’s type of incontinence is:

1. Secondary to a disease process or injury to the bladder, which results in irreversible loss of control of the urinary bladder and/or rectal sphincter;

2. Secondary to an injury to the brain or spinal cord;

3. Secondary to a disease or condition that causes incontinence; or

4. Attributed to a profound cognitive disability or progressive neurological disorder, such as severe intellectual disability, dementia, or tardive dyskinesia, that results in an inability to achieve continence through bladder training;

b. The PA shall be approved for a period of 6-months if the recipient’s type of incontinence is:

1. Secondary to a surgical procedure, such as prostatectomy, resulting in temporary urinary incontinence; or

2. Secondary to an injury to the bladder and/or urinary sphincter, including nerve injury and detrusor muscle instability, resulting in temporary urinary incontinence; and

c. The following quantity limits shall apply, unless the prior authorization request specifies and medically justifies a greater quantity:

1. Disposable chux underpads shall be limited to a total of 3 per day, up to 93 per month, except that if package sizes necessitate dispensing a greater monthly quantity, the monthly quantity shall not exceed 105 per month;

2. Incontinence briefs, pull-ups, and diapers shall be limited to a total of 6 per day, up to 186 per month, except as follows:

(i) If package sizes necessitate dispensing a monthly quantity which is greater than 186, the monthly quantity shall not exceed 216 per month; and

(ii) The dispensing provider shall dispense the fewest number of packages that result in a quantity as close as possible to the 186 limit without going under, for example, if a package size is 10 diapers per package, then 19 packages equaling 190 diapers shall be dispensed, not 20 nor 21 packages; and

3. Pads and liners used to line undergarments shall be limited to a total of 3 per day, up to 93 per month, except as follows:

(i) If package sizes necessitate dispensing a monthly quantity which is greater than 93, the monthly quantity shall not exceed 144 per month; and

(ii) The dispensing provider shall dispense the fewest number of packages that result in a quantity as close as possible to the 93 limit without going under, for example, if a package size is 16 liners per package, then 6 packages equaling 96 liners shall be dispensed, not 17, 18, nor 19 packages;

(19) Functional electric stimulation (FES), which is used to enable a recipient with spinal cord injury to ambulate, shall be covered when the recipient meets all of the following:

a. Has intact lower motor units, L1 and below, both muscle and peripheral nerve;

b. Can bear weight on upper and lower extremities to maintain an upright posture independently;

c. Demonstrates brisk muscle contraction in response to neuromuscular electrical stimulation through a trial use of the equipment by the recipient’s physical therapist, and has sensory perception of electrical stimulation sufficient for muscle contraction;

d. Is motivated and has the cognitive ability to use such devices for walking;

e. Can transfer independently and stand for at least 3 continuous minutes;

f. Possesses hand and finger function to manipulate the controls;

g. Is at least 6-months post-recovery of spinal cord injury and restorative surgery;

h. Does not have hip or knee degenerative disease and has no history of long bone fracture secondary to osteoporosis; and

i. Has successfully completed a training program, which consists of at least 32 physical therapy sessions with the device over a 3-month period;

(20) Pediatric specialty beds shall be covered for infants and children up to the age of 12, as follows:

a. The recipient has one or more of the following diagnoses:

1. Traumatic brain injury;

2. Moderate or severe cerebral palsy;

3. Seizure disorder with daily seizure activity, characterized by loss of consciousness or lack of awareness to surroundings;

4. Pervasive developmental disorder;

5. Psychiatric, neurological, or metabolic diagnosis with documented risk of self-injury; or

6. Severe behavioral disorder;

b. The recipient has cognitive and communication impairment;

c. There is documentation of medical necessity that includes at least one of the following:

1. Daily seizure activity as described in a.3. above;

2. Uncontrolled perpetual involuntary movement related to a medical diagnosis; or

3. Self-injurious behavior, such as head banging, where a helmet was tried and was not successful at reducing the self-injurious behavior;

d. There is evidence of a safety risk that includes at least one of the following:

1. The recipient demonstrates unsafe mobility that will put the recipient at risk for serious injury, not just a possibility of injury, such as climbing out of bed;

2. The recipient has balance problems or vertigo; or

3. The recipient has history of injury that has occurred prior to the request;

e. There is documented use of more cost effective alternatives for which the outcomes were unsuccessful, such as:

1. Positional aids and side rails with padding around the regular bed;

2. Alternative bedding, such as moving the mattress to the floor with surrounding padding;

3. Management of seizure disorder;

4. Pharmacotherapy;

5. Helmet for head protection;

6. Behavioral therapy;

7. Environmental assessment and removal of safety hazards and use of appropriate child protective devices, such as on the door knob or use of a baby gate to prevent the child from leaving the room; or

8. Use of portable monitoring devices, such as a baby monitor to listen in on the child’s activities; and

f. The LMN includes the following:

1. The recipient’s medical, psychiatric, neurological, metabolic, and behavioral diagnosis;

2. The recipient’s needs that are a result of the diagnosis that shows the medical need for the specialty bed;

3. The specific name, type, and bed model that addresses each of the recipient’s needs with specific requirements such as full safety rails, height required for safety, or the necessity of articulation to raise the head or feet of the child to feed, medicate, or provide mobility;

4. Documentation as to how the recipient’s current bed or crib or modifications to the bedroom fail to address the clinical need and which states whether the recipient has the capacity to climb;

5. Current and previous treatment modalities, including an explanation why these modalities were not successful;

6. Assessment of cognitive function including developmental age equivalent for motor function, cognitive function, and habilitation potential; and

7. Detailed history of safety issues including incidence and resulting injury;

(21) Coverage of other items that are not specifically listed elsewhere in this rule, such as those listed below, shall be based on the National Coverage Determinations (NCD) criteria published in the Medicare Coverage Database (MCD) at the time of the coverage determination, as found at http://www.cms.gov/medicare-coverage-database/, including:

a. Pressure-reducing surfaces;

b. Enteral feeding pumps;

c. Hospital beds and accessories;

d. External infusion pumps, with the exception of insulin pumps, which shall be subject to the criteria set forth in He-W 571.04(c)(3) above;

e. Negative pressure wound therapy pumps;

f. Pneumatic compression devices;

g. Hoyer type lifts and other patient lift transfer systems;

h. Transcutaneous electrical nerve stimulators (TENS);

i. Trapeze bars;

j. Osteogenesis stimulators;

k. Parenteral nutrition pumps;

l. Suction machines;

m. Airway clearance devices, such as inexsufflators;

n. Voice activated home glucose monitors;

o. Seat lift mechanisms that are not part of a wheelchair;

p. Continuous passive motion machines; and

q. Oxygen compressors and humidification devices; and

(22) For items that are not specifically listed elsewhere in this rule and are also not listed in the MCD, the department shall review the recipient’s medical information and shall cover the item when the department determines that coverage of the item:

a. Is clinically appropriate in terms of type, frequency of use, extent, site, and duration, and consistent with the established diagnosis or treatment of the recipient’s illness, injury, disease, or its symptoms as determined by a review of the coverage criteria set forth in the New Hampshire or New England commercial insurance coverage as listed in He-W 530.05(b)(32)b.;

b. Is not primarily for the convenience of the recipient or the recipient’s family, caregiver, or health care provider;

c. Is no more costly than other items or services that would produce equivalent diagnostic, therapeutic, or treatment results as related to the recipients’ illness, injury, disease, or its symptoms;

d. Is not experimental, investigative, cosmetic, or duplicative in nature; and

e. Is allowable under Medicaid and does not otherwise conflict with the New Hampshire Medicaid State Plan.

(d) All items billed with any Healthcare Common Procedure Coding System (HCPCS) miscellaneous procedure code shall be covered when prescribed, supported by an LMN, and prior authorized in accordance with He-W 571.05, and as follows:

(1) Customized car seats shall be covered for recipients who have a neuromotor diagnosis and whose needs cannot be met by a commercially available car seat with minor adaptations that do not reduce the effectiveness or safety of the car seat nor make the manufacturer’s warranty null and void; and

(2) Protective helmets for recipients with drop seizures or severe head-banding disorders.

Source. (See Revision Note at chapter heading He-W 500); ss by #6158, eff 12-29-95, EXPIRED: 12-29-03

New. #8961, eff 8-20-07; amd by #8983, INTERIM, eff 9-21-07, EXPIRES: 3-19-08 (deletion of former paragraphs (b)-(f) and renumbering remaining paragraph (a) as (a)-(f)); amd by #9103, eff 3-12-08; ss by #11046, eff 2-27-16

He-W 571.05 Prescription, LMN, and Prior Authorization Requirements.

(a) The prescription required in He-W 571.04(a)-(c) above shall be written by the provider and include the following:

(1) The recipient’s name, address, date of birth, and NH medicaid identification number (MIN);

(2) The specific monthly quantity(s) to be dispensed, not to exceed the limits set forth in this rule;

(3) The specific type of item(s) to be dispensed;

(4) The frequency of use for the medical supply(s) being dispensed; and

(5) The dated signature or electronic signature of the provider.

(b) The LMN required in He-W 571.04(b)-(c) above shall be written by the provider and include the following:

(1) The recipient’s name, address, date of birth, and NH MIN;

(2) A narrative description of the recipient’s medically diagnosed health condition, illness, or injury, including an indication of whether the diagnosis is a pre-existing condition or a presenting condition;

(3) The recipient’s prognosis;

(4) An estimation of the effect on the recipient if the requested item(s) is not provided;

(5) The medical justification for the item(s) being requested, including its contribution to the treatment of the recipient’s illness or injury or to the improvement of the recipient’s physical condition;

(6) The anticipated length of time the item(s) is expected to be needed;

(7) The expected outcome of providing the requested item(s);

(8) The recommended timeframe to achieve the expected outcome;

(9) A summary of any previous treatment plans, including outcomes, which were used to treat the diagnosed condition for which the requested item(s) is being recommended;

(10) A statement, with supporting documentation, assuring that the requested item(s) is the least restrictive, least costly item available to meet the recipient’s needs;

(11) Supporting documentation that demonstrates the medical need for the item(s); and

(12) The dated signature, or electronic signature, of the provider.

(1) Not be written retroactively; and

(2) Be valid for one year from the date written so long as the medical treatment remains unchanged.

(d) All PA requests shall be sent to the department for review and approval, and include the following documentation:

(1) A copy of the prescription, as described in (a) above;

(2) An LMN containing all of the information specified in (b) above; and

(3) A completed PA form specific to the item being requested, as follows:

a. For all DME, a completed Form 272D, “Durable Medical Equipment Prior Authorization Request” form (January 2016) shall be signed and dated by an authorized representative of the NH medicaid enrolled dispensing provider;

b. For all disposable incontinence supplies, a completed Form 272DIA, “Incontinence Products Prior Authorization Request Form” (January 2016) shall be completed by an authorized representative of the NH medicaid enrolled dispensing provider;

c. In addition to submitting the forms required by a. above, requests for all wheelchairs, scooters, and customized strollers must also include a completed Form 272M, “Mobility Evaluation Form” (January 2016), including the following:

1. A dated signature and printed name of the provider completing the evaluation;

2. A dated signature and printed name of the recipient or the recipient’s parent or legal guardian, if applicable;

3. A dated signature and printed name of an authorized representative of the NH medicaid enrolled dispensing provider; and

4. A copy of the manufacturer’s invoice or quote, which includes the Manufacturer’s Suggested Retail Price (MSRP) and acquisition cost;

d. In addition to the requirements specified in (3)c. above, PA request for the purchase of accessories for a wheelchair shall also include the following documentation from the ordering physician:

1. Documentation that the ordering physician has assessed the recipient for the accessory within 60 days of making the PA request;

2. A written diagnosis, including a brief medical history justifying the need for the accessory; and

3. When applicable, an estimate of the length of time the accessory will be required; and

e. In addition to submitting the form required by a. above, requests for all standers, gait trainers, and bath and toileting items shall also include a completed Form 272EQ, “Medical Equipment Request Evaluation Form Non-Wheelchair” (January 2016), including the following:

1. A dated signature and printed name of the provider completing the evaluation;

2. A dated signature and printed name of the recipient or the recipient’s parent or legal guardian, if applicable;

3. A dated signature and printed name of an authorized representative of the NH Medicaid enrolled dispensing provider; and

4. A copy of the manufacturer’s invoice or quote, which includes the MSRP and acquisition cost.

(e) A dispensing provider may complete and submit Form 272REV “Incontinence Products Prior Authorization Revision Request Form” (October 2015) in order to provide products which better suit a recipient’s needs when such changes are to:

(1) Product size that will result in a new T-code or modifier;

(2) Product absorbency that will result in a new T-code or modifier; or

(3) Product style that will result in a new T-code or modifier.

(f) Requests for PA shall be approved by the department if the department determines the following:

(1) With the exception of disposable incontinence supplies, the item meets the definition of DME, prosthetic devices, medical supplies, or orthotic devices as defined in He-W 571.01;

(2) The medical documentation was completed and submitted in accordance with (d) above;

(3) The PA request demonstrates that the item is consistent with the established diagnosis or treatment of the recipient’s illness, injury, disease, or its symptoms as determined by a review of the coverage criteria set forth in He-W 571.04 above; and

(4) The item is cost effective, as determined by a finding that:

a. There is no other less costly item, as identified by the department that would effectively meet the recipient’s needs; or

b. Less expensive, appropriate alternatives are not covered or generally not available.

(g) A dispensing provider shall request and obtain prior authorization from the department before providing the item(s).

(h) A provider shall conduct and document a face-to-face encounter with the recipient no earlier than 60 days prior to submitting a prior authorization request and the provider’s written order shall include the date of the encounter and the primary clinical reason the recipient needs the item(s).

(i) Requests for a PA shall be denied by the department if the department determines that the requirements set forth in (f) above have not been met.

(j) Decisions made by the department in accordance with this section shall not be superseded by the treating, ordering, or consultative health care provider’s prescription, orders, or recommendations.

(k) If the department approves the PA request, the state’s fiscal agent shall send written confirmation of the approval to the dispensing provider.

(l) If the department denies the PA request or partially denies it, the state’s fiscal agent shall forward a notice of denial to the recipient and the provider, which includes the following information:

(1) The reason for, and legal basis of, the denial or partial denial; and

(2) Information that a fair hearing on the denial may be requested within 30 days of the date on the notice of the denial, in accordance with He-C 200.

(m) The dispensing provider shall be responsible for determining that the recipient is eligible for NH medicaid on the date of service as defined in He-W 571.01(a).

Source. (See Revision Note at chapter heading He-W 500); ss by #6158, eff 12-29-95, EXPIRED: 12-29-03

New. #8961, eff 8-20-07; amd by #8983, INTERIM, eff 9-21-07, EXPIRES: 3-19-08 (deletion of former subparagraph (b)(6) and renumbering remaining subparagraphs); ss by #11046, eff 2-27-16

He-W 571.06 Non-Covered Services. The following items shall not be covered:

(a) Items that do not meet the coverage criteria set forth in He-W 571.04;

(b) Specialty formulas when not needed for life-sustaining purposes, or as the sole source of nutrition, except as allowed under He-W 546;

(c) Common, over-the-counter, household and medicine-chest items that can be purchased without a prescription, including, but not limited to:

(1) Corn plasters and foot pads;

(2) Nursery supplies;

(3) Hand cleaners or sanitizers, such as Hygenall or Purell;

(4) Personal hygiene items including body lotions, toothbrushes, electric shavers, razors, and other hair removal devices and services;

(5) Thermometers;

(6) Odor barrier products;

(7) Toileting wipes, except as allowed by He-W 571.04(c)(18) above;

(8) First aid kits and supplies, including adhesive bandages and scissors;

(9) Mechanical heated water circulating pads and pumps, including hydrocollator heating units;

(10) Non-legend medications specified in accordance with He-W 570.05(d); and

(11) Nutritional supplements or formula as follows:

a. Dietary or food supplements;

b. Lactose-free foods or products that aid in lactose digestion;

c. Gluten-free products;

d. Low carbohydrate diets;

e. Weight-loss foods, formulas, and related products intended to aid in weight loss;

f. Normal grocery items, including over-the counter infant formulas;

g. Baby food and banked breast milk;

h. Grocery items that can be prepared in a blender and used with an enteral feeding system;

i. High protein powders and mixes;

j. Medical food products that:

1. Are prescribed without a diagnosis requiring such foods;

2. Used for convenience purposes;

3. Have no proven therapeutic benefit without an underlying disease, condition, or disorder;

4. Used as a substitute for acceptable standard dietary interventions; or

5. Are used exclusively for nutritional supplementation; and

k. Enteral nutrition when the recipient has food allergies or dental problems, but has the ability to meet his or her nutritional requirements through an alternative store-bought food source;

(d) Environmental modifications and controls, including:

(1) Wheelchair ramps;

(2) Tub rails;

(3) Space heaters and heat lamps;

(4) Air conditioners and fans;

(5) Air purifiers, including HEPA and vacuum filters;

(6) Vaporizers, humidifiers, and dehumidifiers;

(7) Aromatherapy;

(8) Stairway lifts and elevators;

(9) Lifting devices including electric patient lifts and hydraulics and ceiling tract lifting devices;

(10) Power generators; and

(11) Adaptive or computer switch toys;

(e) Items typically not used by the general public for a medical purpose, including:

(1) Furniture for non-mobility purposes including, but not limited to:

a. Corner seats;

b. Positioning chairs;

c. High chairs or other feeding type chairs;

d. All beds, except hospital beds as allowed by He-W 571.04(c)(20)c., and the pediatric specialty beds as allowed in He-W 571.04(c)(20) above;

e. Toddler beds, bassinets, portable cribs, or playpens; and

f. Massage and therapy tables and related equipment;

(2) Lumbar support cushions;

(3) Bedding, including electric or weighted blankets;

(4) Clothing items, including sportswear such as neoprene shorts;

(5) Hot Tubs, whirlpool equipment, aqua massagers, and sauna baths;

(6) Recreational, therapeutic, or exercise equipment including, but not limited to, bicycles, treadmills, weights, tables, mats, and swings; and

(7) Video, computer games, or computer applications intended for the purpose of exercise, recreation, education, or instruction;

(f) Items that contribute to or enhance fertility or procreation;

(g) Items typically used by the general public for preventing injury or ensuring safety, including:

(1) Car seats, except as allowed by He-W 571.04(d)(1);

(2) Helmets, including protective helmets used for sports and recreation, except as allowed by He-W 571.04(d)(2); and

(3) Pneumatic vests and lumbar supports;

(h) Disposable incontinence supplies for:

(1) Recipients younger than 3 years of age, except as allowed by He-W 546; and

(2) Recipients 21 years of age or older who do not meet the criteria set forth in He-W 571.04(c)(18);

(i) Bed wetting alarms;

(j) Sleep positioning wraps;

(k) Computer controlled and programmable lateral rotation therapy bed systems;

(l) Chewelry, and similar non-toxic jewelry, intended to be chewed;

(m) Magnets, crystals, gemstones, and similar non-evidenced based, experimental, or investigational healing items;

(n) Glucowatches;

(o) Auto-feeders;

(p) Automated medication reminder systems;

(q) Cast bags, such as Aquashield;

(r) Electric resuscitators and portable defibrillators;

(s) Bi-directional static progressive stretch devices, including, but not limited to, Joint Active Systems (JAS) splints;

(t) Service or therapy animals and related expenses;

(u) Apnea monitors, except when the criteria in He-W 571.04(c)(2) have been met;

(v) Prosthetic fingers, thumbs, and toes when not part of a covered prosthesis;

(w) Commercially available strollers;

(x) Wheelchairs requested within 24 months of the purchase of a customized stroller;

(y) The following accessories and options for wheelchairs, customized strollers, or other mobility devices:

(1) Wheelchair remote controls and attendant control switches;

(2) Power assist devices or equipment to modify a manual wheelchair into a power wheelchair;

(3) Air suspension systems;

(4) Power standers and seat lift mechanisms;

(5) Grade aids and anti-roll devices for manual wheelchairs;

(6) Wheelchairs with stair climbing options;

(7) Titanium framed and sport-type wheelchairs;

(8) Custom wheels for off-road use or for sport and recreational purposes;

(9) Any wheelchair accessory or option for purposes of allowing the recipient to perform leisure, social, or recreational activities;

(10) Lights, horns, mirror, baskets, pouches, backpacks, and similar accessories; and

(11) Back-up or spare wheelchairs for recipients who already have a wheelchair, power scooter, or customized stroller;

(z) Any back-up or spare equipment, with the exception of ventilators;

(aa) Replacement, repair, or modifications of an item when the need for which is the result of:

(1) Recipient abuse, misuse, or neglect;

(2) Failure to protect the item from the elements;

(3) Using the item inappropriately or contrary to its designed and intended use;

(4) Making improper repairs to the item, which would void any manufacturer’s warranty;

(5) Loss of the item when basic safeguarding measures could have been instituted;

(6) Failure to maintain the item through proper routine maintenance by an authorized dealer; or

(7) Taking any action that would otherwise void the manufacturer’s written warranty or is contrary to the manufacturer’s recommendations for care, use, and maintenance;

(ab) Repairs, modifications, or adjustments to any rented item, including wheelchairs;

(ac) Repairs to recipient owned items, when the recipient does not meet the criteria for coverage of the item, or when such repairs, modifications, or adjustments are:

(1) Within the dispensing provider’s or manufacturer’s warranty; or

(2) Within one year of the purchase of the item or accessory, unless written documentation from the provider demonstrates a significant change in the recipient’s medical condition that meets the coverage criteria for the item and the repair or modification is warranted;

(ad) Upgrades to or replacement of any functioning item that still meets the recipient’s needs, but is being requested solely as a result of changing technology;

(ae) Items which are more costly than other available items which could be expected to provide the same, similar, or duplicate outcome;

(af) Any items that are primarily intended for use at a school, are part of a child’s care plan at school, and could be obtained through the “Medicaid to Schools” program in accordance with He-M 1301, and the child and the child’s school participate in the “Medicaid to Schools” program; and

(ag) Any items that are experimental, investigational, or non-FDA approved.

Source. (See Revision Note at chapter heading He-W 500); ss by #6158, eff 12-29-95, EXPIRED: 12-29-03

New. #8961, eff 8-20-07; amd by #8983, INTERIM, eff 9-21-07, EXPIRES: 3-19-08; amd by #9103, eff 3-12-08; amd by #9637, eff 1-16-10; amd by #9836, eff 12-18-10; ss by #11046, eff 2-27-16 (from He-W 571.05)

He-W 571.07 Requirements for Maintaining Documentation.

(a) The dispensing provider shall maintain supporting records in accordance with He-W 520 and this part, and failure to maintain records in accordance with He-W 520 and this part shall entitle the department to recoupment of state or federal medicaid payments made as permitted by 42 CFR 455, 42 CFR 447, and 42 CFR 456.

(b) In addition to the requirement set forth in (a) above, the dispensing provider shall maintain the following documentation for a minimum of 6 years or until the resolution of any legal action(s) commenced within the 6 year period, whichever is longer:

(1) All letters of medical necessity (LMN) described in He-W 571.05(b);

(2) Documentation of adjustments made to and inspections of items or related accessories;

(3) Documentation showing:

a. The date and proof of delivery of all items to the recipient;

b. For custom wheelchairs and customized strollers, the date of the order;

c. For custom prosthetic and orthotic devices, the date of fabrication;

d. For frame and seating systems to pediatric and adult wheelchairs, the date of order; and

e. For medical supplies shipped, the date of shipment;

(4) Documentation of a face-to-face encounter between the recipient and the recipient’s provider no earlier than 60 days of the PA request as described in He-W 571.05(h) above; and

(5) All other supporting documentation needed to justify monthly quantity(s) and type of item(s) dispensed.

Source. (See Revision Note at chapter heading He-W 500); ss by #6158, eff 12-29-95, EXPIRED: 12-29-03

New. #8961, eff 8-20-07; amd by #9103, eff 3-12-08; amd by #9637, eff 1-16-10; amd by #10031, eff 11-19-11; ss by #11046, eff 2-27-16

He-W 571.08 Third Party Liability.

(a) All third party obligations shall be exhausted before medicaid shall be billed, in accordance with 42 CFR 433.

(b) Dispensing providers shall request information from the recipient regarding other insurance coverage.

(c) If other insurance coverage is available, dispensing providers shall contact the insurer to verify benefits initially and at least annually thereafter or when the insurance carrier changes.

(d) Dispensing providers shall maintain a record of any other insurance verifications in the recipient’s medical record.

Source. (See Revision Note at chapter heading He-W 500); ss by #6158, eff 12-29-95, EXPIRED: 12-29-03

New. #8961, eff 8-20-07; ss by #11046, eff 2-27-16 (from He-W 571.09)

He-W 571.09 Utilization Review and Control. The department’s provider program integrity unit shall monitor utilization of items to identify, prevent, and correct potential occurrences of fraud, waste, and abuse, in accordance with 42 CFR 455, 42 CFR 456, and He-W 520.

Source. (See Revision Note at chapter heading He-W 500); ss by #6158, eff 12-29-95, EXPIRED: 12-29-03

New. #8961, eff 8-20-07; ss by #11046, eff 2-27-16 (from He-W 571.10)

He-W 571.10 Payment for Items.

(a) The department shall establish rates for all items in accordance with RSA 161:4, VI(a).

(b) All dispensing providers shall submit clean claim(s) as defined in He-W 571.01(c).

(c) All dispensing providers shall submit clean claims for payment to the department’s fiscal agent, and the department shall be entitled to recoupment of state and federal medicaid payments as permitted in 42 CFR 455, 42 CFR 456, and 42 CFR 447.

(d) All dispensing providers shall maintain supporting records supporting submitted claims in accordance with He-W 520 and He-W 571.07.

(e) Payment shall not be made for items that require prior authorization when prior authorization was not received and approved before the items were provided, in accordance with He-W 571.05. Retroactive prior authorization requests shall be denied.

(f) Payment for disposable incontinence supplies, including gloves and toileting wipes used for this condition, provided to recipients shall be made only for supplies obtained from the exclusive supplier of incontinence supplies contracted through the department.

(g) Billing of and payment for items and repair parts shall be made at the lesser of:

(1) The dispensing provider’s usual and customary charge to the public, as defined in RSA 126-A:3, III(b);

(2) The lowest amount the dispensing provider accepts from any other third party payor; or

(3) The rate established by the department in accordance with RSA 161:4, VI(a).

(h) Payment for labor costs for repairs shall be at a rate established by the department in accordance with RSA 161:4, VI(a).

(i) Payment shall be denied or recouped if the dispensing provider bills for and is paid for disposable incontinence supplies, including gloves and toileting wipes used for such condition, which are not obtained from the exclusive supplier of incontinence supplies contracted through the department.

(j) Except as allowed by (k) below, payment shall be denied if the recipient is not eligible on the date of service, even when a prior authorization request has been approved.

(k) For the following items only, payment shall be denied if the recipient is not medicaid eligible on the date of service as defined in He-W 571.01(a).

(l) No item shall be paid for prior to delivery to the recipient and dispensing providers shall maintain documentation in accordance with He-W 571.07 and 571.10 which demonstrates that the items were delivered to the recipient.

(m) No payment shall be made for items left unattended which results in the item(s) destruction or damage to the item so that it is unusable.

(n) In accordance with the payment rates established in (a) above, the rate for wheelchairs shall include the following required services:

(1) Delivery and assembly of the wheelchair;

(2) Training to the recipient and recipient’s family and other caregiver(s) in the use of the equipment, maintenance care, and equipment diagnostics; and

(3) Wheelchair adjustments and any follow-up training within 30 days following the delivery of the chair.

(o) Dispensing providers shall supply a comparable substitute wheelchair at no additional cost for 2 weeks during the repair of the original wheelchair. For repairs that require more than 2 weeks to complete, the dispensing provider may request PA for a rental fee.

Source. (See Revision Note at chapter heading He-W 500); ss by #6158, eff 12-29-95, EXPIRED: 12-29-03

New. #8961, eff 8-20-07; ss by #11046, eff 2-27-16 (formerly He-W 571.11)

PART He-W 572 AMBULANCE SERVICES

He-W 572.01 Definitions.

(a) “Acute care hospital” means a hospital that provides short-term medical treatment for patients who have an acute illness or injury, or who are recovering from surgery.

(b) “Advanced life support (ALS) services” means “advanced life support (ALS)” as defined by Saf-C 5901.05, namely, “medical procedures and the scope of practice rendered by advanced emergency medical care providers in accordance with RSA 153-A:12.”

(c) “Air ambulance” means a fixed-wing or rotary-wing aircraft that is certified by the Federal Aviation Administration as an air ambulance and which is designed and equipped for the provision of medically necessary supplies and services.

(d) “Ambulance” means any vehicle designed, equipped, and used for the transport of sick or injured individuals and which are licensed to do so in the state in which they operate.

(e) “Basic life support (BLS) services” means “basic life support (BLS)” as defined by Saf-C 5901.10, namely, “fundamental medical procedures and the scope of practice in which emergency medical care providers at any of the following licensing levels are trained:

(1) Emergency medical responder;

(2) New Hampshire emergency medical technician-basic (NH-EMT-B); or

(3) Emergency medical technician (EMT).”

(f) “Department” means the New Hampshire department of health and human services.

(g) “Emergency medical condition” means:

(1) A medical condition manifesting itself by acute symptoms of sufficient severity, including severe pain, such that a prudent layperson, with an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in:

a. Placing the health of the recipient, or, with respect to a pregnant woman, the health of the woman or her unborn child, in serious jeopardy;

b. Serious impairment to bodily functions; or

c. Serious dysfunction of any bodily organ or part; or

(2) With respect to a pregnant woman who is having contractions:

a. That there is inadequate time to effect a safe transfer to another hospital before delivery; or

b. That transfer may pose a threat to the health or safety of the woman or unborn child.

(h) “Medicaid” means the Title XIX and Title XXI programs administered by the department which makes medical assistance available to eligible individuals.

(i) “Prior authorization agent” means an individual or agency contracted by the department responsible for reviewing all scheduled and routine ambulance transportation requests.

(j) “Recipient” means an individual who is eligible for and receiving medical assistance under the medicaid program.

(k) “Scheduled and routine ambulance transportation” means transportation by an ambulance for the purpose of attending an appointment to obtain a medicaid covered service from a medicaid enrolled provider when the use of any other mode of transportation would likely endanger the health and safety of the recipient and when the medicaid covered service is not to treat an emergency medical condition as defined in (g) above.

(l) “Title XIX” means the joint federal-state program described in Title XIX of the Social Security Act and administered in New Hampshire by the department under the medicaid program.

(m) “Title XXI” means the joint federal-state program described in Title XXI of the Social Security Act and administered in New Hampshire by the department under the medicaid program.

Source. (See Revision Note at chapter heading He-W 500); ss by #6641, eff 11-27-97; EXPIRED: 11-27-05

New. #8502, INTERIM, eff 12-2-05, EXPIRES: 5-31-06; ss by #8638, eff 5-30-06; amd by #10139, eff 7-1-12; ss by #10294, eff 12-1-13; ss by #13840, INTERIM, eff 12-29-23;ss by #14007, eff 6-25-24

He-W 572.02 Recipient Eligibility. All recipients shall be eligible for ambulance services, in accordance with He-W 572.

Source. (See Revision Note at chapter heading He-W 500); ss by #6641, eff 11-27-97; EXPIRED: 11-27-05

New. #8502, INTERIM, eff 12-2-05, EXPIRES: 5-31-06; ss by #8638, eff 5-30-06; ss by #10294, eff 12-1-13; ss by #13840, INTERIM, eff 12-29-23; ss by #14007, eff 6-25-24

He-W 572.03 Provider Participation. All participating ambulance providers shall:

(a) Be licensed in the state in which they operate; and

(b) Be an enrolled New Hampshire medicaid provider.

Source. (See Revision Note at chapter heading He-W 500); ss by #6641, eff 11-27-97; EXPIRED: 11-27-05

New. #8502, INTERIM, eff 12-2-05, EXPIRES: 5-31-06; ss by #8638, eff 5-30-06; ss by #10294, eff 12-1-13; ss by #13840, INTERIM, eff 12-29-23; ss by #14007, eff 6-25-24

He-W 572.04 Covered Services.

(a) The following ambulance services, in the case of an emergency medical condition, shall be covered:

(1) Transportation to the nearest acute care hospital with appropriate treatment facilities, including loaded mileage and routine disposable supplies used en-route;

(2) Transportation from an acute care hospital inpatient bed or acute care hospital emergency department to an inpatient psychiatric facility or a designated receiving facility for admission; and

(3) Transportation from one acute care hospital to another acute care hospital when the necessary treatment or diagnostic testing cannot be provided by the originating hospital and the recipient is discharged from the originating hospital.

(b) Air ambulance services, in the case of an emergency medical condition, shall be covered if the recipient’s condition is such that:

(1) The recipient cannot be safely transported in a timely basis via an ALS ground transportation with appropriate staff; and

(2) The recipient is at imminent risk of losing life or limb if the fastest means of transport is not utilized to move the recipient to the nearest facility capable of treating the recipient.

(c) Scheduled and routine ambulance transportation, as defined in He-W 572.01(k), to and from the destination, including loaded mileage and routine disposable supplies used en-route, shall be covered when the service has been determined medically necessary in accordance with He-W 572.06.

(d) Waiting time for scheduled and routine ambulance transportation authorized pursuant to He-W 572.06 shall be covered up to a maximum of 2 hours, rounded to the nearest half hour.

Source. (See Revision Note at chapter heading He-W 500); ss by #6641, eff 11-27-97; EXPIRED: 11-27-05

New. #8502, INTERIM, eff 12-2-05, EXPIRES: 5-31-06; ss by #8638, eff 5-30-06; ss by #10294, eff 12-1-13; ss by #10294, eff 12-1-13; ss by #13840, INTERIM, eff 12-29-23; ss by #14007, eff 6-25-24

He-W 572.05 Non-Covered Services. Non-covered ambulance services shall include:

(a) Transportation for a recipient whose condition permits transport in any type of vehicle other than an ambulance, such as a private vehicle or a wheelchair van, without endangering the recipient’s health;

(b) Transportation in an ambulance, except for the following which are covered services pursuant to He-W 572.04:

(1) Scheduled and routine ambulance transportation, as defined in He-W 572.01(k);

(2) For an emergency medical condition, as defined in He-W 572.01(g); or

(3) Transportation of a recipient from one hospital to another inpatient facility such as a hospital or inpatient psychiatric facility, wherein the recipient is coming from the emergency department of the originating hospital or has been discharged from the originating hospital;

(d) Transportation from one acute care hospital to another acute care hospital for necessary treatment or diagnostic testing while the recipient maintains inpatient status with the originating hospital; and

(e) Waiting time that exceeds 2 hours.

Source. (See Revision Note at chapter heading He-W 500); ss by #6641, eff 11-27-97; EXPIRED: 11-27-05

New. #8502, INTERIM, eff 12-2-05, EXPIRES: 5-31-06; ss by #8638, eff 5-30-06; ss by #10294, eff 12-1-13; ss by #13840, INTERIM, eff 12-29-23; ss by #14007, eff 6-25-24

He-W 572.06 Mobility Determination Requirements for Scheduled and Routine Ambulance Transportation.

(a) Medical necessity of a scheduled and routine ambulance transportation shall be documented using the “Mobility Determination for Non-Emergency Medical Transportation Universal Form for All Medicaid Plans” (June 2024), to be a covered service.

(b) A “Mobility Determination for Non-Emergency Medical Transportation Universal Form for All Medicaid Plans” (June 2024) shall be completed, signed, and submitted by a healthcare professional such as a registered nurse, medical doctor, care manager, or case manager to the department or its designee by either fax or mail.

(d) The department or its designee shall utilize the “Mobility Determination for Non-Emergency Medical Transportation Universal Form for All Medicaid Plans” to determine the most appropriate vehicle type to meet the recipient’s medical needs and notify the recipient and the health care provider who submitted the form of the determination, including information that the recipient may appeal the department or designee’s decision as to the most appropriate vehicle type for transportation according to medical necessity, in accordance with He-C 200.

Source. (See Revision Note at chapter heading He-W 500); ss by #6641, eff 11-27-97; EXPIRED: 11-27-05

New. #8502, INTERIM, eff 12-2-05, EXPIRES: 5-31-06; ss by #8638, eff 5-30-06; ss by #10294, eff 12-1-13; ss by #13840, INTERIM, eff 12-29-23; ss by #14007, eff 6-25-24

He-W 572.07 Documentation.

(a) Each ambulance provider shall maintain supporting records in accordance with He-W 520 and He-W 521.

(b) Each ambulance provider shall maintain documentation in their records to fully support each claim billed for services, including:

(1) For emergency transportation, documentation of the nature of the recipient’s emergency medical condition; and

(2) For all ambulance transportation, documentation that justifies the level of service, whether ALS or BLS, claimed.

(c) For each trip billed in (b) above, the ambulance provider shall maintain a run sheet or patient care report that includes at a minimum the following information, which is legibly written:

(1) Recipient name and medicaid identification number;

(2) Date of service;

(3) Origin and destination;

(4) Recipient vital signs;

(5) Recipient signs and symptoms upon arrival at the point of pick-up;

(6) Recipient status en-route;

(7) Services provided;

(8) The name of the person who provided the service or care in the ambulance, including signature and credentials; and

(9) The response code that indicates the mode of response for the ambulance making the trip.

Source. (See Revision Note at chapter heading He-W 500); ss by #6641, eff 11-27-97; EXPIRED: 11-27-05

New. #8502, INTERIM, eff 12-2-05, EXPIRES: 5-31-06; ss by #8638, eff 5-30-06; ss by #10294, eff 12-1-13 (from He-W 572.06); ss by #13840, INTERIM, eff 12-29-23; ss by #14007, eff 6-25-24

He-W 572.08 Utilization Review and Control. The department shall monitor utilization of ambulance services, in accordance with 42 CFR 455, 42 CFR 456, He-W 520, and He-W 521.

Source. (See Revision Note at chapter heading He-W 500); ss by #6641, eff 11-27-97; EXPIRED: 11-27-05

New. #8502, INTERIM, eff 12-2-05, EXPIRES: 5-31-06; ss by #8638, eff 5-30-06; ss by #10294, eff 12-1-13 (from He-W 572.06); ss by #13840, INTERIM, eff 12-29-23; ss by #14007, eff 6-25-24

He-W 572.09 Third Party Liability. All third party obligations shall be exhausted before medicaid may be billed, in accordance with 42 CFR 433.139.

Source. #8638, eff 5-30-06; ss by #10294, eff 12-1-13 (from He-W 572.08); ss by #13840, INTERIM, eff 12-29-23; ss by #14007, eff 6-25-24

He-W 572.10 Payment for Services.

(a) Payment for ambulance services shall be made in accordance with the rates established by the department in accordance with RSA 161:4, VI(a).

(b) Payment shall consist of the following separate components, as applicable:

(1) A base rate;

(2) A mileage rate, which shall be paid for the most direct route to and from a destination and for loaded miles only, which:

a. Shall be the distance traveled while transporting a recipient from a pick-up point to a drop-off point; and

b. Does not include mileage incurred on the way to pick up a recipient or after dropping off a recipient;

(3) Payment for waiting time, as allowed by He-W 572.04(d); and

(4) Payment for routine disposable supplies used en-route.

(d) Payment shall be based on the level of service provided, not on the vehicle used, even if the local government requires an ALS response for all calls.

(e) The ambulance provider shall not bill medicaid for transporting a recipient from an acute care hospital to another acute care hospital or medical provider to obtain necessary treatment or diagnostic testing not available while the recipient is still an inpatient of the originating acute care hospital.

(f) The ambulance provider shall submit claims for payment to the department’s fiscal agent.

Source. #10294, eff 12-1-13 (from He-W 572.09); ss by #13840, INTERIM, eff 12-29-23; ss by #14007, eff 6-25-24

PART He-W 573 WHEELCHAIR VAN SERVICES

He-W 573.01 Definitions.

(a) “Department” means the New Hampshire department of health and human services.

(b) “Medicaid” means the Title XIX and Title XXI programs administered by the department, which makes medical assistance available to eligible individuals.

(d) “Round trip” means transportation from a pick-up point, to a medical provider waiting for the recipient, and transporting the recipient back to the point of pick-up.

(e) “Title XIX program” means the joint federal-state program described in Title XIX of the Social Security Act and administered in New Hampshire by the department under the medicaid program.

(f) “Title XXI program” means the joint federal-state program described in Title XXI of the Social Security Act and administered in New Hampshire by the department under the medicaid program.

(g) “Wait time” means the time a wheelchair van drivers may have to wait for a recipient to complete a medical appointment.

Source. (See Revision Note at chapter heading He-W 500); ss by #6598, eff 10-8-97; ss by #8401, INTERIM, eff 8-20-05, EXPIRES: 2-16-06; ss by #8563, eff 2-7-06; amd by #10139, eff 7-1-12; ss by #10605, eff 5-23-14

He-W 573.02 Recipient Eligibility. All medicaid recipients, including all home and community-based care (HCBC) waiver recipients and recipients residing in nursing facilities, shall be eligible to receive wheelchair van services, in accordance with this part, when:

(a) The recipient is confined to a wheelchair for mobility, which means:

(1) At the time of a wheelchair van service, the recipient is unable to ambulate without the use of a wheelchair; and

(2) The recipient is unable to be transported in a private vehicle without special equipment or modifications to the vehicle; and

(b) The wheelchair van services are required as certified on Form 975 “Documentation to Support the Use of Wheelchair Van Services” (May 2014) by the signature of the recipient’s treating physician, physician assistant (PA), advanced practice registered nurse (APRN), or registered nurse (RN).

Source. (See Revision Note at chapter heading He-W 500); ss by #6598, eff 10-8-97; ss by #8401, INTERIM, eff 8-20-05, EXPIRES: 2-16-06; ss by #8563, eff 2-7-06; ss by #10605, eff 5-23-14

He-W 573.03 Provider Participation. All participating wheelchair van service providers shall:

(a) Be enrolled as a NH medicaid provider;

(b) At the time of enrollment, provide proof of vehicle registration in accordance with He-W 573.07(a);

(d) Comply with all applicable requirements of RSA 153-A:1, Saf-C 5919, 49 CFR 37, and 49 CFR 38.

Source. (See Revision Note at chapter heading He-W 500); ss by #6598, eff 10-8-97; ss by #8401, INTERIM, eff 8-20-05, EXPIRES: 2-16-06; ss by #8563, eff 2-7-06; ss by #10605, eff 5-23-14

He-W 573.04 Service Limits.

(a) Except as provided by He-W 573.10 below, wheelchair van services shall be limited to 24 trips, per recipient per state fiscal year.

(b) A one way trip and a round trip each shall count as one trip towards the service limit described in (a) above.

Source. (See Revision Note at chapter heading He-W 500); ss by #6598, eff 10-8-97; ss by #8401, INTERIM, eff 8-20-05, EXPIRES: 2-16-06; ss by #8563, eff 2-7-06; amd by #10016, eff 11-1-11; ss by #10605, eff 5-23-14

He-W 573.05 Covered Services.

(a) Wheelchair van services shall be covered to transport eligible recipients to and from an enrolled NH Medicaid provider to receive necessary medical and dental services that are covered by the NH Medicaid program.

(b) Wait times shall be covered for round trips only and for up to a maximum of 2 hours, rounded to the nearest half hour.

(c) Transportation shall be to the nearest available NH medicaid enrolled provider of the necessary medical or dental service, unless the department determines that:

(1) The cost to transport the recipient is less than double the cost to transport the recipient to the nearest available NH medicaid enrolled provider; or

(2) The recipient has an established relationship with a provider.

Source. (See Revision Note at chapter heading He-W 500); ss by #6598, eff 10-8-97; ss by #8401, INTERIM, eff 8-20-05, EXPIRES: 2-16-06; ss by #8563, eff 2-7-06; amd by #9622, eff 1-1-10; ss by #10605, eff 5-23-14

He-W 573.06 Non-Covered Services. The following services shall not be covered as wheelchair van services:

(a) Transportation for purposes of recipient or provider convenience;

(b) Transportation that is otherwise available free of charge or payable by another agency, or when the item can be obtained using a free delivery service;

(c) Transportation for any purpose other than to receive NH medicaid covered services from an enrolled NH medicaid provider;

(d) Transportation that does not meet the requirements of He-W 573.05(c);

(e) Any wait time associated with one way trips;

(f) Wait time that exceeds 2 hours for round trips;

(g) The payment of tolls; and

(h) The payment of parking fees and fines.

Source. (See Revision Note at chapter heading He-W 500); ss by #6598, eff 10-8-97; ss by #8401, INTERIM, eff 8-20-05, EXPIRES: 2-16-06; ss by #8563, eff 2-7-06; ss by #10605, eff 5-23-14

He-W 573.07 Provider Requirements. Wheelchair van service providers shall:

(a) Ensure that all vehicles used for wheelchair van services are registered in accordance with RSA 261:40 and have been inspected in accordance with RSA 266:1;

(b) Obtain and maintain vehicle insurance for general and professional liability in accordance with Saf-C 5919.01(a)(1)b;

(c) Ensure that all drivers they employ, or otherwise engage, possess a valid NH driver’s license in accordance with RSA 263:1 and RSA 263:1-a; and

(d) Provide proof of compliance with (a)-(c) above, when requested by the department or the medicaid fraud control unit (MFCU) of the New Hampshire department of justice (NHDOJ).

Source. (See Revision Note at chapter heading He-W 500); ss by #6598, eff 10-8-97; ss by #8401, INTERIM, eff 8-20-05, EXPIRES: 2-16-06; ss by #8563, eff 2-7-06; ss by #10605, eff 5-23-14

He-W 573.08 Documentation.

(a) When wheelchair van services are required, a Form 975, “Documentation to Support the Use of Wheelchair Van Services” (May 2014), shall be completed prior to the services being provided, and as follows:

(1) The wheelchair van provider shall complete section 1 of the form by providing information specific to the wheelchair van provider;

(2) The recipient’s treating physician, doctor of osteopathic (DO), physician assistant (PA), advanced practice registered nurse (APRN), or registered nurse (RN) shall complete section 2 of the form and certify by signature that the services are necessary; and

(3) When submitting a request for a service limit override, the wheelchair van provider shall complete section 3 of the form, and submit the form in accordance with He-W 573.10 below.

(b) Wheelchair van service providers shall obtain and retain copies of the signed and completed Form 975 “Documentation to Support the Use of Wheelchair Van Services” (May 2014), and provide copies of said documentation upon request to the department or the MFCU.

(c) Wheelchair van service providers shall retain, and provide when requested by the department or MFCU, copies of the trip logs, which shall contain the following documentation for each trip:

(1) Origin;

(2) Destination;

(3) Date of service;

(4) Driver’s name;

(5) Time of pick-up and drop off;

(6) Whether the trip was one-way or round-trip;

(7) Amount of wait time if applicable;

(8) Loaded mileage incurred; and

(9) Names and number of recipients transported concurrently during each trip.

(d) Wheelchair van service providers shall retain, and provide when requested by the department or MFCU, the following documentation concerning the safety of wheelchair vans used for transporting recipients:

(1) Proof that the vehicle was registered in accordance with RSA 261:40 and inspected in accordance with RSA 266:1, during the time of medicaid wheelchair van service; and

(2) Proof of insurance in accordance with He-W 573.07(b) during the time period that services were delivered.

Source. (See Revision Note at chapter heading He-W 500); ss by #6598, eff 10-8-97; ss by #8401, INTERIM, eff 8-20-05, EXPIRES: 2-16-06; ss by #8563, eff 2-7-0606; ss by #10605, eff 5-23-14

He-W 573.09 Safety Requirements. Wheelchair van providers shall comply with all of the applicable parts of Saf-C 5919.19 and 49 CFR 38.23 to ensure that all wheelchair vans are properly equipped and supplied.

Source. #8563, eff 2-7-06; ss by #10605, eff 5-23-14

He-W 573.10 Service Limit Override and Review.

(a) All requests for consideration of additional wheelchair van services beyond the 24 trip limit shall require prior authorization from the department before the recipient receives the additional services in accordance with He-W 530.07(a)-(f) and this section.

(b) The wheelchair van provider shall make requests for additional wheelchair van services beyond the 24 trip limit by submitting a copy of Form 975 “Documentation to Support the Use of Wheelchair Van Services” (May 2014), completed in accordance with He-W 573.08(a) above, to the department’s prior authorization agent.

(c) A request for a service limit override submitted in accordance with (a) through (b) above shall be approved by the department’s prior authorization agent when the department’s prior authorization agent determines that the recipient meets the eligibility requirements described in He-W 573.02.

(d) If the department’s prior authorization agent approves the service limit override request in accordance with (c) above, the state’s fiscal agent shall send written confirmation of the approval to the provider.

(e) The department’s prior authorization agent shall deny a request for a service limit override when the department's prior authorization agent determines that the recipient does not meet the eligibility requirements of He-W 573.02.

(f) If the department’s prior authorization agent denies the request for a service limit override, the department’s prior authorization agent shall forward a notice of denial to the recipient and the wheelchair van provider.

(g) The notice of denial shall contain the information required by 42 CFR 431.210, including:

(1) The reason for, and legal basis of, the denial; and

(2) Information that an appeal of the denial may be requested, in accordance with He-C 200, within 30 calendar days of the date on the notice of the denial.

Source. #8563, eff 2-7-06; amd by #10016, ef 11-1-11; ss by #10605, eff 5-23-14

He-W 573.11 Utilization Review and Control. The department’s provider program integrity unit shall monitor utilization of wheelchair van services, to identify, prevent, and correct potential occurrences of fraud, waste and abuse, in accordance with 42 CFR 455, 42 CFR 456, and He-W 520.

Source. #8563, eff 2-7-06; ss by #10605, eff 5-23-14

He-W 573.12 Third Party Liability. All third party obligations shall be exhausted before medicaid may be billed, in accordance with 42 CFR 433.139.

Source. #8563, eff 2-7-06; ss by #10605, eff 5-23-14

He-W 573.13 Payment for Services.

(a) Payments for wheelchair van services shall be made in accordance with rates established by the department, in accordance with RSA 161:4, VI(a).

(b) Payments for wheelchair van services shall consist of the following components:

(1) A base rate, which shall:

a. Include the first 5 miles of travel;

b. Be paid once only for a single one-way trip or round trip; and

c. Be paid twice for 2 one-way trips for the same recipient on the same day;

(2) A mileage rate, which shall:

a. Be based on the most direct route to and from a destination, and not necessarily the route used;

b. Be paid for loaded miles only, which:

1. Shall be the distance traveled while transporting recipients from a pick-up point to a drop-off point; and

2. Does not include mileage incurred on the way to pick up a recipient or after dropping off a recipient;

c. Not include the first 5 miles; and

d. Be paid only once per trip regardless of the number of recipients transported; and

(3) A payment for the wait time described in He-W 573.05(b).

(d) The wheelchair van provider shall maintain supporting records, in accordance with He-W 573.08 and He-W 520.03.

Source. #8563, eff 2-7-06; ss by #10605, eff 5-23-14

REVISION NOTE He-W 574:

Document #14393, effective 10-1-25, made extensive changes to the wording and numbering of part He-W 547 Non-Emergency Medical Transportation. Document #14393 repealed content, including removing the definitions for “commissioner”, “general medical transportation”, “out of area”, “point of origin”, “recipient driver”, and “volunteer”, and also repealed former section He-W 574.09 Extenuating Circumstances.

PART He-W 574 NON-EMERGENCY MEDICAL TRANSPORTATION

He-W 574.01 Definitions.

(a) “Assistance group” means the individuals living together with or without benefit of a dwelling pursuant to He-W 830.01(a), whose needs, income, and resources are considered and combined together when determining eligibility or the amount of benefits for financial or medical assistance.

(b) “Broker” means a person or entity, contracted by the department, that arranges non-emergency medical transportation for recipients through contracts with drivers or transportation companies.

(d) “Driver(s)” means a person, company, or entity that provides non-emergency medical transportation services for a recipient.

(e) “Family and friends driver” means a recipient’s family member or friend who is able to transport the recipient.

(f) “Medicaid” means the Title XIX and Title XXI programs administered by the department which makes medical assistance available to eligible individuals.

(g) “Medicaid address” means the recipient’s residence as listed in the recipient’s eligibility file at the department.

(h) “Non-emergency medical transportation” means non-emergency transportation for the purpose of accessing medicaid covered medical, dental, or behavioral health services via motorized public or private transportation pursuant to 42 CFR 441.62(a), 42 CFR 431.53, and 42 CFR 440.170.

(i) “Private transportation” means transportation via a recipient’s own vehicle or family and friend’s vehicle that does not meet the definition of public transportation.

(j) “Public transportation” means transportation via commercial buses, boats, airplanes, helicopters, or trains.

(k) “Recipient” means any individual who is eligible for and receiving medical assistance under the medicaid program.

(l) “Round trip” means transportation from a point of pick-up to a medical, dental, or behavioral health provider waiting for the recipient, and back to the point of pick-up.

(m) “Title XIX” means the joint federal-state program described in Title XIX of the Social Security Act and administered in NH by the department under the medicaid program.

(n) “Title XXI” means the joint federal-state program described in Title XXI of the Social Security Act and administered in NH by the department under the medicaid program.

(o) “Transportation company” means an entity that provides transportation.

(p) “Usual and customary” means “usual and customary” as defined in RSA 126-A:3, III(b).

(q) “Wait time” means the time a driver might have to wait for a recipient to complete a medical, dental, or behavioral health appointment.

Source. (See Revision Note at chapter heading He-W 500); ss by #6163, eff 1-4-96, EXPIRED: 1-4-04

New. #8732, eff 9-30-06; amd by #10139, eff 7-1-12; ss by #10810, eff 4-9-15; ss by #14393, eff 10-1-25, EXPIRES: 10-1-35

He-W 574.02 Recipient Eligibility.

(a) All recipients shall be ensured assistance to locate transportation or be reimbursed for miles traveled to access medicaid covered medical, dental, and behavioral health services as required by 42 CFR 441.62(a), 42 CFR 431.53, and 42 CFR 440.170.

(b) All recipients, including all home and community-based waiver service recipients and recipients residing in nursing facilities, shall be eligible to receive non-emergency medical transportation services by wheelchair van, when:

(1) The recipient is confined to a wheelchair for mobility, which means:

a. At the time of service, the recipient is unable to ambulate without the use of a wheelchair; and

b. The recipient is unable to be transported in a private vehicle without special equipment or modifications to the vehicle; and

(2) The use of a wheelchair van is required as certified on a completed “Mobility Determination for Non-Emergency Medical Transportation Universal Form for All Medicaid Plans” (September 2025), completed by a health care professional and submitted to the broker prior to the wheelchair van ride.

Source. (See Revision Note at chapter heading He-W 500); ss by #6163, eff 1-4-96, EXPIRED: 1-4-04

New. #8732, eff 9-30-06; ss by #10810, eff 4-9-15; ss by #14393, eff 10-1-25, EXPIRES: 10-1-35

He-W 574.03 Broker Participation. Brokers shall:

(a) Be enrolled with the department with an active medicaid provider number;

(b) Comply with the provisions of 42 CFR 440.170(a)(4)(ii);

(c) Screen all drivers, upon hire and monthly thereafter, for exclusions against the Office of Inspector General (OIG) exclusion and sanction database found at https://exclusions.oig.hhs.gov pursuant to section 1866(j)(2) of the Social Security Act, section 1903(i) of the Social Security Act, and 42 CFR 1001.1901; and

(d) Ensure that all vehicles used for transportation services:

(1) Are registered in accordance with RSA 261:40; and

(2) Are properly equipped and supplied in accordance with 49 CFR 38.23.

Source. #14393, eff 10-1-25, EXPIRES: 10-1-35

He-W 574.04 Driver Participation.

(a) All transportation company drivers shall be participants with the broker.

(b) The broker shall acquire and store the following required documentation for all family and friend drivers:

(1) A copy of the driver’s license of the driver(s);

(2) A completed “Family and Friends Mileage Reimbursement Program New Driver Enrollment Sheet” (September 2025) agreeing to the following:

a. “Participation in the Family and Friends Program is both voluntary and a privilege and that failure to comply with any of the rules of the program may result in my immediate termination from this milage reimbursement program;

b. Medicaid fraud is a serious crime and fraudulent submissions for reimbursement under this program can result in criminal penalties up to 7 years in State prison;

c. If I move I must update and provide proof of my new address to Medicaid before I submit my next reimbursement form;

d. Driver must have a valid driver’s license in order to receive reimbursement under this program;

e. Driving without a license, driving with a suspended license, or driving while designated as a habitual offender are all crimes in New Hampshire and submissions made under this program can and will be used against me in criminal proceedings;

f. If the New Hampshire Department of Health and Human Service or its partners has reason to suspect any potential violations of the Family and Friends Program, I understand that my driver’s history, motor vehicle records, and/or my criminal background may be checked;

g. Having a criminal history or driving records does not necessarily prevent me from participating in this program;

h. My participation in this program will be governed in accordance with the Department of Health and Human Services’ Administrative Rule He-W 574.”; and

i. “That all information contained in this application and the information in the accompanying documents is true and accurate and that any material falsities contained herein may result in a prosecution for false swearing under RSA 641:3.”;

(3) A completed “Request for Reimbursement of Medical Transportation by Private Car” (September 2025) signed by:

a. The member and certifying that:

“The information on this form is true, accurate, and complete. I understand that payment of this claim may be from Federal and State funds and that any false or altered claims, statements, documents, or the concealment of material fact may be prosecuted under applicable Federal and State laws. I agree to accept transportation payment as payment in full but understand that I have the right to appeal the reimbursement amount”; and

b. The medicaid provider and certifying that:

“The patient named above visited my office/clinic/pharmacy for non-emergency medical appointment(s) or Medicaid covered pharmaceuticals on the date(s) as noted.”; and

(4) A copy of a review of the Office of Inspector General list of excluded individuals and entities, pursuant to He-W 574.03(c), at start of service and monthly thereafter.

(c) The broker shall acquire and store the following documentation for all transportation company drivers for a period of 6 years:

(1) A completed, signed, and dated credentialing packet from the transportation company;

(2) Proof of a valid driver’s license;

(3) A copy of the document received from the IRS which provided the driver’s federal tax ID number;

(4) A completed IRS W-9 form at the time of enrollment;

(5) A copy of the document received from the IRS which indicates the applicant’s non-profit tax-exempt status, if applicable;

(6) Proof of automobile liability insurance;

(7) Updated proof of insurance at the time it is renewed, and at any other time when a change in status has occurred;

(8) Review of the Office of Inspector General list of excluded individuals and entities upon hire and monthly checks;

(9) Background checks;

(10) Records of recipient complaints including actions taken to investigate and resolve complaint;

(11) Training records;

(12) Dispatch travel logs including driver name, transportation company name, recipient name, and date of service, with signature log of all parties;

(13) Billing and payment records; and

(14) Proof that the vehicle is safe for transporting passengers.

(d) Wheelchair van drivers shall:

(1) Retain and submit the following documentation when requested, to the broker:

a. Proof that the vehicle was registered in accordance with RSA 261:40 during the time of medicaid wheelchair van service; and

b. Proof of vehicle insurance during the time period that services were delivered; and

(2) Comply with all applicable requirements of 49 CFR 37 and 49 CFR 38.

Source. (See Revision Note at chapter heading He-W 500); ss by #6163, eff 1-4-96, EXPIRED: 1-4-04

New. #8732, eff 9-30-06; ss by #10810, eff 4-9-15; ss by #14393 (formerly He-W 574.03), eff 10-1-25, EXPIRES: 10-1-35

He-W 574.05 Covered Services.

(a) Non-emergency medical transportation shall be covered for the purpose of allowing a recipient to access medicaid covered medical, dental, or behavioral health services from a medicaid enrolled provider pursuant to 42 CFR 441.62(a) and 42 CFR 440.170.

(b) The covered service shall be the least costly available to meet the recipient’s needs.

(d) Only the actual number of miles traveled to and from the medicaid address and medicaid covered services shall be reimbursable and as described in He-W 574.08(a).

(e) Non-emergency medical transportation shall be to the nearest appropriate medicaid enrolled provider of the covered medical, dental, or behavioral health service, as determined by the department.

(f) Transportation shall be provided via the least costly route, as described in He-W 574.10(c).

(g) Wait times shall be covered for round trips only and for up to a maximum of 2 hours, rounded to the nearest half hour.

(h) Transportation via ambulance shall be covered as non-emergency medical transportation when medically necessary and pursuant to the requirements in He-W 572.06.

(i) Non-emergency medical transportation shall be covered, pursuant to He-W 546.05(d):

(1) For EPSDT-eligible children;

(2) For any person who needs to accompany an eligible child to the child’s medical, dental, or behavioral health service; and

Source. (See Revision Note at chapter heading He-W 500); ss by #6163, eff 1-4-96, EXPIRED: 1-4-04

New. #8732, eff 9-30-06; ss by #10810, eff 4-9-15; ss by #14393 (formerly He-W 574.04), eff 10-1-25, EXPIRES: 10-1-35

He-W 574.06 Non-Covered Services.

(a) Non-emergency medical transportation shall be a non-covered service when it:

(1) Is being provided for a purpose other than for the recipient to access medicaid covered medical, dental, or behavioral health services;

(2) Is to a medicaid enrolled provider who transports the recipient to their own location of service unless the provider is participating with the broker as a transportation driver;

(3) Is for purposes of recipient or provider convenience; or

(4) Was performed by a driver who has not complied with the requirements of He-W 574.04.

(b) The following shall not be covered:

(1) Any wait time associated with one-way trips; and

(2) Wait time that exceeds 2 hours for round trips.

Source. (See Revision Note at chapter heading He-W 500); ss by #6163, eff 1-4-96, EXPIRED: 1-4-04

New. #8732, eff 9-30-06; ss by #10810, eff 4-9-15; ss by #14393 (formerly He-W 574.05), eff 10-1-25, EXPIRES: 10-1-35

He-W 574.07 Submission of Claims.

(a) The broker shall submit to the department an invoice identifying the monthly reimbursement amount for family and friends drivers.

(b) Submission of claims for multiple trips in one day shall be limited to the submission of one claim per trip regardless of the number of passengers.

Source. (See Revision Note at chapter heading He-W 500); ss by #6163, eff 1-4-96, EXPIRED: 1-4-04

New. #8732, eff 9-30-06; ss by #10810, eff 4-9-15; ss by #14393 (formerly He-W 574.06), eff 10-1-25, EXPIRES: 10-1-35

He-W 574.08 Payment for Services.

(a) Except as provided by (d) below, claims for family and friends non-emergency medical transportation delivered via private transportation shall be reimbursed at the lesser amount of:

(1) Actual number of miles billed multiplied by rate per mile; or

(2) The maximum allowable mileage for the trip, multiplied by the rate per mile.

(b) Public transportation shall be coordinated by the broker and the broker shall be responsible for reimbursement.

(c) Reimbursement for tolls and parking fees shall be paid if receipts are submitted with the family and friends reimbursement claim.

(d) Reimbursement for family and friends drivers when a trip includes multiple passengers shall be as follows:

(1) For multiple trips in one day this shall be limited to the submission of one claim per trip regardless of the number of passengers;

(2) For the total miles from the medicaid address of the first recipient to the final destination and return to the original pickup address; and

(3) For total miles in the claim submission described in (2) above shall be paid at the actual mileage traveled or the maximum mileage allowance per trip, in accordance with He-W 574.10(b), whichever is less.

(e) Reimbursement shall not be made:

(1) For trips provided prior to the date the provider was enrolled with the broker, unless prior authorized by the broker;

(2) For claims submitted 90 days or more from the date of the trip;

(3) If the medicaid enrolled provider’s signature is missing on the “Request for Reimbursement of Medical Transportation by Private Car” (September 2025); or

(4) If the signature of the driver or the recipient, or both, is missing on the “Request for Reimbursement of Medical Transportation by Private Car” (September 2025).

(f) Reimbursement shall be made to the recipient who then shall be responsible for paying the family and friends driver.

Source. (See Revision Note at chapter heading He-W 500); ss by #6163, eff 1-4-96, EXPIRED: 1-4-04

New. #8732, eff 9-30-06; ss by #10810, eff 4-9-15; ss by #14393 (formerly He-W 574.07), eff 10-1-25, EXPIRES: 10-1-35

He-W 574.09 Prior Authorization.

(a) The broker shall contact the department to obtain prior authorization for non-emergency medical transportation services when transportation is needed outside of the mileage limits in He-W 574.10(b).

(b) The recipient shall receive prior authorization for transportation outside the mileage limits as described in (a)(1) above, based on the following information:

(1) The recipient’s name and address;

(2) The recipient’s medicaid identification (MID) number;

(3) Details describing the illness or condition sufficient to enable the department to understand the physical or emotional condition of the recipient and the reason(s) for which the medical, dental, or behavioral health service is required;

(4) That the needed medical, dental, or behavioral health services cannot be obtained within the mileage limits in He-W 574.10(b);

(5) The expected outcome and recommended timetable of the prescribed medical, dental, or behavioral health service; and

(6) The name and address of the medicaid enrolled provider.

(1) All of the required information described in (b) above is received; and

(2) The department determines, based on the information provided, that the transportation is necessary and appropriate for the recipient’s medical, dental, or behavioral health condition, as supported by the information provided in the request.

(d) The department shall deny requests for prior authorization if:

(1) The provisions set forth in (c) above are not met; or

(2) The department determines that the recipient does not meet the eligibility requirements of He-W 574.02.

(e) If prior authorization is approved, payment for non-emergency medical transportation shall still comply with all of the provisions of He-W 574.

(f) If prior authorization is denied, the department shall forward a notice of denial to the recipient and the provider.

(g) The notice of denial shall contain the information required by 42 CFR 431.210, including:

(1) The reason for, and legal basis of, the denial; and

(2) Information that an appeal of the denial may be requested, in accordance with He-C 200, within 30 calendar days of the date on the notice of the denial.

Source. (See Revision Note at chapter heading He-W 500); ss by #6163, eff 1-4-96, EXPIRED: 1-4-04

New. #8732, eff 9-30-06; ss by #10810, eff 4-9-15; ss by #14393 (formerly He-W 574.08), eff 10-1-25, EXPIRES: 10-1-35

He-W 574.10 Mileage Limits and Rate.

(a) The rate paid shall be that established by the commissioner in accordance with RSA 161:4, VI(a).

(b) The maximum allowed traveled round trip mileage to medicaid enrolled providers by drivers shall not exceed the following limits:

(1) 90 miles to a hospital;

(2) 50 miles to a physician or behavioral health provider;

(3) 300 miles to a dentist;

(4) 90 miles to a physical, speech, or occupational therapist;

(5) 90 miles to a dialysis provider;

(6) 400 miles to a specialty provider; and

(7) 30 miles to a pharmacy.

(c) Determination of the least costly route shall be by the use of a web-based mapping tool containing a mileage calculator, which has the functionality to allow the input of addresses and the calculation of distance between them and to identify toll roads.

(d) Payments for wheelchair van services shall consist of the following components:

(1) A base rate, which shall:

a. Be paid once only for a single one-way trip or each way of a round trip; and

b. Be paid twice for 2 one-way trips for the same recipient on the same day;

(2) A mileage rate, which shall:

a. Be based on the most direct route to and from a destination, and not necessarily the route used;

b. Be paid for loaded miles only, which shall:

1. Be the distance traveled while transporting recipients from a pick-up point to a drop-off point; and

2. Not include mileage incurred on the way to pick up a recipient or after dropping off a recipient;

c. Include all miles traveled; and

d. Be paid only once per trip regardless of the number of recipients transported; and

(3) A payment for the wait time described in He-W 574.05(f).

Source. (See Revision Note at chapter heading He-W 500); ss by #6163, eff 1-4-96, EXPIRED: 1-4-04

New. #8732, eff 9-30-06; ss by #10810, eff 4-9-15; ss by #14393, eff 10-1-25, EXPIRES: 10-1-35

He-W 574.11 Hearings. Any recipient who has been denied reimbursement for non-emergency medical transportation services may appeal an adverse decision by requesting a fair hearing in accordance with He-C 200. Requests for fair hearings shall be submitted no later than 30 days after the date the notice of decision being appealed is issued.

Source. (See Revision Note at chapter heading He-W 500); ss by #6163, eff 1-4-96, EXPIRED: 1-4-04

New. #8732, eff 9-30-06; ss by #10810, eff 4-9-15; ss by #14393, eff 10-1-25, EXPIRES: 10-1-35

He-W 574.12 Third Party Liability. All third party obligations shall be exhausted before the NH medicaid program may be billed, in accordance with 42 CFR 433.139.

Source. (See Revision Note at chapter heading He-W 500); ss by #6163, eff 1-4-96, EXPIRED: 1-4-04

New. #8732, eff 9-30-06; ss by #10810, eff 4-9-15; ss by #14393, eff 10-1-25, EXPIRES: 10-1-35

He-W 574.13 Utilization Review and Control. The department’s bureau of program integrity shall monitor utilization of non-emergency medical transportation services to identify, prevent, and correct potential occurrences of fraud, waste, and abuse, in accordance with 42 CFR 455, 42 CFR 456, and He-W 520.

Source. (See Revision Note at chapter heading He-W 500); ss by #6163, eff 1-4-96, EXPIRED: 1-4-04

New. #8732, eff 9-30-06; ss by #10810, eff 4-9-15 (formerly He-W 574.14); ss by #14393, eff 10-1-25, EXPIRES: 10-1-35

PART He-W 575 AUGMENTATIVE AND ALTERNATIVE COMMUNICATION AID SERVICES

He-W 575.01 Definitions.

(a) “Augmentative and alternative communication (AAC)” means all forms of communication other than oral speech that are used to express thoughts, needs, wants, and ideas.

(b) “Augmentative and alternative communication (AAC) aids” means electronic or non-electronic aids, devices or systems that assist an individual to overcome or ameliorate the communication limitations that preclude or interfere with meaningful participation in current and projected daily activities, such as communication boards or books, speech amplifiers, electronic devices that produce speech and/or written output.

(c) “Augmentative and alternative communication (AAC) consultant” means the speech language pathologist who participates in the AAC evaluation and who provides ongoing consultation to the recipient regarding AAC implementation.

(d) “Augmentative and alternative communication (AAC) evaluation” means an evaluation that assesses the recipient’s communication skills and abilities, and their AAC needs.

(e) “Date of service” means the date the AAC provider orders the prior authorized AAC aid or accessory.

(f) “Department” means the NH department of health and human services.

(g) “Functionally communicate” means to share information, to impart knowledge, and/or to have interchanges of thoughts.

(h) “Medicaid” means the Title XIX and Title XXI programs administered by the department, which makes medical assistance available to eligible individuals.

(i) “Recipient” means any individual who is eligible for and receiving medical assistance under the medicaid program.

(j) “Title XIX” means the joint federal-state program described in Title XIX of the Social Security Act and administered in New Hampshire by the department under the medicaid program.

(k) “Title XXI” means the joint federal-state program described in Title XXI of the Social Security Act and administered in New Hampshire by the department under the medicaid program.

Source. #10636, eff 7-12-14

He-W 575.02 Recipient Eligibility. A recipient shall be eligible to receive AAC aids as prescribed by a physician when:

(a) The recipient has a significant, expressive communication or language comprehension impairment such as apraxia of speech, dysarthria, and cognitive communication disabilities, and the impairment or disability either temporarily or permanently causes communication limitations that preclude or interfere with the recipient's meaningful participation in current and projected daily activities; and

(b) The prescribed AAC aid is coverable in accordance with this rule.

Source. #10636, eff 7-12-14

He-W 575.03 Provider Participation. All participating AAC providers shall:

(a) Be an enrolled New Hampshire Medicaid durable medical equipment (DME) provider;

(b) Request and obtain prior authorization from the department in accordance with He-W 575.06 below; and

(c) Provide the recipient and caregiver with equipment training and related supports, including equipment set-up, training in the use and maintenance of the AAC aid, and technical support.

Source. #10636, eff 7-12-14

He-W 575.04 Covered Services. The following AAC aids, accessories, and services shall be covered:

(a) The purchase, repair, and modifications of AAC aids and accessories when they:

(1) Meet the definition of durable medical equipment (DME) per He-W 571.01;

(2) Are medically necessary;

(3) Are the most clinically appropriate and least costly alternative;

(4) Are a dedicated communication device used only for communication purposes;

(5) Are to be used solely by the recipient; and

(6) Have been prior authorized in accordance with He-W 575.06 below;

(b) Rental of AAC aids for up to 2 months when prior authorized in accordance with He-W 575.06 below, and at least one of the following is true:

(1) Time is needed to assess the appropriateness of the AAC aid, and whether it will meet the person’s current needs and accommodate reasonable anticipated future needs;

(2) Rental is needed because the recipient’s AAC aid is out for authorized repair and no loaner equipment is available from the AAC provider or manufacturer; or

(3) Rental is needed during the time period between order and delivery of the aid approved for purchase, and no loaner equipment is available from the AAC provider or manufacturer; and

(1) Identified in the AAC evaluation, conducted in accordance with He-W 575.07 below, as the recipient’s only AAC aid allowing for functional communication;

(2) Are medically necessary;

(3) Are the most clinically appropriate and least costly alternative;

(4) Are a dedicated communication device used only for communication purposes;

(5) Are to be used solely by the recipient; and

(6) Have been prior authorized in accordance with He-W 575.06 below.

Source. #10636, eff 7-12-14

He-W 575.05 Non-Covered Services. The following equipment, accessories, items, and services shall not be covered:

(a) Computer equipment and accessories that do not meet the criteria in He-W 575.04(c) above;

(b) Software or computer equipment that is not specifically integral to communication devices;

(c) Multiple AAC aids and accessories unless such items together expand the functional capability of the aid, such as increased recording time or vocabulary, and represent the most clinically appropriate and least costly alternative in equipment options for the recipient;

(d) Equipment that duplicates equipment already funded by medicaid, per He-W 530.05(b)(25);

(e) More than one charger per AAC aid;

(f) Extended warranty and maintenance agreements;

(g) Shipping and handling fees on purchased equipment, except as allowed by He-W 575.11(e)-(f) below;

(h) Repair of original AAC aids once a replacement has been provided;

(i) Replacement or repair of rented AAC aids;

(j) Replacement of AAC aids when the replacement is requested solely as a result of changing technology, or when the existing device effectively addresses the beneficiary’s needs;

(k) Replacement of AAC aids when the replacement occurs within 5 years from the date of purchase of the original equipment unless there is a clinical justification for a replacement in less time, such as a significant change in the recipient’s needs and abilities relative to AAC use such that the current aid limits communication, or no longer provides access to communication;

(l) Environmental control equipment;

(m) Equipment or appliances that are not considered medical equipment in nature, such as tape recorders, fans, lights, radios, and toys, with the exception of computer equipment and accessories covered in accordance with He-W 574.04(c) above;

(n) Internet access, including costs associated with initial and recurring internet service provider fees, purchase or rental of modems, mobile device data plans, or network access for mobile devices;

(o) Subscriptions for mobile device applications, also known as “apps”; and

(p) Replacement, repair, or modifications of an item when the need is the result of:

(1) Abuse, misuse, or inappropriate use or neglect of the AAC aid;

(2) Failure to protect the item from the elements;

(3) Using the item inappropriately or contrary to its designed and intended use;

(4) Making improper repairs to the item, which would void any manufacturer’s warranty;

(5) Loss of the item when basic safeguarding measures could have been instituted;

(6) Failure to maintain the item through proper routine maintenance by an authorized dealer; or

(7) Taking any action that would otherwise void the manufacturer’s written warranty or is contrary to the manufacturer’s recommendations for care, use, and maintenance.

Source. #10636, eff 7-12-14

He-W 575.06 Prior Authorization.

(a) An AAC provider shall request and obtain a prior authorization from the department on behalf of a recipient for the purchase, rental, or repair of AAC aids and accessories.

(b) Prior authorization requests for purchases and rentals shall include the following:

(1) A statement from the recipient’s physician that includes:

a. An explanation of the medical need of the AAC aid being requested;

b. A statement that the physician concurs with the recommendation of the AAC evaluation, conducted in accordance with He-W 575.07; and

c. When the request is for a rental, an indication of which of the coverage criteria has been met per He-W 575.04(b) above;

(2) An AAC evaluation as described in He-W 575.07; and

(3) A completed Form #288-Q, “Quote for Augmentative and Alternative Communication (AAC) Aids Funding Request” (June 2014), completed and signed by a NH Medicaid DME provider.

(1) The all-inclusive cost of the repair;

(2) Replacement cost of the current AAC aid;

(3) A letter from a licensed speech language pathologist (SLP) that establishes the recipient’s prognosis for continued use of the current AAC aid, including the expected life-span of the AAC aid with repair;

(4) A copy of the safeguarding plan, as described in He-W 575.07(c)(10)b., that is less than one year old and contains current contact information; and

(5) A signed statement from the recipient attesting that the need for the repair is not the result of any of the condition listed in He-W 575.05(q).

(d) Prior authorization requests for modification of an existing AAC aid shall include the following:

(1) The all-inclusive cost of the modification;

(2) A justification of need, as described in He-W 575.07(c)(6), from a licensed SLP, including updated clinical information; and

(3) The results of an AAC evaluation completed in accordance with He-W 575.07 within the last 3 years.

(e) In addition to the requirements of (c) and (d) above, prior authorization requests for the repair or modification of an existing AAC aid shall include current clinical information regarding the recipient’s use of the AAC aid, as well as current contact information of the individuals listed in He-W 575.07(c)(2).

(f) Prior authorization requests shall be approved when the department’s prior authorization agent determines that the purchase, rental, or repair of the AAC aid being requested is determined to be the most clinically appropriate and least costly alternative, as supported by the documentation submitted in accordance with (b), (c), or (d) above.

(g) The department’s prior authorization agent shall forward written confirmation of the department’s approval of a prior authorization request to the provider.

(h) The AAC provider shall be responsible for determining that the recipient is Medicaid eligible on the date of service.

(i) The department’s prior authorization agent shall deny a PA request if the agent determines that the requirements set forth in this part have not been met.

(j) If the department’s prior authorization agent denies the prior authorization request, the department’s prior authorization agent shall forward a notice of denial to the recipient and the AAC provider.

(k) The notice of denial shall contain the information required by 42 CFR 431.210, including:

(1) The reason for, and legal basis of, the denial; and

(2) That a fair hearing on the denial may be requested within 30 calendar days of the date on the notice of the denial.

Source. #10636, eff 7-12-14

He-W 575.07 AAC Evaluation.

(a) An AAC evaluation shall be required for prior authorization of all AAC aids.

(b) An AAC evaluation shall be completed by a SLP licensed as such by the state in which he or she practices, and who has one of the following credentials:

(1) Has at least 3 years’ experience in the provision of AAC aids; or

(2) Has completed an accredited training in AAC.

(1) The recipient’s identifying information including name and medicaid identification (MID) number;

(2) A Form #288-F, “Augmentative and Alternative Communication (AAC) Aids Funding Information” (June 2014) that has been signed by the SLP who conducted the AAC evaluation;

(3) The recipient’s medical and communication diagnoses;

(4) An explanation of the medical need of the recommended AAC aid, and how it will allow the recipient the ability to functionally communicate, including the recipient’s communication prognosis both with and without the use of the AAC aid;

(5) The recipient’s past and current communication skills, including information about past AAC use;

(6) A justification of need which indicates the need for modified equipment including information about any of the following areas:

a. The recipient’s environment;

b. The recipient’s behavior, cognitive skills, motor skills, perceptual skills, and sensory impairments;

c. The recipient’s ability to access and activate the AAC aid including activation through touch, eye gaze, or scanning; and

d. The need for the AAC aid to be positioned and mounted;

(7) A comparison of at least 3 different AAC aids from the same device code category using features match, simulation, or trial, and the results of the comparison including:

a. Identification of the chosen aid and the rationale as to why it was chosen over the others;

b. An explanation of how the chosen aid meets the recipient’s communication needs including data demonstrating improvement over baseline using the selected equipment; and

c. An explanation as to how the AAC aid represents the least costly, most clinically appropriate alternative given the recipient’s demonstrated cognitive and linguistic abilities;

(8) Except as allowed by (d) below, the results of a one-month long trial of the AAC aid identified in (7)a. above, which shall be provided on Form #288-T, “Augmentative and Alternative Communication (AAC) Aids Trial Summary” (June 2014), showing that the recipient’s ability to communicate has been maintained or has improved over baseline, and signed by a SLP who completed the evaluation;

(9) A detailed list of recommended AAC aids and accessories to be ordered as a result of the completed evaluation;

(10) A plan of care for the recipient’s use of the AAC aid, which shall include:

a. Training of the recipient and the caregiver(s) in the use, maintenance, and care of the AAC aid;

b. A safeguarding plan, which shall be provided on Form #288-SG, “Augmentative and Alternative Communication (AAC) Aids Safeguarding Plan” (June 2014), and signed by the SLP who completed the evaluation; and

c. The frequency of direct treatment and/or consultation by the licensed SLP responsible for integration of the AAC aid or by the AAC consultant;

(11) Documentation indicating that the use of the AAC aid will be supported in the home, school, and work settings as applicable;

(12) Signature of the SLP who completed the evaluation who attests to his or her agreement with the findings of the evaluation and its recommendations; and

(13) Signatures of any individuals who, as part of the plan of care, are responsible for ensuring that the plan is effectively implemented at home, at school, or at work, and their acknowledgement that they understand their role in the implementation of the plan.

(d) When an AAC aid has 8 minutes of recording time or less and can be accessed by direct selection or scanning and light tech materials, a trial period shall not be required.

(e) None of the individuals signing the evaluation in (c) above shall have any financial affiliation with the manufacturer or the supplier of the AAC aids.

(f) The AAC evaluation shall be valid for 3 years from the date it was completed.

Source. #10636, eff 7-12-14

He-W 575.08 Documentation.

(a) In accordance with He-W 520, the AAC provider shall maintain supporting records to substantiate claims submitted for reimbursement for a period of at least 6 years from the date of service or until the resolution of any legal action(s) commenced in the 6 year period, whichever is longer.

(b) The AAC provider shall maintain records of equipment training and related support provided in accordance with He-W 575.03(c) above.

Source. #10636, eff 7-12-14

He-W 575.09 Third Party Liability. All third party obligations shall be exhausted before medicaid may be billed in accordance with 42 CFR 433.129.

Source. #10636, eff 7-12-14

He-W 575.10 Utilization Review and Control. The department’s provider integrity unit shall monitor utilization of AAC aids and services to identify, prevent, and correct potential occurrences of fraud, waste, and abuse in accordance with 42 CFR 455, 42 CFR 456, and He-W 520.

Source. #10636, eff 7-12-14

He-W 575.11 Payment for AAC Aids. Payment for AAC aids shall be made as follows:

(a) The DME provider of AAC aids shall submit claims for payment to the department’s fiscal agent;

(b) Claims shall not be submitted prior to the date the AAC aid is delivered to the recipient;

(d) Payment for the purchase of AAC aids shall be made at the lesser of the following amounts:

(1) Usual and customary charge to the public, as established by the provider; or

(2) Provider acquisition cost, plus a mark-up, which shall be determined as follows:

a. For purchases from providers who have a program in place for ongoing education and technical support for the use of the AAC aid(s) after purchase, the mark-up shall be no greater than 35%; and

b. For purchases from providers who do not have a program in place for ongoing education and technical support for the use of the AAC aid(s) after purchase, the mark-up shall be as follows:

1. For AAC aids with a total cost of less than $301, the mark up shall be no greater than 35%;

2. For AAC aids with a total cost from $301 to $750, the mark-up shall be no greater than 30%;

3. For AAC aids with a total cost from $751 to $1,200, the mark-up shall be no greater than 25%; and

4. For AAC aids with a total cost of $1,201 and above, the mark-up shall be no greater than 20%;

(e) Payment as calculated in (d) above shall not include shipping costs, except for cases in which the AAC aids are purchased from multiple vendors, or the provider would receive less than $35 per vendor over their cost when shipping is included;

(f) When the AAC provider receives less than $35 over the acquisition cost when shipping is included, then an amount shall be included in the total payment to account for the cost of shipping;

(g) In the case of an AAC aid that has been rented before purchase, the cost of one month’s rental shall be deducted from the purchase amount computed in (d) above;

(h) For rental of AAC aids:

(1) No prepayment shall be made; and

(2) The provider shall submit claims at the end of the rental period;

(i) Payment for repairs of purchased AAC aids shall be the all-inclusive usual and customary charge to the public, except that:

(1) The allowable labor costs shall not exceed $50.00/hour; and

(2) Payment shall not include the cost of shipping and handling;

(j) Recipients shall not be liable for shipping and handling costs associated with repairs, rentals, and purchases; and

(k) Payment shall be denied if the recipient is not eligible for NH Medicaid on the date the authorized AAC aid is ordered.

Source. #10636, eff 7-12-14

PART He-W 576 MANAGED CARE ORGANIZATIONS - EXPIRED

He-W 576.01 – 576.05

Source. (See Revision Note at chapter heading He-W 500); ss by #4907, eff 9-1-90, EXPIRED: 9-1-96

New. #6926, eff 12-30-98

He-W 576.06 – 576.09

Source. (See Revision Note at chapter heading He-W 500); ss by #5165, eff 6-17-91, EXPIRED: 6-17-97

New. #6926, eff 12-30-98

PART He-W 577 LABORATORY SERVICES

He-W 577.01 Definitions.

(a) “Current procedural terminology (CPT) code” means a unique identifying code in the field of medical nomenclature and designated by the United States department of health and human services as the national coding standard utilized in government and private health insurance programs for reporting medical services and procedures.

(b) “Department” means the New Hampshire (NH) department of health and human services.

(c) “Medicaid” means the Title XIX and Title XXI programs administered by the department, which makes medical assistance available to eligible individuals.

(d) “Recipient” means an individual who is eligible for and receiving medical assistance under the medicaid program.

(e) “Title XIX” means the joint federal-state program described in Title XIX of the Social Security Act and administered in NH by the department under the medicaid program.

(f) “Title XXI” means the joint federal-state program described in Title XXI of the Social Security Act and administered in NH by the department under the medicaid program.

Source. #8564, eff 2-7-06; amd by #10139, eff 7-1-12; ss by #10513, eff 1-24-14; ss by #14414, eff 10-22-2025, EXPIRES: 10-22-2035

He-W 577.02 Recipient Eligibility. All medicaid recipients shall be eligible for laboratory services, in accordance with He-W 577.

Source. #8564, eff 2-7-06; ss by #10513, eff 1-24-14; ss by #14414, eff 10-22-2025, EXPIRES: 10-22-2035

He-W 577.03 Provider Participation.

(a) All participating laboratory service providers shall:

(1) Be licensed by the states in which they practice;

(2) Be certified to participate in the medicare program if the provider is an independent laboratory;

(3) Be clinical laboratory improvement amendments (CLIA) certified in accordance with 42 USC 263a; and

(4) Be an enrolled New Hampshire medicaid provider.

(b) If a laboratory test cannot be performed within the capabilities of the participating laboratory services provider, the specimens may be referred to another laboratory that is certified in the appropriate specialties and subspecialties of services in accordance with the requirements of 42 CFR 493.

Source. #8564, eff 2-7-06; ss by #10513, eff 1-24-14; ss by #14414, eff 10-22-2025, EXPIRES: 10-22-2035

He-W 577.04 Covered Services. Laboratory services shall be covered when:

(a) Ordered and provided under the direction of a physician or other licensed practitioner within the scope of their practice; or

(b) Ordered by a physician but provided by a referral laboratory in accordance with 42 CFR 440.30.

Source. #8564, eff 2-7-06; ss by #10513, eff 1-24-14; ss by #14414, eff 10-22-2025, EXPIRES: 10-22-2035

He-W 577.05 Utilization Review and Control.

(a) The department’s bureau of program integrity shall monitor utilization of laboratory services to identify, prevent, and correct potential occurrences of fraud, waste, and abuse, in accordance with 42 CFR 455, 42 CFR 456, and He-W 520.

Source. #8564, eff 2-7-06; ss by #10513, eff 1-24-14; ss by #14414, eff 10-22-2025, EXPIRES: 10-22-2035

He-W 577.06 Third Party Liability.

(a) All third party obligations shall be exhausted before medicaid can be billed, in accordance with 42 CFR 433.139.

(b) Laboratory service providers shall request information from the recipient regarding other insurance coverage.

(c) If other insurance coverage is available, providers shall contact the insurer to verify benefits initially and at least annually thereafter or when the insurance carrier changes.

(d) Providers shall maintain a record of any other insurance verifications in the recipient’s medical record in accordance with He-W 520.

Source. #8564, eff 2-7-06; ss by #10513, eff 1-24-14; ss by #14414, eff 10-22-2025, EXPIRES: 10-22-2035

He-W 577.07 Payment for Services.

(a) Laboratory service providers shall bill:

(1) Utilizing the appropriate CPT code and code guidelines established for use with these procedure codes;

(2) For services referred to and provided by another laboratory in accordance with He-W 577.03(b); and

(3) For tests performed as groups and combinations utilizing the CPT codes for automated multichannel procedures.

(b) All laboratory tests shall be included in the panel if:

(1) A panel procedure code is utilized for billing; and

(2) The panel procedure code is listed in the National Correct Coding Initiative (NCCI), found at the Centers for Medicare and Medicaid Services, at www.cms.hhs.gov.

(c) Payments to laboratory service providers shall be made in accordance with rates established by the department pursuant to RSA 161:4, VI.

(d) The department shall directly reimburse a physician for laboratory services provided by a laboratory service provider with which the physician has a contract or agreement.

(e) Laboratory service providers shall submit claims for payment to the department’s fiscal agent and in accordance with He-W 521.04.

(f) Laboratory service providers shall maintain supporting documentation, in accordance with He-W 520.

Source. #8564, eff 2-7-06; ss by #10513, eff 1-24-14; ss by #14414, eff 10-22-2025, EXPIRES: 10-22-2035

PARTS He-W 578 through He-W 588 - RESERVED

PART He-W 589 Medical Assistance Services Provided by Education Agencies

Revision Note:

Document #12994, effective 2-21-20, readopted with amendments and renumbered He-M 1301.01 through He-M 1301.09 in Part He-M 1301 titled “Medical Assistance Services Provided by Education Agencies” as He-W 589.01 through He-W 589.09 in Part He-W 589 also titled “Medical Assistance Services Provided by Education Agencies”. The source note information for He-W 589.01 through He-W 589.09 includes the documents filed under the former rule numbers in He-M 1301 indicated in each source note.

He-W 589.01 Purpose. The purpose of these rules is to describe the services provided by school districts and school administrative units that are reimbursable under NH medicaid for which federal financial participation (FFP) can be claimed and to describe the required qualifications of clinicians, licensed by a board under the office of professional licensure and certification for healthcare professionals, delivering reimbursable services in schools and preschools. Reimbursable services include both the NH medicaid state plan services, and other optional services that are not covered under the NH medicaid state plan, but covered pursuant to 1905(a) of the Social Security Act through the early and periodic screening, diagnostic, and treatment (EPSDT) benefit. Requesting FFP for medicaid services is optional for school districts and school administrative units. These service descriptions are established to allow students to receive medically necessary services within the least restrictive environment. Participation in medicaid is discretionary on the part of school districts and school administrative units. These rules are not intended to impose upon school districts and school administrative units the responsibility to provide any services that they are not otherwise legally responsible to provide under RSA 186-C or other law.

Source. #4925, INTERIM, eff 8-31-90; ss by #5038, eff
12-28-90; ss by #5456, eff 9-1-92, EXPIRED: 9-1-98

New. #6861, INTERIM, eff 10-2-98, EXPIRED: 1-30-99

New. #6987, eff 4-27-99; ss by #8874, INTERIM, eff
4-25-07, EXPIRED: 10-22-07

New. #9035, eff 11-22-07; ss by #11025, eff 1-23-16

New. #12994, eff 2-21-20 (formerly He-M 1301.01) (See Revision Note at part heading for He-W 589); ss by #14432, eff 11-25-25, EXPIRES: 11-25-35

He-W 589.02 Definitions.

(a) “Activities of daily living (ADL)” means basic self-care tasks such as personal hygiene, grooming, eating, dressing, transferring, mobility, and toileting.

(b) “Applied behavior analysis (ABA)” means a treatment modality that employs the process of systematically applying interventions based on the principles of learning theory to improve socially significant behaviors, and is covered through the EPSDT benefit pursuant to He-W 546 and in accordance with He-W 589.04(at).

(c) “Augmentative and alternative communication (AAC) aids” means electronic or non-electronic aids, devices, or systems ordered by a licensed speech-language pathologist, including a certified speech- language specialist as described in RSA 326-F:3, IV(b), that assist a student to overcome or ameliorate the communication limitations that preclude or interfere with meaningful participation in current and projected daily activities, such as communication boards or books, speech amplifiers, and electronic devices that produce speech, written output, or both. This term includes “AAC devices”.

(d) “Care plan” means a written health care plan, including, but not limited to, an individualized education program or a 504 plan, which is maintained in the student’s file and documents and supports the medical necessity of all claims to NH medicaid for FFP.

(e) “Carry-over tasks” means tasks, therapies, or activities that a rehabilitative assistant performs as instructed by the licensed clinician in support of the care plan’s goals or the licensed clinician’s treatment plan.

(f) “Durable medical equipment (DME)” means a type of item pursuant to He-W 571 that is:

(1) Non-disposable and able to withstand repeated use;

(2) Primarily used to serve a medical purpose for the treatment of an acute or chronic medically diagnosed health condition, illness, or injury; and

(3) Not useful to an individual in the absence of an acute or chronic medically diagnosed health condition, illness, or injury.

(g) “Early and periodic screening, diagnosis, and treatment (EPSDT) services” means a benefit pursuant to 42 CFR 440.40 and He-W 546, designed to provide preventative health care, diagnostic services, and early detection and treatment of disease or abnormalities to medicaid enrolled individuals under age 21.

(h) “Enrolled school provider” means a NH local education agency (LEA) or school administrative unit (SAU) that has agreed to participate in NH medicaid pursuant to these rules and has enrolled with NH medicaid.

(i) “Federal financial participation (FFP)” means the federal share of costs for services.

(j) “Group” means 2 or more persons.

(k) “Individualized education plan (IEP)” means a written statement for a child with a disability that is developed, reviewed, and revised in accordance with 34 CFR 300.320 through 300.324, Ed 1109.01, and Ed 1109.03.

(l) “Instrumental activities of daily living” (IADL) means personal hygiene, light housework, laundry, meal preparation, transportation, grocery shopping, using the telephone, medication management, and money management.

(m) “Local education agency (LEA)” means a local school district.

(n) “Medical assistance” means the federally financed medical assistance program established pursuant to Title XIX and Title XXI of the Social Security Act also known as the medicaid program.

(o) “Medically necessary” means reasonably calculated to prevent, diagnose, correct, cure, alleviate, or prevent the worsening of conditions that endanger life, cause pain, result in illness or infirmity, threaten to cause or aggravate a handicap, or cause physical deformity or malfunction, and no other equally effective course of treatment is available or suitable for the student requesting the medically necessary service.

(p) “Order” means a written authorization for the provision of services issued by an advance practice registered nurse (APRN), physician assistant, physician, or other licensed clinician with ordering privileges.

(q) “Other licensed clinician” means any person licensed under state law and practicing within the scope of their licensure as authorized by the appropriate board, commission, or council responsible for licensing and regulating health care professions under the NH office of professional licensure and certification.

(r) “Performing-only provider” means a health care provider that the medicaid program does not allow to independently enroll with medicaid and is affiliated with an enrolled school provider. The term includes healthcare providers such as rehabilitative assistants pursuant to this part, personal care service workers for individuals under the age of 21, and board certified behavior analysts.

(s) “Personal care services” means medically necessary services related to assistance with ADL or IADL due to a student’s illness, injury, or disability which are furnished to a student who is not an inpatient or resident of a hospital, nursing facility, intermediate care facility for people with developmental disabilities, or institution for mental illness, and are covered through the EPSDT benefit pursuant to He-W 546 and in accordance with He-W 589.04(aw).

(t) “Physician” means a person licensed to practice medicine in NH or the state in which they practice.

(u) “Private duty nursing” means the provision of skilled nursing services for students who require more individual and continual skilled nursing observation, judgment, assessment, or interventions than are available from a visiting nurse, in contrast to part-time or intermittent care, such as wound care.

(v) “Psychologist” means a person licensed to practice psychotherapy in NH pursuant to RSA 329-B or an equivalent licensing board in the state in which they practice.

(w) “Psychotherapist” means a licensed clinical social worker, pastoral psychotherapist, clinical mental health counselor, or marriage and family therapist licensed under RSA 330-A who provides mental health services. This term includes psychiatrists licensed as physicians under RSA 329, advanced practice registered nurse (APRN) licensed under RSA 326-B:18 as psychiatric nurse practitioners, and psychologists, school psychologists, or associate school psychologists licensed by the board of psychology under RSA 329-B. This term also includes “mental health practitioner”.

(x) “Psychotherapy” means the professional treatment, assessment, or counseling of a mental or emotional illness, symptom, or condition.

(y) “Rehabilitative assistance services” means non-skilled interventions covered through the EPSDT benefit and ordered by a physician, physicians’ assistant, APRN, or other licensed clinician, as listed in the student’s care plan.

(z) “School administrative unit (SAU)” means a legally organized administrative body responsible for one or more school districts pursuant to RSA 194-C:1.

(aa) “Section 504 plan (504 plan)” means a plan for services for a student in accordance with Section 504 of the Rehabilitation Action of 1973 as amended.

(ab) “Signature” means:

(1) A person’s name handwritten by that person, excluding any photocopy, stamp, or other facsimile of such name; or

(2) An electronic signature that complies with RSA 294-E.

(ac) “Student” means a person who is eligible for and receiving medical assistance under medicaid pursuant to He-W 589.03.

(ad) “Under the direction” means that, except as prohibited by state law, the licensed clinician, whether or not they are physically present at the time that services are provided:

(1) Assumes professional responsibility for the services provided;

(2) Assures that the services are medically appropriate and performed safely; and

(3) Assures compliance with the clinical oversight requirements as required by law or rule adopted by the appropriate board, commission, or council responsible for licensing and regulating health care professions under the NH office of professional licensure and certification.

Source. #4925, INTERIM, eff 8-31-90; ss by #5038, eff
12-28-90; ss by #5456, eff 9-1-92, EXPIRED: 9-1-98

New. #6861, INTERIM, eff 10-2-98, EXPIRED: 1-30-99

New. #6987, eff 4-27-99; ss by #8874, INTERIM, eff 4-25-07, EXPIRED 10-22-07

New. #9035, eff 11-22-07; amd by #10278, eff 2-23-13; EXPIRED: 11-22-15 in paras. (a)-(g) and (i)-(s); amd by #11045-A, INTERIM, eff 2-25-16, EXPIRES: 8-23-16; ss by #11165, eff 8-23-16; ss by #12607, EMERGENCY RULE, eff 8-20-19, EXPIRED: 2-16-19 (and #11165 effective again pursuant to RSA 541-A:18, V); ss by #12861, EMERGENCY RULE, eff 8-28-19

New. #12994, eff 2-21-20 (formerly He-M 1301.02) (See Revision Note at part heading for He-W 589); ss by #14432, eff 11-25-25, EXPIRES: 11-25-35

He-W 589.03 Student Eligibility. To be eligible for medicaid reimbursement for covered services, a student shall:

(a) Have a care plan;

(b) Be between the ages of 3 and 22, provided that the students aged 21 through 22 are not eligible for medicaid reimbursement for services covered only under the EPSDT benefit;

(d) Be served by an LEA or SAU that is an enrolled school provider.

Source. #4925, INTERIM, eff 8-31-90; ss by #5038, eff 12-28-90; ss by #5456, eff 9-1-92, EXPIRED: 9-1-98

New. #6861, INTERIM, eff 10-2-98, EXPIRED: 1-30-99

New. #6987, eff 4-27-99; ss by #8874, INTERIM, eff 4-25-07, EXPIRED 10-22-07

New. #9035, eff 11-22-07; ss by #11025, eff 1-23-16; ss by #12607, EMERGENCY RULE, eff 8-20-19, EXPIRED: 2-16-19 (and #11025 effective again pursuant to RSA 541-A:18, V); ss by #12861, EMERGENCY RULE, eff 8-28-19

New. #12994, eff 2-21-20 (formerly He-M 1301.03) (See Revision Note at part heading for He-W 589); ss by #14432, eff 11-25-25, EXPIRES: 11-25-35

He-W 589.04 Covered Services and Provider Qualifications.

(a) All enrolled school providers shall:

(1) Be enrolled with NH medicaid for the purposes of administration and billing;

(2) Verify the qualifications, licensure, and certifications, as applicable, of performing-only providers upon hire and at the time of any licensure or certification renewal and maintain proof of verification;

(3) Screen all providers, employees, contractors, and school personnel that are involved with administering or delivering medicaid services, upon hire and on a monthly basis thereafter, for exclusions against the Office of Inspector General (OIG) exclusion and sanction database pursuant to section 1866(j)(2) of the Social Security Act, section 1903(i) of the Social Security Act, and 42 CFR 1001.1901. The OIG exclusion and sanction database may be found at https://exclusions.oig.hhs.gov; and

(4) Ensure all providers have knowledge in the following areas:

a. Medicaid recipient rights, and the reporting of abuse and neglect; and

b. Record keeping and documentation requirements pursuant to this part, including the penalties associated with improper recordkeeping and documentation.

(b) All covered services shall be:

(1) Provided through a student's LEA or SAU;

(2) Medically necessary;

(3) Included and documented in the student’s care plan in accordance with this part;

(4) Provided in a variety of locations and settings as specified in a student’s care plan and might occur outside the hours of the usual school day;

(5) Provided by qualified clinicians pursuant to this part and who comply with the scope of their board licensure for their clinical practice including supervision and ordering requirements; and

(6) Prior authorized if required by the NH medicaid state plan, federal or state law, or the rules adopted thereunder.

(c) Covered services may be provided by staff employed or subcontracted by the enrolled school provider and who shall be:

(1) Either licensed by the applicable clinical boards to provide the services provided or otherwise under the direction of the appropriate licensed clinician to provide the services as permitted by applicable licensure law; or

(2) Board certified behavior analysts (BCBA) appropriately certified by the national Behavior Analyst Certification Board, and if supervising others, have a supervisory certification issued by the national board and be acting within the scope of that certification.

(d) Covered supplies and equipment described under He-W 589.04 shall:

(1) Be acquired for the use of a specific student;

(2) When purchased, be the property of the student and their family; and

(3) When rented or acquired through a used equipment exchange program, be the property of the student and their family during the period used.

(e) DME shall be provided by a qualified DME provider, and in accordance with the requirements pursuant to He-W 571.

(f) AAC devices and aids shall be provided by a qualified DME provider, and in accordance with the requirements of He-W 575.

(g) A medical evaluation shall be covered when performed to address a recipient complaint or illness and shall include the following:

(1) An initial evaluation conducted by a physician, APRN, or physician assistant; and

(2) The opinion or advice of a physician, APRN, or physician assistant regarding the evaluation or treatment of the student’s condition including services rendered.

(h) If after the initial evaluation in (g) above the physician, APRN, or physician assistant assumes the continuing care of the student, any service(s) provided subsequent to the initial evaluation by such physician, APRN, or physician assistant shall not be considered an evaluation but might be coverable as another service pursuant to this part.

(i) The following medical evaluation services performed by the providers in (g) above shall be billable under the category of medical evaluation:

(1) Examination of a single organ system, including:

a. Documentation of complaint(s);

b. Physical examination and diagnosis of current illness; and

c. Establishment of a plan of management relating to a specific problem; and

(2) In-depth evaluation with development and documentation of medical data, including:

a. Chief complaint;

b. Present illness;

c. Family history;

d. Medical history;

e. Personal history;

f. System review; and

g. Physical examination.

(j) Any consult service for which the student was present at least 51% of the time shall be a covered consultation service.

(k) Nursing services shall be medically necessary to meet the health needs of a student and include:

(1) Any assessments or treatments performed by a licensed registered nurse, licensed practical nurse (LPN), or APRN for a student; and

(2) Supplies and equipment necessary for the provision of the covered nursing services as determined by the licensed registered nurse, LPN, or APRN.

(l) Nursing services shall be performed by the following:

(1) An APRN licensed to practice in NH by the NH board of nursing in accordance with RSA 326-B:18 or the state in which they practice as a registered nurse in an advance practice role;

(2) A registered nurse who is:

a. Licensed to practice in NH or the state in which they practice in accordance with RSA 326-B; and

b. Acting under the direction of a physician, APRN, or physician assistant for those activities that require an order; or

(3) A LPN who is:

a. Licensed to practice in NH under RSA 326-B or the state in which they practice; and

b. Acting under the direction of a physician, APRN, registered nurse, or physician assistant.

(m) Nursing services shall include the following:

(1) Administration of medication(s);

(2) Positioning or repositioning;

(3) Assistance with specialized feeding programs;

(4) Management and care of specialized medical equipment such as:

a. Colostomy bags:

b. Nasogastric tubes;

c. Tracheostomy tubes; and

d. Related medical devices;

(5) Observation of students with chronic medical illnesses in order to assure that medical needs are being appropriately identified, addressed, and monitored; and

(6) Other services determined by a registered nurse, LPN, or APRN to be medically necessary and appropriate.

(n) Billable categories of nursing services shall include the following:

(1) Nursing assessment;

(2) Nursing treatment; and

(3) Supplies and equipment necessary to provide covered nursing services.

(o) Private duty nursing services shall be:

(1) Covered services when they are part of the student’s medical regimen and rendered under the order and under the direction of the student’s physician; and

(2) Covered and delivered in accordance with the requirements of He-W 540.

(p) Occupational therapy services shall be covered if the services are medically necessary to implement a program of activities to develop or maintain adaptive skills necessary to achieve adequate and appropriate physical and mental functioning of a student including:

(1) Any evaluations, treatment, or assessments performed by an occupational therapist of students whose abilities to carry out age appropriate tasks are threatened or impaired by physical illness, injury, or disease, mental illness, emotional disorder, or congenital or developmental disability;

(2) Supplies and equipment necessary to provide the covered occupational therapy services as recommended by an occupational therapist; and

(3) Occupational therapy services performed by an occupational therapy assistant carrying out a therapy plan developed by the occupational therapist.

(q) Occupational therapy services shall be provided by:

(1) An occupational therapist who is licensed to practice in NH or the state in which they practice; or

(2) An occupational therapy assistant as defined in RSA 326-C:1, III working under the direction of a licensed occupational therapist.

(r) Occupational therapy services shall include:

(1) Task-oriented activities to correct physical or emotional deficits or to minimize the disabling effect of these deficits in the life of the student;

(2) Evaluations of:

a. Sensorimotor abilities;

b. Self-care activities;

c. Capacity for independence;

d. Physical capacity for prevocational and work tasks; and

e. Play and leisure performance;

(3) Specific occupational therapy techniques involving:

a. Improving skills for ADLs;

b. The fabrication and application of splinting devices;

c. Sensorimotor activities;

d. The use of specifically designed manual and creative activities;

e. Guidance in the selection and use of adaptive equipment; and

f. Specific exercises to enhance functional performance and physical capabilities needed for work activities; and

(4) Other services determined by an occupational therapist to be medically necessary and appropriate.

(s) Billable categories of occupational therapy services shall include the following:

(1) Occupational therapy, evaluation;

(2) Occupational therapy, individual;

(3) Occupational therapy, group; and

(4) Supplies and equipment necessary for the provision of covered occupational therapy services.

(t) Physical therapy services shall include:

(1) Any evaluations to determine a student's level of physical functioning, including performance tests to measure strengths, balance, endurance, and range of motion;

(2) Any treatment services, evaluations, or assessments which might utilize therapeutic exercises or the modalities of heat, cold, water, and electricity, for the purpose of preventing, restoring, or alleviating a lost or impaired physical function;

(3) Other services, including supplies and equipment, determined by a physical therapist to be medically necessary and appropriate for a student's physical therapy; and

(4) Physical therapy services performed by a physical therapy assistant carrying out a therapy plan developed by the physical therapist.

(u) Physical therapy services shall be provided by:

(1) A physical therapist who is a graduate of a program of physical therapy approved by the Committee on Allied Health Education and Accreditation of the American Medical Association and the American Physical Therapy Association or its equivalent and licensed to practice in the state of NH or the state in which they practice; or

(2) A physical therapy assistant as defined in RSA 328-A:2, VIII who is under the direction of a licensed physical therapist pursuant to (1) above.

(v) Physical therapy services shall be medically necessary.

(w) Billable categories of physical therapy services shall include the following:

(1) Physical therapy, evaluation;

(2) Physical therapy, individual;

(3) Physical therapy, group; and

(4) Supplies and equipment necessary for the provision of covered physical therapy services.

(x) Psychiatric services shall be medically necessary for the evaluation, assessment, diagnosis, and treatment of mental or emotional conditions.

(y) Psychiatric services shall be provided by:

(1) A psychiatrist who is a physician licensed to practice in NH as defined in RSA 135-C:2, XIII, or the state in which they practice and either board certified or board eligible according to the most recent regulations of the American Board of Psychiatry and Neurology, Inc. or its successor organization; or

(2) An APRN with a psychiatric specialty pursuant to RSA 326-B:18.

(z) Billable categories of psychiatric services shall include the following:

(1) Psychiatric evaluation and diagnosis; and

(2) Psychiatric treatment.

(aa) Psychological services shall require an order and be medically necessary for the evaluation, diagnosis, treatment, and counseling of mental or emotional illnesses, symptoms, or conditions.

(ab) Psychological services shall be provided by:

(1) A psychologist who is a school psychologist or associate school psychologist certified by the state board of education in NH or in the state in which they practice and licensed by the NH board of psychologists or another state’s board of psychology;

(2) A psychologist or associate psychologist licensed by the NH board of psychologists or licensed by another state’s board of psychology;

(3) A physician;

(4) APRNs with a psychiatric specialty pursuant to RSA 326-B:18;

(5) Psychotherapists acting within the scope of their licensure; or

(6) A master licensed alcohol and drug counselor (MLADC) for co-occurring mental health and substance use disorders.

(ac) Billable categories of psychological services shall include the following:

(1) Psychological testing and evaluation;

(2) Psychodiagnostic testing;

(3) Psychological counseling, individual treatment;

(4) Psychological counseling, group treatment; and

(5) Family counseling, during which the student shall be present at 51% of the counseling session.

(ad) Mental health services, other than psychiatric and psychological services, shall:

(1) Be covered if they are medically necessary and ordered; and

(2) Include, but not be limited to:

a. Behavior management;

b. Individual counseling;

c. Group counseling;

d. Family counseling, during which the student shall be present at 51% of the counseling session; and

e. Crisis intervention.

(ae) Persons providing mental health services shall be:

(2) A mental health practitioner or a psychotherapist as defined in RSA 330-A:2, VII and VIII, respectively;

(3) A psychologist licensed by the board of psychologists pursuant to RSA 329-B; or

(4) An APRN with a psychiatric specialty pursuant to RSA 326-B:18.

(af) Substance use disorder (SUD) treatment and recovery support services shall be provided by the licensed qualified providers described in He-W 513, and in accordance with the requirements in He-W 513.

(ag) Applied behavior analysis (ABA) shall be covered for individuals with the following diagnoses:

(1) Autism spectrum disorder; or

(2) Pervasive developmental disability.

(ah) ABA shall be provided by:

(1) A BCBA appropriately certified by the national Behavior Analyst Certification Board, and if supervising others, have a supervisory certification issued by the national Behavior Analyst Certification Board and be acting within the scope of that certification;

(2) A rehabilitation assistant, as defined by (al), under the appropriate supervision of (1) above;

(3) A board certified assistant behavior analyst (BCABA), under the appropriate supervision of (1) above; or

(4) A registered behavior technician (RBT), under the appropriate supervision of (1) above.

(ai) Billable categories of ABA shall include the following:

(1) Behavior identification assessment; and

(2) Adaptive behavior treatment.

(aj) ABA services shall be recommended by a licensed clinician who has experience in the diagnosis and treatment of autism spectrum disorder or pervasive developmental disorder and holds at least one of the following educational degrees and valid license:

(1) Physician;

(2) Psychologist;

(3) Nurse practitioner specializing in developmental medicine; or

(4) Physician’s associate specializing in developmental medicine.

(ak) Rehabilitative assistance services shall include the following:

(1) Mobility assistance such as positioning, transfers, correct application of ankle-foot orthosis, bracing or orthotic devices, range of motion, fall prevention, safety risk precautions, and physical therapy carry-over tasks as directed by the licensed physical therapist;

(2) Communication assistance such as assistance with sign language, prompting to facilitate expressive and receptive language, assistance with AAC devices and other such devices that ameliorate communication limitations, and speech language carry-over tasks as directed by the licensed speech language pathologist;

(3) Assistance with the implementation of behavioral management plans to increase adaptive behavioral functioning and carry-over tasks as directed by the mental health practitioner or BCBA;

(4) Nutrition such as assistance with eating, cutting food, food preparation, and safe eating plan carry-over tasks as directed by the speech language pathologist or occupational therapist;

(5) Cueing, prompting, and guiding, when provided as part of the assistance with ADLs, communication, or behavior management;

(6) Assistance with adaptive or assistive devices when linked to the student’s medical condition;

(7) Assistance with the use of DME when linked to the student’s medical condition;

(8) Medication administration to the extent allowable under RSA 326-B and pursuant to Nur 404.07 when the rehabilitative assistant has been trained by a nurse in medication administration, and the nurse has delegated the task of medication administration to the rehabilitative assistant;

(9) Personal care services such assistance with ADL and IADL and assistance with occupational therapy, physical therapy, or speech language carry-over tasks;

(10) Carry-over of therapy skills training as delegated by a speech language pathologist, physical therapist, and occupational therapist;

(11) Observation and reporting of signs of distress in the student’s medical condition as trained by a registered nurse;

(12) Implementation of safe eating plans and g-tube feedings as delegated by a registered nurse with applicable training;

(13) Maintaining a safe environment to assure the student’s safety concerns are met for the student, other students, and staff; and

(14) Any other remedial services that are included in the student’s care plan as medically necessary for the maximum reduction of a student's physical or mental disabilities, excluding educational and social activities such as classroom instruction and academic tutoring.

(al) Rehabilitative assistants shall:

(1) Either:

a. Be certified pursuant to Ed 504.05 or Ed 504.06, requirements and certification for paraeducators;

b. Have qualifications determined by the department to be equivalent to the requirements for certification under Ed 504.05 or 504.06; or

c. Be other licensed clinicians; and

(2) If applicable for the tasks delegated to the rehabilitative assistant or if required by law have knowledge in the following areas:

a. Personal care and nutrition;

b. Infection control and universal precautions designed to prevent the transmission of infectious diseases;

c. Safety and emergency procedures, including basic first aid and 911 protocols; and

d. Proper lifting techniques.

(am) Rehabilitative assistants shall provide rehabilitation assistance services in accordance with Ed 1113.12.

(an) Rehabilitative assistance services shall be medically necessary and require an order.

(ao) Provision of rehabilitative assistance services shall be reviewed by a licensed clinician designated by the enrolled school provider’s care plan team every 30 days. Documentation for the 30-day review shall include:

(1) The type of contact including face to face, observation, or telephone call;

(2) Areas covered such as duties and expectations, and skills development;

(3) A list of trainings completed within the past 30 days;

(4) Issues identified, if any, and action to be taken;

(5) Date of current session;

(6) Date of next session;

(7) Attestation that the services were provided; and

(8) Licensed clinician signature and attestation that the services were conducted in accordance with the care plan.

(ap) Speech and language services shall be covered services if they are services, supplies, or equipment ordered by a licensed audiologist or licensed speech-language pathologist or a speech-language specialist certified by the department of education, as described in RSA 326-F:3, IV(b) to be medically necessary for the evaluation, diagnosis, or treatment of speech, language, and hearing disorders which result in communication disabilities.

(aq) Speech and language services shall include services performed by speech language assistants listed in (ar) below carrying out a therapy plan developed by the speech language pathologist and speech-language specialists certified by the department of education, as described in RSA 326 F:3, IV(b).

(ar) Speech and language services shall be provided by:

(1) A speech-language pathologist who is either:

a. Licensed pursuant to RSA 326-F to practice in NH, which shall be considered equivalent to having met the requirements for the American Speech-Language-Hearing Association (ASHA) Certificate of Clinical Competence in Speech-Language Pathology; or

b. Licensed in the state in which they practice and have one of the following:

1 A Certificate of Clinical Competence from the ASHA;

2 Completed the equivalent educational requirements and work experience necessary for the certificate; or

3 Completed the academic program and is acquiring supervised work experience to qualify for the certificate;

(2) A speech-language assistant as defined in RSA 326-F:1, XI working under the direction of a licensed speech-language pathologist pursuant to (2) above; or

(3) A certified speech-language specialist as described at RSA 326-F:3, IV(b).

(as) Billable categories of speech and language services shall include the following:

(1) Individual speech or language evaluation;

(2) Speech or language, individual treatment;

(3) Speech or language, group treatment; and

(4) Supplies and equipment necessary for the provision of covered speech and language services.

(at) Audiology services shall be medically necessary for the prevention or rehabilitation of hearing impairment or restoration of a student with a hearing impairment to their best possible functional level and be provided by an audiologist.

(au) Billable categories of audiology services shall include the following:

(1) Individual hearing evaluation;

(2) Hearing therapy, individual treatment;

(3) Hearing therapy, group treatment; and

(4) Supplies and equipment necessary for the provision of covered hearing services.

(av) Vision services shall be medically necessary for the prevention or rehabilitation of visual impairment or restoration of a student with a visual impairment to their best possible functional level and be provided by an optometrist licensed under RSA 327, a physician licensed under RSA 329 with a specialty in ophthalmology, or an optician licensed under RSA 327-A.

(aw) EPSDT comprehensive and age-appropriate medical assessments and screenings of a student’s physical and mental status, including vision and hearing screenings shall be provided in accordance with the requirements pursuant to He-W 546.05.

(ax) Services that are not covered or have coverage limits under the NH medicaid state plan shall be covered through the EPSDT benefit when medically necessary, coverable under Section 1905(a) of the Social Security Act, and requested in accordance with the requirements of He-W 546.

(ay) Except as indicated in (ba) below, the following shall be examples of services subject to the requirements of He-W 546:

(1) Rehabilitative assistance services;

(2) Applied behavior analysis;

(3) Personal care services for individuals under the age of 21;

(4) Wrap around services;

(5) Case management services; and

(6) Other optional services listed in 1905(a) of the Social Security Act and not included in the NH medicaid state plan or included as a covered service under this part.

(az) The following services shall not be subject to the prior authorization requirements of He-W 546:

(1) Rehabilitative assistance services;

(2) Applied behavior analysis; and

(3) Personal care services for individuals under the age of 21.

(ba) Any services not listed as covered under the NH medicaid state plan or services with coverage limits shall be given independent review by the department for coverage based on medical necessity in accordance with the EPSDT benefit pursuant to He-W 546.

(bb) Specialized transportation shall be a billable service as follows:

(1) Transportation shall be listed in the student’s IEP as a required service and the student shall be physically in the vehicle for the transportation to be billable to medicaid;

(2) Transportation shall be considered a required service if:

a. The student requires transportation in a vehicle specially adapted to serve the needs of the disabled student, including a specially adapted school bus; or

b. The student resides in an area that does not have school bus transportation, such as those areas in close proximity to a school, but has a medical need for transportation that is noted in the IEP;

(3) The following transportation may be billed as a medicaid service:

a. Transportation to and from school only on a day when the student receives a medicaid coverable service at school during the school day; and

b. Transportation to and from a medicaid coverable service in the community during the school day;

(4) The medicaid coverable service in (3)a. and (3)b. above shall be listed in the student’s IEP as a required service; and

(5) In addition to the documentation required by He-W 589.06, transportation providers shall maintain a daily transportation log to include:

a. Student’s name;

b. Date of service;

c. Clear indication that the student is being transported either one-way or round-trip;

d. The total number of students on the bus, both in the morning and the afternoon;

e. The total miles the bus traveled, both in the morning and the afternoon;

f. Driver’s name; and

g. Driver’s signature.

Source. #4925, INTERIM, eff 8-31-90; ss by #5038, eff 12-28-90; ss by #5456, eff 9-1-92, EXPIRED: 9-1-98

New. #6861, INTERIM, eff 10-2-98, EXPIRED: 1-30-99

New. #6987, eff 4-27-99; ss by #8874, INTERIM, eff 4-25-07, EXPIRED 10-22-07

New. #9035, eff 11-22-07; amd by #10278, eff 2-23-13; EXPIRED: 11-22-15 in paras. (a)-(d), (f)-(h), (j), (k), (m), (n), (p), (r), (t), (v)-(x), (z)-(ad) and (af); amd by #11045-A, INTERIM, eff 2-25-16, EXPIRES: 8-23-16; ss by #11165, eff 8-23-16; ss by #12607, EMERGENCY RULE, eff 8-20-19, EXPIRED: 2-16-19 (and #11165 effective again pursuant to RSA 541-A:18, V); ss by #12861, EMERGENCY RULE, eff 8-28-19

New. #12994, eff 2-21-20 (formerly He-M 1301.04) (See Revision Note at part heading for He-W 589); ss by #14432, eff 11-25-25, EXPIRES: 11-25-35

He-W 589.05 Non-Covered Services. The following shall be non-covered services and shall not be eligible for reimbursement:

(a) Services not listed in a student’s care plan;

(b) Services that are not coverable under the Social Security Act and for which no FFP is available for said service;

(c) Services performed by unqualified individuals pursuant to the Social Security Act, or services delivered by provider types not approvable under the Social Security Act to provide medicaid services;

(d) Consultations, visits, trainings, meetings, or discussions between healthcare providers or individuals in which the student was not physically present for at least 51% of the time;

(e) Services which are non-covered pursuant to He-W 500 and are not covered under EPSDT;

(f) Supported employment such as vocational goals and job tasks;

(g) Services which are solely educational, remedial education, or vocational instruction or tutoring;

(h) Services performed by educators or individuals who are not licensed clinicians such as teachers of the visually impaired or deaf unless:

(1) The individual has a valid license issued by the appropriate licensing board, commission, or council and is acting within the scope of their license;

(2) The individual is a rehabilitative assistant providing rehabilitative assistance services pursuant to He-W 589.04(ak)-(ao); or

(3) The individual currently holds a certification as a BCBA;

(i) Leisure and social activities that are non-medical;

(j) General supervision of a student as required for any student based on the student’s development and for non-medical reasons;

(k) Services that are solely personal care services delivered by a legally responsible family member pursuant to 42 CFR 440.167;

(l) Performance of tasks for the sole purpose of assistance with completion of educational assignments;

(m) Services under a Centers for Medicare and Medicaid Services (CMS) NH medicaid waiver;

(n) Medicaid state plan services only provided under the 1915(i) provisions of the Social Security Act;

(o) Day care;

(p) Teaching parenting skills;

(q) Review of records, documentation development, or report writing;

(r) Attending meetings, including individualized education program meetings and IEP team meetings;

(s) Parent consultations, contacts, or trainings;

(t) School guidance counselor services unless:

(1) The individual has a valid clinical license issued by the appropriate licensing board, commission, or council and is acting within the scope of their license;

(2) The individual is a rehabilitative assistant providing rehabilitative assistance services pursuant to He-W 589.04(ak)-(ao); or

(3) The individual currently holds a certification as a BCBA;

(u) Services by individuals not having a current license for the practice specialty area for the service area being provided; and

(v) Services requiring the technical or professional skill that a state statute or regulation mandates shall be performed by a clinician licensed or certified by the state.

Source. #4925, INTERIM, eff 8-31-90; ss by #5038, eff 12-28-90; amd by #5132, eff 5-1-91; ss by #5456, eff 9-1-92, EXPIRED: 9-1-98

New. #6861, INTERIM, eff 10-2-98, EXPIRED: 1-30-99

New. #6987, eff 4-27-99; ss by #8874, INTERIM, eff 4-25-07, EXPIRED 10-22-07

New. #9035, eff 11-22-07; amd by #10278, eff 2-23-13; EXPIRED: 11-22-15 in paras. (a), (b)(1)-(7), and (b)(9)-(14); amd by #11045-A, INTERIM, eff 2-25-16, EXPIRES: 8-23-16; ss by #11165, eff 8-23-16; ss by #12607, EMERGENCY RULE, eff 8-20-19, EXPIRED: 2-16-19 (and #11165 effective again pursuant to RSA 541-A:18, V); ss by #12861, EMERGENCY RULE, eff 8-28-19

New. #12994, eff 2-21-20 (formerly He-M 1301.05) (See Revision Note at part heading for He-W 589); ss by #14432, eff 11-25-25, EXPIRES: 11-25-35

He-W 589.06 Documentation and Payment for Services.

(a) Reimbursement to enrolled school providers shall be the lesser of the following:

(1) One half of the actual cost; or

(2) The rate established by the department, in accordance with RSA 161:4, VI(a).

(b) Enrolled school providers shall bill by unit of service, using the current procedural code for the service delivered, and submit claims for payment that include the actual cost of the service to the department’s fiscal agent.

(c) Enrolled school providers shall submit claims for medicaid covered services consistent with this chapter and with federal medicaid law pursuant to 42 CFR 455, 42 CFR 456, 42 CFR 431, and 42 CFR 1001.

(d) Enrolled school providers shall maintain documentation in accordance with He-W 520 and this part for the delivered services in each student's individual record, with such documentation to include:

(1) A copy of the care plan and, if an IEP, evidence of implementation of the IEP as required by Ed 1109.04(b);

(2) The name of the student, the medical assistance ID number, and documentation demonstrating receipt of each unit of the covered service;

(3) The names, qualifications, and credentials of all performing providers for each service delivered for which the school sought FFP;

(4) The documentation of the qualifications, names, and signatures of persons directing or supervising the individuals providing the covered services if direction or supervision is required under this part or applicable law, and the date of supervisory approval;

(5) Date(s) of each service delivered and the location where the services were performed;

(6) The type of covered service provided and a description of each service provided;

(7) The duration of the provision of the each covered service, number of units performed, and the number of minutes for each delivered service;

(8) The start and stop times of the delivered services, and whether there was a break in services or time away by the performing provider;

(9) Indication whether the services were delivered in a group setting or individually;

(10) Indication of whether the student was actually present for the service and indication whether the student was present for at least 51% of the time;

(11) In the case of group services, documentation of the number of participants in the group who received the covered service regardless of the participants’ medicaid eligibility;

(12) A copy of a physician's or other licensed clinician’s order if required; and

(13) Documentation of the qualifications and a digitally signed electronic or handwritten signature of the individual(s) attesting to the medical non-academic nature of the covered rehabilitative assistance services.

(e) Enrolled school providers shall submit claims for physical, occupational, and speech-language therapy services in accordance with the following:

(1) Only units of direct treatment performed by a physical therapist, occupational therapist, speech language pathologist (SLP), a physical therapy assistant, occupational therapy assistant, or speech-language assistant shall be billed, meaning the time the therapist or physical therapy assistant, occupational therapy assistant, or speech-language assistant spends providing direct treatment to one student;

(2) Therapists working as a team to treat one or more students shall not each bill separately for the same or different service provided at the same time to the same student; and

(3) If a student requires co-treatment simultaneously by 2 therapists, the total number of units shall be divided between the therapists and billed separately by each therapist to equal the total time the student was receiving actual therapy services.

(f) Enrolled school providers shall only bill covered service time provided simultaneously by more than one licensed clinician and a rehabilitative assistant as follows:

(1) If rehabilitative assistance is provided simultaneously with another covered service, the rehabilitative assistance shall be billed in addition to the covered service; or

(2) If rehabilitative assistance is provided by more than one rehabilitative assistant simultaneously, each assistant’s service shall be billed separately.

(g) In calculating the cost for transportation, the enrolled school providers may include the following actual costs related to the trip:

(1) Fuel;

(2) Insurance;

(3) Driver’s salary and benefits;

(4) Salary and benefits of other persons working on the bus;

(5) Depreciation, and

(6) Maintenance.

(h) The total cost calculated in (g) above shall then be divided by the total number of miles for the trip both ways, and then divided by the total number of students on the bus, regardless of the students’ medicaid eligibility, to determine the cost per mile per student.

(i) In accordance with 34 CFR 300.154(d)(2)(iv) and Ed 1120.08, informed parental consent shall be obtained prior to the enrolled school provider billing the student’s medicaid.

(j) Enrolled school providers shall maintain records in support of claims submitted for reimbursement for a period of at least 6 years from the date of service or until the resolution of any legal action(s) commenced in the 6-year period, whichever is longer.

(k) As applicable, the creation, storage, retention, disclosure, and destruction of documentation required by this part shall comply with all federal and state privacy and security laws and rules including the substance use disorder patient records regulations pursuant to 42 CFR Part 2, Family Educational Rights and Privacy Act, and the Health Insurance Portability and Accountability Act of 1996.

Source. #4925, INTERIM, eff 8-31-90; ss by #5038, eff 12-28-90; ss by #5456, eff 9-1-92, EXPIRED: 9-1-98

New. #6861, INTERIM, eff 10-2-98, EXPIRED: 1-30-99

New. #6987, eff 4-27-99; ss by #8874, INTERIM, eff 4-25-07, EXPIRED 10-22-07

New. #9035, eff 11-22-07; amd by #10278, eff 2-23-13; EXPIRED: 11-22-15 in paras. (a)-(d) and (f)-(l); amd by #11045-A, INTERIM, eff 2-25-16, EXPIRES: 8-23-16; ss by #11165, eff 8-23-16; ss by #12607, EMERGENCY RULE, eff 8-20-19, EXPIRED: 2-16-19 (and #11165 effective again pursuant to RSA 541-A:18, V); ss by #12861, EMERGENCY RULE, eff 8-28-19

New. #12994, eff 2-21-20 (formerly He-M 1301.06) (See Revision Note at part heading for He-W 589); ss by #14432, eff 11-25-25, EXPIRES: 11-25-35

He-W 589.07 Utilization Review and Control.

(a) The department’s program integrity unit shall monitor utilization of medical services delivered in schools to identify, prevent, and correct potential occurrences of fraud, waste, and abuse in accordance with 42 CFR 455, 42 CFR 456, 42 CFR 1001, and He-W 589.

(b) The department shall recoup state and federal medicaid payments as permitted by 42 CFR 455, 42 CFR 447, and 42 CFR 456 for an enrolled school provider’s failure to comply with these rules and to maintain supporting records in accordance with He-W 520 and He-W 589.

Source. #12607, EMERGENCY RULE, eff 8-20-19, EXPIRED: 2-16-19

New. #12861, EMERGENCY RULE, eff 8-28-19

New. #12994, eff 2-21-20 (formerly He-M 1301.07) (See Revision Note at part heading for He-W 589); ss by #14432, eff 11-25-25, EXPIRES: 11-25-35

He-W 589.08 Documentation of Expenditure of Non-Federal Funds.

(a) The enrolled school provider shall provide documentation annually regarding all services rendered pursuant to these rules.

(b) Such documentation shall:

(1) Demonstrate that:

a. The percentage of federal medical assistance reimbursed, as required by section 1905(b) of the Social Security Act, does not exceed 50% of the actual cost of covered services claimed under medicaid; and

b. Services that are reimbursable under medicaid, but paid by other federal funding, are not claimed by the enrolled school provider under NH medicaid;

(2) Be reviewed and signed by the enrolled school provider’s superintendent;

(3) Be submitted to the department no later than October 30 of each year for the preceding fiscal year period; and

(4) Be accompanied by a completed form “Documentation of Expenditure of Non-Federal Funds” (November 2025) for a specific July 1 through June 30 time period which includes an attestation signed and dated by the superintendent stating:

“I hereby certify that all Medicaid funds paid to the above named districts under He-W 589.08, Medical Assistance Services Provided by Educational Agencies for the period July 1, xxxx through June 30, xxxx have been supplemented with LEA/SAU and/or non-federal funds to total 100% of the cost of services rendered and that the Medicaid reimbursement does not exceed 50% of the total cost of the services rendered.”

Source. #4925, INTERIM, eff 8-31-90; ss by #5038, eff 12-28-90; ss by #5456, eff 9-1-92, EXPIRED: 9-1-98

New. #6861, INTERIM, eff 10-2-98, EXPIRED: 1-30-99

New. #6987, eff 4-27-99; ss by #8874, INTERIM, eff 4-25-07, EXPIRED 10-22-07

New. #9035, eff 11-22-07; amd by #10278, eff 2-23-13; EXPIRED: 11-22-15 in paras. (a), (b)(1), and (b)(2); amd by #11045-A, INTERIM, eff 2-25-16, EXPIRES: 8-23-16; ss by #11165, eff 8-23-16; renumbered by #12607, EMERGENCY RULE, (formerly He-M 1301.07) (renumbered as He-M 1301.07 again pursuant to RSA 541-A:18, V upon expiration 2-16-19 of #12607); ss by #12861, EMERGENCY RULE, eff 8-28-19 (formerly He-M 1301.07)

New. #12994, eff 2-21-20 (formerly He-M 1301.08) (See Revision Note at part heading for He-W 589); ss by #14432, eff 11-25-25, EXPIRES: 11-25-35

He-W 589.09 Waivers.

(a) An enrolled school provider may request a waiver of specific procedures outlined in He-W 589 by writing to the department.

(b) The waiver shall be requested in writing to the department, detailing which rule provision is to be waived and how the school plans to meet the objective or intent of the rule.

Department of Health and Human Services

Office of Medicaid Medical Services

Hugh J. Gallen State Office Park

129 Pleasant Street, Brown Building

Concord, NH 03301

(d) No federally mandated requirement and no provision or procedure prescribed by state statute shall be waived.

(e) The request for a waiver shall be granted by the commissioner or their designee within 30 days if the waiver:

(1) Meets the objective or intent of the rule;

(2) Does not negatively impact the health or safety of the student(s); and

(3) Does not affect the quality of services to students.

(f) Upon receipt of approval of a waiver request, the enrolled school provider’s subsequent compliance with the alternative provisions or procedures approved in the waiver shall be considered compliance with the rule for which waiver was sought.

(g) Waivers shall be effective for a maximum of 2 years if requested by the provider and the waiver addresses the reason for the waiver.

(h) An enrolled school provider may request a renewal of a waiver from the department. Such request shall be made at least 30 days prior to the expiration of a current waiver. A request for renewal of a waiver shall be approved in accordance with the criteria specified in (e) above.

Source. #4925, INTERIM, eff 8-31-90; ss by #5038, eff 12-28-90; ss by #5456, eff 9-1-92, EXPIRED: 9-1-98

New. #6861, INTERIM, eff 10-2-98, EXPIRED: 1-30-99

New. #6987, eff 4-27-99; ss by #8874, INTERIM, eff 4-25-07, EXPIRED 10-22-07

New. #9035, eff 11-22-07; ss by #11025, eff 1-23-16; renumbered by #12607, EMERGENCY RULE, (formerly He-M 1301.08) (renumbered as He-M 1301.08 again pursuant to RSA 541-A:18, V upon expiration 2-16-19 of #12607); ss by #12861, EMERGENCY RULE, eff 8-28-19 (formerly He-M 1301.08)

New. #12994, eff 2-21-20 (formerly He-M 1301.09) (See Revision Note at part heading for He-W 589); ss by #14432, eff 11-25-25, EXPIRES: 11-25-35

PART He-W 590 NURSING FACILITY SERVICES

He-W 590.01 Definitions.

Source. (See Revision Note at chapter heading He-W 500); ss by #5085, eff 3-5-91; amd by #6159, eff 12-29-95; rpld by #7749, eff 8-17-02

He-W 590.02 Recipient Eligibility. - EXPIRED

Source. (See Revision Note at chapter heading He-W 500); ss by #4908, eff 8-17-90; amd by #5164, eff 6-12-91, EXPIRED: 8-17-96 and 6-12-97

He-W 590.03 through He-W 590.14 - EXPIRED

Source. (See Revision Note at chapter heading He-W 500); ss by #4908, eff 8-17-90, EXPIRED: 8-17-96

He-W 590.15 Absence from the Facility.

Source. (See Revision Note at chapter heading He-W 500); ss by #5965, eff 1-27-95; rpld by #7749, eff 8-17-02

He-W 590.16 Resident Assessment System.

Source. (See Revision Note at chapter heading He-W 500); ss by #6159, eff 12-29-95; rpld by #7749, eff 8-17-02

PART He-W 591 NURSING FACILITY ENFORCEMENT REMEDIES - EXPIRED

Source. (See Revision Note at chapter heading He-W 500); ss by #6082, eff 8-22-95; ss by #7936, INTERIM, eff 8-22-03, EXPIRED: 2-18-04

PART He-W 592 NURSING ASSISTANT TRAINING REIMBURSEMENT

He-W 592.01 Definitions. - EXPIRED

Source. (See Revision Note at chapter heading He-W 500); ss by #5618, eff 8-1-93, EXPIRED: 8-1-99

He-W 592.02 Requirements, Conditions and Limitations.

Source. (See Revision Note at chapter heading He-W 500); ss by #5618, eff 4-28-93; amd by #6033, eff 5-1-95; rpld by #7750, eff 8-17-02

He-W 592.03 Payment to CAN.

Source. (See Revision Note at chapter heading He-W 500); ss by #5618, eff 4-28-93; amd by #6033, eff 5-1-95; rpld by #7750, eff 8-17-02

PART He-W 593 NURSING FACILITY REIMBURSEMENT - EXPIRED (Now He-E 806)

Source. (See Revision Note at chapter heading He-W 500); ss by #6547, eff 7-26-97; amd by #8185, eff 10-2-04; ss by #8391, INTERIM, eff 7-26-05, EXPIRED: 1-22-06

PARTS He-W 594 through He-W 599 – RESERVED

APPENDIX A: Incorporation by Reference Information

Rule	Title	Publisher; How to Obtain; and Cost
He-W 511.05	Chapter 3, Section 3910, Medicaid Payments for Recipients under Group Health Plans, of the federal Centers for Medicare and Medicaid Services (CMS), State Medicaid Manual	Publisher: Centers for Medicare and Medicaid Services (CMS). This document is available for free on the CMS website at: http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Paper-Based-Manuals-Items/CMS021927.html
He-W 513.02(b)(2), (p)(3); 513.04(f); 513.05(b)(1), (h)-(l), (m)(3)-(4), (n) intro, (n)(6), (o) intro, (u)(3)e.; and 513.06(a)	ASAM Criteria: Treatment Criteria for Substance-Related, Addictive, and Co-Occurring Conditions, 3^rd edition (2013)	Publisher: American Society of Addiction Medicine (ASAM). The ASAM Criteria (2013) can be purchased online through the ASAM website at: http://www.asamcriteria.org/. Cost = $95 (non-members) or $85 (members). Discounts are available for large purchases.
He-W 513.02(b)(3), (q)(3); 513.04(g); 513.05(b)(1), (h)intro.-(l)intro, (n) intro, (n)(5), (o) intro, (u)(2)e.; 513.06(a), and 513.11	ASAM Criteria: Treatment Criteria for Substance-Related, Addictive, and Co-Occurring Conditions, 3^rd edition (2013)	Publisher: American Society of Addiction Medicine (ASAM). The ASAM Criteria (2013) can be purchased online through the ASAM website at: http://www.asamcriteria.org/. Cost = $95 (non-members) or $85 (members). Discounts are available for large purchases.
He-W 513.02(x), 513.05(l)(1)a.	The Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (2013) (DSM-5)	Publisher: The American Psychiatric Association (APA). The DSM-5 can be purchased on line at: http://www.appi.org/SearchCenter/Pages/SearchDetail.aspx?ItemId=2554 Cost = $199
He-W 513.02(aa), 513.05(l)(1)a.	The Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (2013) (DSM-5)	Publisher: The American Psychiatric Association (APA). The DSM-5 can be purchased on line at: https://www.appi.org/Diagnostic_and_Statistical_Manual_of_Mental_Disorders_DSM-5_Fifth_Edition Cost = $157.50 -$210 depending upon APA affiliation
He-W 513.02(ad)(1) and He-W 513.05(b)(6)	Addiction Counseling Competencies, TAP 21 (2017 revision)	Publisher: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Substance Abuse Treatment, www.samhsa.gov Available free of charge at: https://store.samhsa.gov/files/sma12-4171pdf
He-W 513.02(aa)(1)	Addiction Counseling Competencies, TAP 21 (2011 revision)	Publisher: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Substance Abuse Treatment, www.samhsa.gov Available free of charge at: http://store.samhsa.gov/shin/content//SMA12-4171/SMA12-4171.pdf
He-W 513.02(aa), 513.05(l)(1)a.	The Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (2013) (DSM-5)	Publisher: The American Psychiatric Association (APA). The DSM-5 can be purchased on line at: https://www.appi.org/Diagnostic_and_Statistical_Manual_of_Mental_Disorders_DSM-5_Fifth_Edition Cost = $157.50 -$210 depending upon APA affiliation
He-W 513.02(ad)(1) and He-W 513.05(b)(6)	Addiction Counseling Competencies, TAP 21 (2017 revision)	Publisher: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Substance Abuse Treatment, www.samhsa.gov Available free of charge at: https://store.samhsa.gov/files/sma12-4171pdf
He-W 513.05(c)(3), 513.05(d)(3)	Systems-Level Implementation of Screening, Brief Intervention, and Referral to Treatment, TAP 33 (2013 edition)	Publisher: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Substance Abuse Treatment, www.samhsa.gov Available free of charge at: https://store.samhsa.gov/product/tap-33-systems-level-implementation-screening-brief-intervention-referral-treatment-sbirt
He-W 513.05(g)(1)b.	TIP 63: Medications for Opioid Use Disorder (2018)	Publisher: The U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration. The document is included in the Clinical Guidelines for the Use of Buprenorphine in the Treatment of Opioid Addiction, Treatment Improvement Protocol (Tips) #40. The document can be accessed online at https://store.samhsa.gov/product/tip-63-medications-opioid-use-disorder-%E2%80%93-full-document-including-executive-summary-parts-1-5
He-W 513.05(g)(1)c.	Federation of State Medical Boards – Model Policy Guidelines for Opioid Addiction Treatment in the Medical Office (2004)	Publisher: The U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration. The document is included in the Clinical Guidelines for the Use of Buprenorphine in the Treatment of Opioid Addiction, Treatment Improvement Protocol (Tips) #40. The document can be accessed online at http://buprenorphine.samhsa.gov/Bup_Guidelines.pdf
He-W 530.05(b)(4)	Medicare Coverage Database	Publisher: Centers for Medicare and Medicaid Services. National Coverage Determinations can be found in the “Medicare Coverage Database” at http://www.cms.gov/medicare-coverage-database/ (under the “Quick Search” function, select “National Coverage Documents”, optionally enter a filter by entering a “keyword” to narrow the search results, and select the “Search by Type” button, or, if a keyword is not entered, the entire list of NCD titles will appear alphabetically and may be selected). There is no cost to access the website or print the material contained therein.
He-W 530.05(b)(32)a.	Medicare Coverage Database	Publisher: Centers for Medicare and Medicaid Services. National Coverage Determinations can be found in the “Medicare Coverage Database” at http://www.cms.gov/medicare-coverage-database/ (under the “Quick Search” function, select “National Coverage Documents”, optionally enter a filter by entering a “keyword” to narrow the search results, and select the “Search by Type” button, or, if a keyword is not entered, the entire list of NCD titles will appear alphabetically and may be selected). There is no cost to access the website or print the material contained therein.
He-W 530.05(b)(32)b.1.	Anthem Medical Policies and Clinical UM Guidelines	Publisher: Anthem Insurance Companies Anthem Medical Policies and Clinical UM Guidelines can be obtained from: http://www.anthem.com/wps/portal/ahpprovider?content_path=provider/wi/f5/s1/t4/pw_ad080065.htm&state=wi&rootLevel=0&label=Anthem%20Medical%20Policies (select the “Continue” button to confirm that the page has been read and proceed to the “Overview” page, then select the “Click Here to Search” button in the middle of this page to continue to the search engine, enter search criteria for the specific coverage policy, and then select the specific coverage policy). There is no cost to access the website or print the material contained therein.
He-W 530.05(b)(32)b.2.	Cigna Coverage Policies	Publisher: Cigna Insurance Company Cigna Coverage Policies can be obtained from https://cignaforhcp.cigna.com (select “RESOURCES” at the top of the page, then select “Coverage Policies”, then select “Medical A-Z Index” for an alphabetical list of policies, and then select the specific coverage policy). There is no cost to access the website or print the material contained therein.
He-W 530.05(b)(32) b.3.	Aetna Clinical Policy Bulletins	Publisher: Aetna Insurance Company Aetna Clinical Policy Bulletins can be obtained from http://www.aetna.com/healthcare-professionals/policies-guidelines/cpb_alpha.html (select specific bulletin from the alphabetical listing of clinical policy bulletins). There is no cost to access the website or print the material contained therein.
He-W 530.07(g)(9)	Milliman Clinical Guidelines, 17th Edition (February/March 2013)	Publisher: MCG Health, LLC. 901 Fifth Avenue, Suite 2000, Seattle, WA 98164. Phone: 206-389-5300; Toll-Free: 888-464-4746. Fax: 206-464-7813. http://www.careguidelines.com/. Cost per guideline: approximately $6,000. NH Medicaid providers and recipients may obtain relevant portions of the guidelines (e.g., the specific criteria related to a prior authorization denial) free of charge and upon request by contacting the Department’s Prior Authorization Agent, KeyPro, at 2810 N. Parham Rd., Suite 305, Henrico, VA 23294 PHONE: (800) 299-5921 FAX: (800) 922-9847.
He-W 531.05(b)-(g)	Interqual Connect Clinical Guidelines, 2019 Edition	Publisher: Change Healthcare (McKesson), 3055 Lebanon Pike, Nashville, TN 37214. Phone:615-932-3000; Toll-Free: 1-800-274-8374. Fax: 615-231-4843. interqualsupport@changehealthcare.com Cost $367,475 NH Medicaid providers and recipients may obtain relevant portions of the guidelines (e.g., the specific criteria related to a prior authorization denial) free of charge and upon request by contacting their managed care organization: AmeriHealth Caritas https://www.amerihealthcaritasnh.com/ Member Services: 1-833-704-1177 (TTY: 1-855-534-6730) New Hampshire Healthy Families, http://www.nhhealthyfamilies.com/ Member Services: 1-866-769-3085 (TTY/TDD: 1-855-742-0123) Well Sense Health Plan, http://www.wellsense.org/ Member Services: 1-877-957-1300 (TTY/TDD: 711)
He-W 531.06(e)	Medicare Coverage Database	Publisher: Centers for Medicare and Medicaid Services. National Coverage Determinations can be found in the “Medicare Coverage Database” at http://www.cms.gov/medicare-coverage-database/ (under the “Quick Search” function, select “National Coverage Documents”, optionally enter a filter by entering a “keyword” to narrow the search results, and select the “Search by Type” button, or, if a keyword is not entered, the entire list of NCD titles will appear alphabetically and may be selected). There is no cost to access the website or print the material contained therein.
He-W 546.05(a)(1) intro.	Recommendations for Preventive Pediatric Health Care (2014)	Publisher: American Academy of Pediatrics/Bright Futures. Available free of charge at: http://www.aap.org/en-us/professional-resources/practice-support/Periodicity/Periodicity%20Schedule_FINAL.pdf
He-W 546.05(a)(1)	American Academy of Pediatrics’ “Recommendations for Preventative Pediatric Health Care” (2023 edition)	Publisher: American Academy of Pediatrics’ Cost: Free of Charge The incorporated document is available at: https://publications.aap.org/pediatrics/article/151/4/e2023061451/190849/2023-Recommendations-for-Preventive-Pediatric?autologincheck=redirected
He-W 546.05(a)(1)j.	Guideline on Periodicity of Examination, Preventive Dental Services, Anticipatory Guidance/Counseling, and Oral Treatment for Infants, Children, and Adolescents (2013 revision)	Publisher: American Academy of Pediatric Dentistry. Available free of charge at: http://www.aapd.org/media/Policies_Guidelines/G_Periodicity.pdf
He-W 546.05(a)(2)	American Academy of Pediatric Dentistry’s “Periodicity of Examination, Preventive Dental Services, Anticipatory Guidance/Counseling, and Oral Treatment for Infants, Children, and Adolescents” (2022 revision)	Publisher: American Academy of Pediatric Dentistry Cost: Free of Charge The incorporated document is available at: https://www.aapd.org/globalassets/media/policies_guidelines/bp_periodicity.pdf
He-W 546.05(b)(5)	Recommended Immunization Schedules for Persons Aged 0 Through 18 Years, United States 2015	Publisher: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention. Available free of charge at: http://www.cdc.gov/vaccines/schedules/downloads/child/0-18yrs-child-combined-schedule.pdf
He-W 547.04(c)(6)d.	“Bright Futures: Guidelines for Health Supervision of Infants, Children and Adolescents,” 3^rd edition, 2008.	Published by the American Academy of Pediatrics. PDFs of each chapter of the guidelines can be downloaded free of charge from: http://brightfutures.aap.org/3rd_Edition_Guidelines_and_Pocket_Guide.html. The complete document can be ordered from the AAP Bookstore at a cost of $64.95 at https://www.nfaap.org/, or by writing to: Bright Futures c/o American Academy of Pediatrics 141 Northwest Point Blvd. Elk Grove, IL 60007
He-W 547.04(c)(6)j.	“Clinical Guideline on Periodicity of Examination, Preventive Dental Services, Anticipatory Guidance, and Oral Treatment for Children”, of the American Academy of Pediatric Dentistry, 81 Reference Manual 2004-2005, Originating Committee- Clinical Affairs Committee, Review Council- Council on Clinical Affairs, adopted 1991, Revised, 1992, 1996, 2000, and 2003.	Published by the American Academy of Pediatric Dentistry. Available on-line, at: http://www.aapd.org/media/Policies_Guidelines/G_Periodicity.pdf. Free of charge.
He-W 568.10(b)	American Medicaid Association’s “Current Procedural Terminology (CPT) 2022 Professional Edition”	Publisher: American Medical Association Cost: $109.76 The incorporated document is available for purchase at https://www.amazon.com/stores/page/112D63A3-2DF2-490B-A8CA-79D03F0F0E99
He-W 569.06(d)(1) & (d)(2)a.-d.	Milliman Clinical Guidelines, 17th Edition (February/March 2013)	Publisher: MCG Health, LLC. 901 Fifth Avenue, Suite 2000, Seattle, WA 98164. Phone: 206-389-5300; Toll-Free: 888-464-4746. Fax: 206-464-7813. http://www.careguidelines.com/. Cost per guideline: approximately $6,000. NH Medicaid providers and recipients may obtain relevant portions of the guidelines (e.g., the specific criteria related to a prior authorization denial) free of charge and upon request by contacting the Department’s Prior Authorization Agent (currently KePro) at 1-800-299-5921.
He-W 571.04(c)(21)	Medicare Coverage Database	Publisher: Centers for Medicare and Medicaid Services. National Coverage Determinations can be found in the “Medicare Coverage Database” at http://www.cms.gov/medicare-coverage-database/ (under the “Quick Search” function, select “National Coverage Documents”, optionally enter a filter by entering a “keyword” to narrow the search results, and select the “Search by Type” button, or, if a keyword is not entered, the entire list of NCD titles will appear alphabetically and may be selected). There is no cost to access the website or print the material contained therein.

APPENDIX B

RULE		STATE OR FEDERAL STATUTE THE RULE IMPLEMENTS
He-W 502.01		RSA 167:6, IV
He-W 502.02		RSA 167:6, IV
He-W 502.03		RSA 167:6, IV
He-W 506.01		RSA 126-A:5, XIX; 42 U.S.C. 1396u–2(a); 42 U.S.C. 1396u-2; RSA 126-A:5, XXIII-XXV
He-W 506.02		RSA 126-A:5, XIX; §1932(a) of the SSA [42 USC 1396u-2(a)]; 42 USC 1396u-2
He-W 506.03		1932(a) of the SSA [42 USC 1396u-2(a)]; 42 USC 1396u-2; 42 CFR 438.2; RSA 126-A:5, XXIII-XXV
He-W 506.04		§1903(m) of the SSA [42 USC 1396b(m)]; 1932(a) of the SSA [42 USC 1396u-2(a)]; 42 USC 1396u-2; 42 CFR 438.210; §1932(a)(3) of the SSA; 42 U.S.C. 1396u-2(a)(3)
He-W 506.05		§1932(a)(4) of the SSA [42 USC 1396u-2(a)(4)]; §1915(b)(1) of the SSA [42 USC 1396n(b)(1)]; §1915(b)(4) of the SSA [42 USC 1396n(b)(4)]; 42 CFR 438.56 and .226
He-W 506.06		§1932(a)(4) of the SSA [42 USC 1396u-2(a)(4)]; 42 CFR 438.52; 42 CFR 438.700
He-W 506.07		42 CFR 438 Subpart F; 42 CFR 438.228
He-W 506.08		42 CFR 438 Subpart F; §1932(a)(5)(iii) of the SSA
He-W 506.09		42 CFR 438 Subpart F; §1932(a)(5)(iii) of the SSA
He-W 507.01		42 CFR 435.540
He-W 507.02		42 CFR 435.222, 42 CFR 435.540
He-W 507.03		RSA 171-A:2, V, 42,CFR 435.222, 42 CFR 435.540
He-W 507.04		42 CFR 435.211, 42 CFR 435.541(f)(3), 42 CFR 435.916
He-W 507.05		42 CFR 435.919, 42 CFR 435.912, 42 CFR 431.211
He-W 507.06		42 CFR 431.200, 42 CFR 435.220, 42 CFR 435.221
He-W 508.01		RSA 167:3-f, II
He-W 508.02		RSA 167:3-f, I; 42 CFR 435.225; 42 CFR 435.217; 42 CFR 435.540; 42 CFR 483.440(a)
He-W 508.03		RSA 167:3-e, III; RSA 167:3-f, III and IV; 42 CFR 435.225; 42 CFR 435.217; 42 CFR 435.540; 45 CFR 233.90(c)(1)(v)(B)
He-W 508.04		RSA 167:3-g; 42 CFR 435.225; SS Act 1902 (e)(3); 42 CFR 435.217; 42 CFR 483.102(b)(2) RSA 171-A:2, V
He-W 508.05		RSA 167:3-f, V and VI
He-W 508.06		RSA 167:3-e, IV
He-W 508.07		RSA 167:3-e, IV
He-W 508.08		RSA 167:3-e, IV
He-W 508.09		RSA 167:3-e, III; RSA 167:3-f, III and IV; 42 CFR 435.225; 42 CFR 435.217; 42 CFR 435.540; 45 CFR 233.90(c)(1)(v)(B)
He-W 508.10		RSA 167:3-e, III; RSA 167:3-f, III and IV; 42 CFR 435.225; 42 CFR 435.217; 42 CFR 435.540; 45 CFR 233.90(c)(1)(v)(B)
He-W 509.01		Section 1902(a)(10)(A)(ii) of the Social Security Act (42 U.S.C. 1396a(a)(10)(A)(ii)); 42 U.S.C 1396d
He-W 509.02		Section 1902(a)(10)(A)(ii) of the Social Security Act (42 U.S.C. 1396a(a)(10)(A)(ii)); 42 U.S.C 1396d; 42 CFR 441.251
He-W 509.03		Section 1902(a)(10)(A)(ii) of the Social Security Act (42 U.S.C. 1396a(a)(10)(A)(ii))
He-W 509.04		42 CFR 440.50; 42 CFR 440.60
He-W 509.05		42 CFR 440.230
He-W 509.06		42 CFR 441 Subpart F; 42 U.S.C 1396d
He-W 509.07		42 CFR 441 Subpart F; 42 U.S.C 1396d
He-W 509.08		42 CFR 431.53
He-W 509.09		42 CFR 447.53(b)(5)
He-W 511.01		42 U.S.C. 1396e
He-W 511.02		42 U.S.C. 1396e
He-W 511.03		42 U.S.C. 1396e
He-W 511.04		42 U.S.C. 1396e
He-W 511.05		42 U.S.C. 1396e
He-W 511.06		42 U.S.C. 1396e
He-W 511.07		42 U.S.C. 1396e
He-W 511.08		42 U.S.C. 1396e
He-W 511.09		42 U.S.C. 1396e
He-W 511.10		42 CFR 433.139
He-W 511.11		42 CFR 455; and 42 CFR 456
He-W 511.12		42 CFR 431.201
He-W 512.01		RSA 126-A:5, XXIV; 42 U.S.C. 1396u-7
He-W 512.02		RSA 126-A:5, XXIV; 42 U.S.C. 1396u-7
He-W 512.03		RSA 126-A:5, XXIV; 42 U.S.C. 1396u-7
He-W 512.04		RSA 126-A:5, XXIV; 42 U.S.C. 1396u-7; RSA 420-J:5
He-W 512.05		RSA 126-A:5, XXIV; 42 U.S.C. 1396u-7
He-W 512.06		RSA 126-A:5, XXIV; 42 U.S.C. 1396u-7
He-W 512.07		RSA 126-A:5, XXIV; 42 U.S.C. 1396u-7; RSA 420-J:5
He-W 512.08		RSA 126-A:5, XXIV; 42 CFR 433.139
He-W 512.09		RSA 126-A:5, XXIV; 42 CFR 455; and 42 CFR 456
He-W 513.01		42 USC 1396u-7(b)(5), RSA 126-A:5, XXIII-XXV, 42 CFR 440.347
He-W 513.02		42 USC 1396u-7(b)(5), RSA 126-A:5, XXIII-XXV, 42 CFR 440.347
He-W 513.03		42 USC 1396u-7(b)(5), RSA 126-A:5, XXIII-XXV, 42 CFR 440.347
He-W 513.04		42 USC 1396u-7(b)(5), RSA 126-A:5, XXIII-XXV, 42 CFR 440.347, Chapter Law 189:2, II, Laws of 2008, Chapter Law 249:24, V, Laws of 2010
He-W 513.05		42 USC 1396u-7(b)(5), RSA 126-A:5, XXIII-XXV, 42 CFR 440.347
He-W 513.06		42 USC 1396u-7(b)(5), RSA 126-A:5, XXIII-XXV, 42 CFR 440.347
He-W 513.07		42 CFR 455 and 42 CFR 456
He-W 513.08		42 CFR 433.139
He-W 513.09		RSA 161:4, VI
He-W 513.10		42 CFR 455 and 42 CFR 456
He-W 513.11		42 CFR 455 and 42 CFR 456
He-W 513.12		RSA 161:4-a, X
He-W 520.01		42 CFR 433, Subpart C; 42 CFR 440.40; 42 CFR 455; 42 CFR 457; Section 1920A of the SSA; 42 USC 1396a(a)(10); 42 USC 1396d(a)
He-W 520.02		42 CFR 430.10, 42 CFR 440.210, 42 CFR 440.220; RSA 161:2, VI; RSA 161:4-a, IX
He-W 520.03		42 CFR 431.107
He-W 520.04		42 CFR 455; 42 CFR 456
He-W 520.05		42 CFR 455.14; 42 CFR 455.15; 42 CFR 455.16
He-W 520.06		42 USC 1395cc(j)(2); 42 CFR 433.139; 42 CFR 424; 42 CFR Part 455; RSA 161:4-a, X; 42 USC 1396a(a)(77); 42 U.S.C. 1396a(kk); RSA 126-A:5, VIII
He-W 521.01		42 CFR 433; RSA 167:4-b(I); RSA 161:4-a, X(g), (h) & (j)
He-W 521.02		42 CFR 433; RSA 167:4-b(I)
He-W 521.03		45 CFR 164.512(d); 42 CFR 455.104(c)(1)
He-W 521.04		42 CFR 447.45
He-W 521.05		RSA 161:4, VI(a); 42 CFR 447.15; 42 CFR 447.52; 42 CFR 447.53; 42 CFR 447.54; 42 CFR 447.55; 42 CFR 447.56
He-W 521.06		42 CFR 433
He-W 521.07		42 CFR 455.21
He-W 521.08		RSA 167:14-a; 42 CFR 433.145(a); 42 CFR 433.147(c); 42 CFR 433.139 (b)
He-W 521.09		RSA 167:14-a, IV; RSA 167:14-a, III
He-W 521.10		42 USC 1396a
He-W 521.11		RSA 167:4-b
He-W 530.01		RSA 318:1; 21 CFR 310.6; 42 CFR 440.120; 21 USC 802(6), 42 CFR 447.53; 42 CFR 456 subpart K; Chapter Law 188 and 281:9, 2004, SB 383-FN, 2004.
He-W 530.01(a)-(c), (e)		RSA 318:1; 21 CFR 310.6; 42 CFR 440.120; 21 USC 802(6)
He-W 530.01(d), (h), (i), (o)		RSA 318:1; 21 CFR 310.6; 42 CFR 440.120; 21 USC 802(6); RSA 318:1; 21 CFR 310.6; 42 CFR 440.120; 21 USC 802(6)
He-W 530.01(f)		RSA 167:3-h, II
He-W 530.01(g), (j)-(n), (p)-(r)		RSA 318:1; 21 CFR 310.6; 42 CFR 440.120; 21 USC 802(6)
He-W 530.02		42 USC 1396o; 42 CFR 447.53, 42 CFR 447.56
He-W 530.03		RSA 167:3-h, IV; 42 CFR 440.230(d); 42 CFR 447.53-55; RSA 326-B:2, I; RSA 326-B:11
He-W 530.04		42 USC 1396o; 42 CFR 447.53, 42 CFR 438.114(a), 42 CFR 447.26(b), 42 CFR 447.56
He-W 530.05		42 CFR 440.230(d)
He-W 530.05(b)(4) & (b)(32)		RSA 541-A:21, VIII
He-W 530.06		42 CFR 447.15
He-W 530.07		42 CFR 440.230(d); 42 CFR 431.107; RSA 126-A:5, VII
He-W 531.01		42 USC 1396
He-W 531.02		42 CFR 440.210, 42 CFR 440.220 & 42 CFR 440.225
He-W 531.03		42 CFR 440.50
He-W 531.04		42 CFR 440.230 & 42 CFR 440.250
He-W 531.05		42 CFR 441.30; 42 CFR 441.35
He-W 531.06		42 CFR 440.230(d)
He-W 531.06(e)		RSA 541-A:21, VIII
He-W 531.06(i)		42 CFR 447.15
He-W 531.07		42 CFR 440.230(d)
He-W 531.08		42 CFR 455; 42 CFR 456
He-W 531.09		42 CFR 433.139
He-W 531.10		42 CFR 447.15; RSA 161:4, VI(a)
He-W 543.01(o)		42 CFR 412.60; 42 CFR 440.210; 42 CFR 440.220; 42 CFR 440.225; 42 CFR 476.1; 42 CFR 475
He-W 531.07		42 CFR 440.230(d)
He-W 531.08		42 CFR 455; 42 CFR 456
He-W 531.09		42 CFR 433.139
He-W 531.10		42 CFR 447.15; RSA 161:4, VI(a)
He-W 532.01		42 CFR 440.110
He-W 532.02		42 CFR 440.210; 42 CFR 440.220; 42 CFR 440.225
He-W 532.03		42 CFR 440.50; RSA 315
He-W 532.04		42 CFR 440.230
He-W 532.05		42 CFR 440.10-50; RSA 315
He-W 532.06		42 CFR 440.230(d)
He-W 532.07		42 CFR 431.107
He-W 532.08		42 CFR 455
He-W 532.09		42 CFR 433.139
He-W 532.10		42 CFR 447.200; 42 CFR 447.202; 42 CFR 447.204; RSA 541-A:21, III
He-W 534.01		RSA 326 B:2; 42 CFR 440.166
He-W 534.02		42 CFR 440.210; 42 CFR 440.220
He-W 534.03		42 CFR 440.166
He-W 534.04		42 CFR 440 Subpart B
He-W 534.05		42 CFR 440.166
He-W 534.06		42 CFR 456
He-W 534.07		42 CFR 433.139
He-W 534.08		RSA 541-A:21; 42 CFR 447 Subpart B
He-W 536.01		42 CFR 440.90
He-W 536.02		42 CFR 440.210, 42 CFR 440.220 & 42 CFR 440.225
He-W 536.03		42 CFR 440.90
He-W 536.04		42 CFR 440.230 and 42 CFR 440.240
He-W 536.05		42 CFR 440.90, 42 CFR 440.230 & 42 CFR 440.240
He-W 536.06		42 CFR 455, 42 CFR 456
He-W 536.07		42 CFR 433.139
He-W 536.08		42 CFR 447.15, 42 CFR 430.0, 42 CFR 447.204 & 42 CFR 431.107; RSA 161:4, VI(a)
He-W 538.01		RSA 326-D:2; RSA 326-D:6
He-W 538.02		42 CFR 440.210, 42 CFR 440.220, 42 CFR 440.225
He-W 538.03		RSA 326-D:2, 42 CFR 440.165, 42 CFR 440.210, 42 CFR 440.220, 42 CFR 440.225
He-W 538.04		RSA 326-D:1 and RSA 326-D:12
He-W 538.05		RSA 326-D:1, V
He-W 538.06		42 CFR 455,42 CFR 456, 42 CFR 447, 42 CFR 1001
He-W 538.07		42 CFR 433.139
He-W 538.08		42 CFR 447.15, RSA 161:4, VI(a)
He-W 540.01		42 CFR 484.60; Nurse Practice Act, RSA 326-B; 42 CFR 440.80
He-W 540.02		42 CFR 440.210; 42 CFR 440.220
He-W 540.03		RSA 151:2, I(b); 42 CFR 440.80
He-W 540.04		42 CFR 440.80
He-W 540.05		RSA 151:2; 42 CFR 434.2; 42 CFR 440.150; 42 CFR 435.1010
He-W 540.06		42 CFR 484.60; 42 U.S.C. 1395n; 42 CFR 440
He-W 540.07		42 CFR 431.107; 42 CFR 440.230
He-W 540.08		42 CFR 447; 42 CFR 455; 42 CFR 456; 42 CFR 1001
He-W 540.09		42 CFR 433.139
He-W 540.10		RSA 161:4, VI(a)
He-W 541.01		42 CFR 441.251, 42 CFR 447
He-W 541.02		42 CFR 440.220; 42 CFR 440.225
He-W 541.03		42 CFR 431.51(b); 42 CFR 431.51(c)(2); 42 CFR 431.107(b)
He-W 541.04		42 CFR 440.230; 42 CFR 440.240
He-W 541.05		42 CFR 441.253; 42 CFR 441.254; 42 CFR 441.255; 42 CFR 441.257; 42 CFR 441.258
He-W 541.06		42 CFR 441.254; 42 CFR 441.255
He-W 541.07		42 CFR 447.53(b)(5)
He-W 541.08		42 CFR 456.3; 42 CFR 455, 42 CFR 447, 42 CFR 456
He-W 541.09		42 CFR 433
He-W 541.10		42 CFR 447.204; 42 CFR 431.107
He-W 543.01		42 CFR 412.60; 42 CFR 440.210; 42 CFR 440.220; 42 CFR 440.225; 42 CFR 476.1; 42 CFR 475
He-W 543.02		42 CFR 440.210; 42 CFR 440.220; 42 CFR 440.225
He-W 543.03		42 CFR 431.52; 42 CFR 476 Subpart C; 42 CFR 482.1, 2, 11, 24, 30; RSA 151; 42 CFR 440.10; 42 CFR 431.107, 108
He-W 543.04		42 CFR 440.2; 42 CFR 440.10; 42 CFR 440.20; 42 CFR 440.50; 42 CFR 440.130
He-W 543.05		42 CFR 440.10; 42 CFR 440.140; 42 CFR 440.160
He-W 543.06		42 CFR 456
He-W 543.07		42 CFR 412, Subpart A - F, and H
He-W 543.08		42 CFR 440.210; 42 CFR 440.220; 42 CFR 440.225
He-W 543.09		42 CFR 433.139
He-W 543.10		42 CFR 455; 42 CFR 447; 42 CFR 456
He-W 543.11		42 CFR 433, Subpart D
He-W 543.12		42 CFR 431.107; 42 CFR 447.204; 42 CFR 447.250-255
He-W 544.01		RSA 137-J; RSA 137-J:35; RSA 464-A; RSA 151; 42 U.S.C. 1395x; 42 CFR 410.74(c); 42 CFR 410.75 (b); 42 CFR 418.3; 42 CFR 484.60
He-W 544.02		42 U.S.C. 1395d(d)(2)
He-W 544.03		RSA 151:2
He-W 544.04		42 U.S.C. 1395d(d)(2); 42 CFR 418.24
He-W 544.05		42 U.S.C. 1395d(d)(2); 42 CFR 418.24
He-W 544.06		42 U.S.C. 1395d(d)(2); 42 CFR 418.22
He-W 544.07		42 U.S.C. 1395d(d)(2); 42 CFR 418.30
He-W 544.08		42 CFR 418.26
He-W 544.09		42 CFR 418.28
He-W 544.10		42 CFR 418.202; RSA 151; 42 CFR 418.100(a) and (e); 42 CFR 418.110; 42 CFR 418.56(c); 42 CFR 418.100 (a) and (e)
He-W 544.11		42 CFR 418.56(c) and (d)
He-W 544.12		42 CFR 455; 42 CFR 456
He-W 544.13		42 CFR 433.139
He-W 544.14		42 U.S.C. 1395f(i)(1)(C)(ii) and 42 U.S.C. 1396a(13)(B)
He-W 544.15		42 CFR 418.302(a), (b), (c), and (g)
He-W 544.16		42 U.S.C. 1396d
He-W 544.17 (repeal)		RSA 541:A-19-b
He-W 546.01		42 CFR 441, Subpart B
He-W 546.02		42 CFR 440.40(b); 42 CFR 441.50
He-W 546.03		42 CFR 441.56
He-W 546.04		42 CFR 441.61; 42 CFR 431.107
He-W 546.05		42 CFR 440.230; 42 CFR 441.56; 42 CFR 441.58; 42 CFR 441.62
He-W 546.06		42 CFR 440.230; 42 CFR 456.3
He-W 546.07		42 CFR 441.61
He-W 546.08		42 CFR 440.230(d)
He-W 546.09		42 CFR 455; 42 CFR 456
He-W 546.10		42 CFR 433.139
He-W 546.11		42 CFR 447.15; 42 CFR 447, Subpart B
He-W 547.01		RSA 167:66-68
He-W 547.02		RSA 167:68, I
He-W 547.03		RSA 167:68, II(e)
He-W 547.04		RSA 167:68, II(e)
He-W 547.05		RSA 167:66-68
He-W 547.06		RSA 167:66-68
He-W 547.07		42 CFR 456
He-W 547.08		42 CFR 433.139
He-W 547.09		RSA 541-A:21, III
He-W 548.01		42 CFR 440.250(p)
He-W 548.02		42 CFR 440.210, 42 CFR 440.220, 42 CFR 440.225, 42 CFR 440.250(p)
He-W 548.03		42 CFR 440.50, 42 CFR 440.60(a), 42 CFR 440.70, 42 CFR 440.90, 42 CFR 440.130, 42 CFR 440.165, 42 CFR 440.166
He-W 548.04		42 CFR 440.250(p), 42 CFR 440.210(a)(2)
He-W 548.05		42 CFR 440.250(p)
He-W 548.06		42 CFR 440.250(p), 42 CFR 455, 42 CFR 447
He-W 548.07		42 CFR 456.3
He-W 548.08		42 CFR 433.139
He-W 548.09		42 CFR 455, 42 CFR 447; RSA 161:4, VI(a)
He-W 549.01		42 USC 1396; 42 USC 702
He-W 549.02		42 CFR 440.210; 42 CFR 440.220; 42 CFR 440.225; 42 CFR 440.250(p)
He-W 549.03		42 CFR 440.230(d)
He-W 549.04		RSA 326-B:1; RSA 326-B:10; RSA 326-B:6; RSA 326-H:12; 42 CFR 440.166; 42 CFR 440.60(a)
He-W 549.04(a) intro and (a)(1)		42 CFR 440.166; 42 CFR 440.60(a)
He-W 549.05		42 CFR 440.210(a)(2); 42 CFR 440.250(p); 42 CFR 440.220; 42 CFR 440.225; 42 CFR 440.130; 42 CFR 441.20
He-W 549.06		42 CFR 440.230(d)
He-W 549.07		RSA 132:12
He-W 549.07(a) intro, (a)(2) intro and (a)(2)b.		RSA 132:12
He-W 549.08		42 CFR 455; 42 CFR 456.33
He-W 549.09		42 CFR 433.139
He-W 549.10		42 CFR 447.15
He-W 550.01-550.08		RSA 161:2, VI & VIII, 42 CFR Section 440.130(c) & (d)
He-W 552.01		42 CFR 440.167, RSA 161-E:1
He-W 552.02		42 CFR 440.167, RSA 161-E:1
He-W 552.03		42 CFR 440.167, 42 CFR 440.210, 42 CFR 440.220, RSA 161-E:1
He-W 552.04		42 CFR 440.167, RSA 161-E:1
He-W 552.05		42 CFR 440.167, RSA 161-E:1
He-W 552.05		42 CFR 440.167, RSA 161-E:1
He-W 552.06		42 CFR 440.167, RSA 161-E:1
He-W 552.07		42 CFR 440.167, RSA 161-E:1
He-W 552.08		42 CFR 440.167, RSA 161-E:1
He-W 552.09		42 CFR 440.167, RSA 161-E:1
He-W 552.10		42 CFR 455, 42 CFR 456
He-W 552.11		42 CFR 433.139
He-W 552.12		42 CFR 440.167, RSA 161-E:1
He-W 552.13		42 CFR 440.167, RSA 161-E:1
He-W 553.01		42 CFR 440.70; RSA 326-B:18
He-W 553.02		42 CFR 440.70; 42 CFR 440.210; 42 CFR 440.220; 42 CFR 441.15; RSA 326-B
He-W 553.03		42 CFR 440.70; 42 CFR 440.210; 42 CFR 440.220
He-W 553.04		42 CFR 440.70(d); RSA 151:2-b,I
He-W 553.05		42 CFR 440.70; 42 CFR 440.230; 42 CFR 484.55
He-W 553.06		42 CFR 440.70; 42 CFR 441.15; RSA 326-B
He-W 553.07		42 CFR 440.230(d)
He-W 558.01-558.09		Section 1915 (c) of the Social Security Act
He-W 559.01		Section 1905(a)(19) and Section 19115(g)(2) Social Security Act
He-W 559.02		42 CFR 440.210, 42 CFR 440.220 and 42 CFR 440.225
He-W 559.03		42 CFR 440.70 and 42 CFR 440.60
He-W 559.04		42 CFR 440.70 and 42 CFR 440.230
He-W 559.05		42 CFR 441.15 and 42 CFR 440.230
He-W 559.06		42 CFR 456.30
He-W 559.07		42 CFR 433.139
He-W 559.08		42 CFR 447.15 and 42 CFR 430.0
He-W 565.01		RSA 327-A:1
He-W 565.01(a), (e) & (f)		42 CFR 440.210; 42 CFR 440.220
He-W 565.02		42 CFR 440.210; 42 CFR 440.220
He-W 565.03		42 CFR 440.120
He-W 565.04		42 CFR 440 Subpart B
He-W 565.05		42 CFR 440.120
He-W 565.06		42 CFR 440.120
He-W 565.07		42 CFR 455; 42 CFR 456
He-W 565.08		42 CFR 433.139
He-W 565.09		RSA 541-A:21; 42CFR 447 Subpart B
He-W 566.01		42 CFR 440.100, and 42 CFR 440.40
He-W 566.02		42 CFR 440.210, 42 CFR 440.220, and 42 CFR 440.225
He-W 566.03		42 CFR 440.100, 42 CFR 431.107, and 42 CFR 431.108
He-W 566.04		42 CFR 440.100, 42 CFR 440.40, 42 CFR 441.56, 42 CFR 440.225, and 42 CFR 440.50
He-W 566.05		42 CFR 440.225, 42 CFR 440.40, and 42 CFR 441.56
He-W 566.06		42 CFR 440.230
He-W 566.07		42 CFR 440.230
He-W 566.08		42 CFR 455, 42 CFR 456, 42 CFR 447, and 42 CFR 1001
He-W 566.09		42 CFR 433, Subpart D
He-W 566.10		42 CFR Subpart B, and RSA 161:4,VI(a)
He-W 567.01		RSA 137-F:2, IV; Section 216(i)(l) of the SSA; Section 1614(a)(2) of the SSA, 42 USC 416, 42 USC 1382c
He-W 567.02		42 CFR 440.210; 42 CFR 440.220
He-W 567.03		RSA 137-F:11; RSA 137-F:8; 42 CFR 440.110; 42 CFR 440.120; 42 CFR 440.70
He-W 567.04		42 CFR 440.230
He-W 567.05		42 CFR 440.110; 42 CFR 440.120; 42 CFR 440.70; 42 CFR 441.57
He-W 567.06		42 CFR 440.110; 42 CFR 440.120; 42 CFR 440.70; 42 CFR 440.230
He-W 567.07		42 CFR 440.230
He-W 567.08		42 CFR 431.107
He-W 567.09		42 CFR 455; 42 CFR 456
He-W 567.10		42 CFR 433, Subpart D
He-W 567.11		42 CFR 447.204
He-W 568.01		RSA 161:4-a, IX
He-W 568.02		42 CFR 440.210; 42 CFR 440.220; 42 CFR 440.225
He-W 568.03		42 CFR 440.110
He-W 568.04		42 CFR 440 Subpart B
He-W 568.05		42 CFR 440.10
He-W 568.06		42 CFR 440.110
He-W 568.07		42 CFR 455; 42 CFR 456; 42 CFR 1001
He-W 568.08		42 CFR 440.10
He-W 568.09		42 CFR 433.139
He-W 568.10		42 CFR 447 Subpart B
He-W 569.01		42 CFR 440.30
He-W 569.02		42 CFR 440.210; 42 CFR 440.220
He-W 569.03		42 CFR 440.30; 42 CFR 441.17
He-W 569.04		42 CFR 440, Subpart B
He-W 569.05		42 CFR 440.30
He-W 569.06		42 CFR 440.230; 42 CFR 456.3
He-W 569.07		42 CFR 455; 42 CFR 456
He-W 569.08		42 CFR 433.139
He-W 569.09		42 CFR 447, Subpart B; RSA 161:4, VI; RSA 541-A:21, III,
He-W 570.01		RSA 318:1, VII; RSA 318:1, XV, RSA 318:1, XVI, RSA 318:21; RSA 126-A:3, III(b), 21CFR 310.6, 42 CFR 440.120
He-W 570.01(a), (p), (q)		42 CFR 447.502; RSA 541-A:21, VIII
He-W 570.01(a) & (q)		42 CFR 447.502; RSA 541-A:21, VIII
He-W 570.01(s)		RSA 318:1, VII; RSA 318:1, XV, RSA 318:1, XVI, RSA 318:21; RSA 126-A:3, III(b), 21CFR 310.6, 42 CFR 440.120, 42 CFR 447.53; 42 CFR 456 subpart K; Chapter 188 and 281:9, 2004, SB 383-FN, 2004
He-W 570.01(u), (aa), (ab)		RSA 318:1, VII; RSA 318:1, XV, RSA 318:1, XVI, RSA 318:21; RSA 126-A:3, III(b), 21CFR 310.6, 42 CFR 440.120, 42 CFR 447.53; 42 CFR 456 subpart K; Chapter 188 and 281:9, 2004, SB 383-FN, 2004
He-W 570.02		42 CFR 440.210, 42 CFR 440.220; 42 CFR 440.225
He-W 570.03		42 CFR 440.120, RSA 318
He-W 570.04		42 CFR 440.120, 42 CFR 441.25, 42 CFR 440.225, 42 CFR 440.230(d), 42 CFR 431 Subpart E, 42 USC 1396r-8(d), 42 USC 1396r-8(k)(2)
He-W 570.05		42 USC 1396r-8(d)(2)(k)
He-W 570.06		42 CFR 431.54(e), 42 CFR 431 Subpart E, 42 CFR 440.230(d), 42 USC 1396r-8(d)(5) and (6); RSA 126-A:5, VIII
He-W 570.07		42 CFR 431.54(e)
He-W 570.08		RSA 318-B:9, IV, 21 CFR 1306.22; 42 USC 1396r-8(d)(7)
He-W 570.09		RSA 318:47-c
He-W 570.10		RSA 146-B:5; RSA 318:47
He-W 570.11		42 CFR 456
He-W 570.12		42 USC 1396r-8(g), 42 CFR 456.3
He-W 570.13		42 USC 1396o; 42 CFR 447.53, 42 CFR 447.56
He-W 570.14		42 CFR 447
He-W 570.14 (a) intro, (a)(2) intro, and (a)(2)a. & b.		42 CFR 447.512(b)
He-W 570.15		RSA 151:2, 42 USC 1396r-8
He-W 571.01		42 CFR 440.120
He-W 571.02		42 CFR 440.210; 42 CFR 440.220
He-W 571.03		42 CFR 440.50; 42 CFR 440.60; 42 CFR 440.166; 42 CFR 431.107; RSA 328-D:1
He-W 571.04		RSA 415:6-c; RSA 415:18-n; RSA 415:18-d; RSA 126-A:5,VII;42 CFR 440.230; 42 CFR 440.130(a); RSA 541-A:21, VIII;
He-W 571.05		42 CFR 440.230(d); 42 CFR 456.3
He-W 571.06		42 CFR 440.230(d); 42 CFR 456.3
He-W 571.07		42 CFR 431.107; 42 CFR 455 Subparts A and B; 42 CFR 447 Subparts A and B; 42 CFR 456 Subparts A and B
He-W 571.08		42 CFR 431.107, 42 CFR 433 Subpart D
He-W 571.09		42 CFR 455 Subparts A and B; 42 CFR 456 Subparts A and B
He-W 571.10		42 CFR 455 Subparts A and B; 42 CFR 456 Subparts A and B, 42 CFR 447.45; RSA 161:4, VI(a); RSA 126-A:3, III(b)
He-W 572.01		42 CFR 440.170
He-W 572.02		42 CFR 440.210; 42 CFR 440.220
He-W 572.03		42 CFR 440.60; RSA 153-A:11; 42 CFR 440.170
He-W 572.04		42 CFR 440.170
He-W 572.05		42 CFR 440.170
He-W 572.06		42 CFR 440.230
He-W 572.07		42 CFR 431.107
He-W 572.08		42 CFR 455
He-W 572.09		42 CFR 433.139
He-W 572.10		RSA 541-A:21, III; 42 CFR 447.200; 42 CFR 447.202; 42 CFR 447.204
He-W 573.01		42 CFR 440.170
He-W 573.02		42 CFR 440.210, 42 CFR 440.220
He-W 573.03		42 CFR 440.170
He-W 573.04		42 CFR 440, Subpart B
He-W 573.05		42 CFR 440.170
He-W 573.06		42 CFR 456
He-W 573.07		42 CFR 433.139
He-W 573.08		RSA 541-A:21, III, 42 CFR 447, Subpart B
He-W 573.09		42 CFR 456.4
He-W 573.10		42 CFR 431.107; 42 CFR 440.230
He-W 573.11		42 CFR 456
He-W 573.12		42 CFR 433.139
He-W 573.13		RSA 541-A:21, III; 42 CFR 447, Subpart B
He-W 574.01		42 CFR 441.62; 42 CFR 431.53; 42 CFR 440.170
He-W 574.02		42 CFR 441.62; 42 CFR 431.53; 42 CFR 440.170
He-W 574.03		42 CFR 440.170
He-W 574.04		42 CFR 441.62; 42 CFR 431.53; 42 CFR 431.107; 42 CFR 440.170; 42 CFR 455; RSA 161:4-a, XI
He-W 574.05		42 CFR 441.62; 42 CFR 431.53; 42 CFR 440 Subpart B; 42 CFR 440.170
He-W 574.06		42 CFR 441.62; 42 CFR 431.53; 42 CFR 440 Subpart B
He-W 574.07		RSA 541-A:21, III; 42 CFR 447, Subpart B
He-W 574.08		RSA 541-A:21, III; 42 CFR 447, Subpart B
He-W 574.09		42 CFR 431.107; 42 CFR 440.230
He-W 574.10		42 CFR 431.53
He-W 574.11		42 CFR 431.220
He-W 574.12		42 CFR 433.139
He-W 574.13		42 CFR 455; 42 CFR 456
He-W 575.01		42 CFR 440.120
He-W 575.02		42 CFR 440.210; 42 CFR 440.220
He-W 575.03		42 CFR 440.50; 42 CFR 440.60; 42 CFR 440.166; RSA 328-D:1
He-W 575.04		RSA 415:6-C; RSA 415:18-n; 42 CFR 440.230; 42 CFR 440.130(a)
He-W 575.05		42 CFR 440.230(d)
He-W 575.06		42 CFR 440.230(d)
He-W 575.07		42 CFR 440.230(d)
He-W 575.08		42 CFR 431.107
He-W 575.09		42 CFR 433.139
He-W 575.10		42 CFR 455; 42 CFR 456
He-W 575.11		42 CFR 447.15
He-W 577.01		42 CFR 440.30
He-W 577.02		42 CFR 440.210; 42 CFR 440.220
He-W 577.03		42 CFR440.30; 42 CFR 441.17
He-W 577.04		42 CFR 440.30
He-W 577.05		42 CFR 455; 42 CFR 456
He-W 577.06		42 CFR 433.139
He-W 577.07		42 CFR 447, Subpart B; RSA 161:4, VI
He-W 591.01(a)		42 CFR 488.442
He-W 591.01(b)		42 CFR 488.3
He-W 591.01(c) – (e)		42 CFR 488.400 - 488.456
He-W 591.01(f)		42 USC 1396r(b)
He-W 591.01(g)		42 CFR 488.402
He-W 591.01(h)		42 USC 1396r(a)
He-W 591.01(i) – (l)		42 CFR 488.400 - 488.456
He-W 591.02(a)		42 CFR 488.11(b), 42 USC 1396r(h)
He-W 591.02(b)		42 CFR 488.110(j)
He-W 591.02(c)		42 CFR 488.402- 488.406
He-W 591.03		42 CFR 488.404-488.446
He-W 591.04(a)		42 CFR 488.402(f)(3)
He-W 591.04(b)		42 CFR 488.402(f)(4)
He-W 591.04(c)		42 CFR 488.402(f); 42 CFR 488.406(a)
He-W 591.04(d)		42 CFR 488.454
He-W 591.05		42 CFR 488.415; 42 CFR 488.454
He-W 591.06		42 CFR 488.430-488.444
He-W 591.07		42 CFR 488.442
He-W 591.08		42 CFR 448.442(f)
He-W 591.09		42 CFR 488.330; 42 CFR 488.454
He-W 591.10		42 CFR 488.454
He-W 591.11 (a) and (b)		RSA 541-A:31
He-W 591.11(c)		42 CFR 431.153(g)
He-W 591.11(d)		42 CFR 488.404(b), 42 CFR 431.151(d)
He-W 591.11(e)		42 CFR 488.438
He-W 591.11(f)		42 CFR 431.151(c)
He-W 591.11(g) – (k)		RSA 541-A:31
He-W 591.11(l)		42 CFR 488.438 (e) and (f)
He-W 591.11(m)		RSA 541-A:31
He-W 591.12 (a) – (c)		RSA 541-A:31
He-W 591.12 (d)		42 CFR 431.153(k)
He-W 591.13		42 CFR 488.426
He-W 591.14		42 CFR 488.452
He-W 593.01		RSA 541-A:7; RSA 161:4, VI(a)
He-W 593.02 - 593.34		RSA 161:4, VI(a); 1902 (a)(13) of the SSA
He-W 593.35		1902 (a)(13) of the SSA, RSA 161:4, VI(a)
He-W 593.36		RSA 161:4, VI(a), 1902 (a)(13) of the SSA
He-W 593.37		1902 (a)(13) of the SSA, RSA 161:4, VI(a)
He-W 593.38 - 593.40		RSA 161:4, VI(a), 1902 (a)(13) of the SSA
He-W 593.41		RSA 541-A:31-36
He-W 593.42		RSA 161:4,VI(a), 1902 (a)(13) of the SSA