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The Pennsylvania Code website reflects the Pennsylvania Code changes effective through 53 Pa.B. 6142 (September 30, 2023).

55 Pa. Code § 1249.59. Limitations on payment.

§ 1249.59. Limitations on payment.

 The following limits apply to payment for covered services:

   (1)  Only one fee will be paid per home health agency visit. Payment for a visit pertains to a separate service, by a separate caregiver, to a recipient. More than one visit can be billed to the same recipient on the same day but only for separate care.

   (2)  After the first 28 days of unlimited home health care, payment is limited to the number of home visits specified on the MA Program Fee Schedule. A new period of unlimited care begins following hospitalization, the onset of a new primary diagnosis or the exacerbation of an existing diagnosis which causes a change in the recipient’s condition and requires a change in the plan of treatment, subject to §  1249.52(a)(4) (relating to payment conditions for various services).

   (3)  For prenatal and postpartum care, the following limits apply:

     (i)   Payment for prenatal care is limited to the number of visits specified on the MA Program Fee Schedule. Complications of pregnancy are not counted as prenatal care but are classified for invoicing purposes as acute illness.

     (ii)   Payment for a postpartum visit includes payment for care provided the newborn child.

   (4)  Payment for hypodermic or intramuscular therapy provided during a home visit is included in the visit fee. If this service is provided during a recipient’s visit to the home health agency, the agency will be paid at the rate specified in the MA Program Fee Schedule.


   The provisions of this §  1249.59 issued under sections 403(a) and (b), 443.2(2) and 509 of the Public Welfare Code (62 P. S. § §  403(a) and (b), 443.2(2) and 509).


   The provisions of this §  1249.59 adopted August 12, 1988, effective September 1, 1988, 18 Pa.B. 3571; amended May 11, 2007, effective May 12, 2007, 37 Pa.B. 2185. Immediately preceding text appears at serial pages (251268) to (251269).

Cross References

   This section cited in 55 Pa. Code §  1249.51 (relating to general payment policy).

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