Health, Health Care Financing, Coverage and Reimbursement Policy

Section R414-40-4

Service Coverage for Private Duty Nursing

Notice of Proposed Rule

(Amendment)

DAR File No.: 35303
Filed: 09/29/2011 11:07:37 AM

RULE ANALYSIS

Purpose of the rule or reason for the change:

The purpose of this change is to clarify Medicaid policy on the number of private duty nursing (PDN) hours that a patient may receive.

Summary of the rule or change:

This change clarifies that the number of PDN hours that a patient may receive depends on how the patient scores on the PDN Acuity Grid. It also removes language that no longer applies to service coverage for PDN patients.

State statutory or constitutional authorization for this rule:

• Section 26-18-3
• Section 26-1-5

Anticipated cost or savings to:

the state budget:

There is no impact to the state budget because this change simply allows for a redistribution of resources to cover Medicaid recipients who do not have access to PDN services. The allocation of resources to provide these services is ongoing so there is no cost or savings to the General Fund.

local governments:

There is no impact to local governments because they do not fund or provide PDN services in the home.

small businesses:

There is no impact to small businesses because this change simply allows for a redistribution of resources to cover Medicaid recipients who do not have access to PDN services. The allocation of resources to provide these services is ongoing so there is no increase or loss in provider revenue.

persons other than small businesses, businesses, or local governmental entities:

There is no impact to Medicaid providers and recipients because this change simply allows for a redistribution of resources to cover recipients who do not have access to PDN services. The allocation of resources to provide these services is ongoing so there is no increase or loss in provider revenue and Medicaid recipients do not incur any out-of-pocket expenses.

Compliance costs for affected persons:

There is no impact to a Medicaid provider or recipient because this change simply allows for a redistribution of resources to cover a recipient who does not have access to PDN services. The allocation of resources to provide these services is ongoing so there is no loss in provider revenue and a Medicaid recipient does not incur any out-of-pocket expenses.

Comments by the department head on the fiscal impact the rule may have on businesses:

No fiscal impact on business, either small or regular, is expected due to this change as private duty nursing services will be allocated through a widely recognized industry standard.

David Patton, PhD, Executive Director

The full text of this rule may be inspected, during regular business hours, at the Division of Administrative Rules, or at:

Health
Health Care Financing, Coverage and Reimbursement Policy
CANNON HEALTH BLDG
288 N 1460 W
SALT LAKE CITY, UT 84116-3231

Direct questions regarding this rule to:

• Craig Devashrayee at the above address, by phone at 801-538-6641, by FAX at 801-538-6099, or by Internet E-mail at cdevashrayee@utah.gov

Interested persons may present their views on this rule by submitting written comments to the address above no later than 5:00 p.m. on:

11/14/2011

This rule may become effective on:

11/21/2011

Authorized by:

David Patton, Executive Director

R414. Health, Health Care Financing, Coverage and Reimbursement Policy.

R414-40. Private Duty Nursing Service.

R414-40-4. Service Coverage for Private Duty Nursing.

(1) Private duty nursing service is a limited benefit that is provided with the expectation that the patient's need for private duty nursing service will decrease over time.

(2) Medicaid covers medically necessary and appropriate private duty nursing service for a limited time to provide skilled nursing care in the home. Medicaid provides private duty nursing service while the private duty nursing service provider trains the recipient's caregivers to provide the necessary care. Once the caregivers have been given sufficient training for the recipient's needs, the private duty nursing service ends. However, a client who still requires more than four hours of ongoing skilled nursing service may receive private duty nursing service as provided in this rule.[ Ventilator dependent recipients who require frequent ventilator checks may receive up to eight hours per day of continued private duty nursing. Ventilator dependency means the recipient requires at least eight continuous hours on the ventilator per day to compensate for decreased lung function.]

(3) The number of private duty nursing (PDN) hours that a patient may receive is based on how the patient scores on the PDN Acuity Grid. The PDN provider shall provide supporting documentation to justify the patient's score. The PDN Acuity Grid must reflect the average daily care given by the nurse during the previous certification period.

[ (3) Medicaid covers medically necessary and appropriate private duty nursing for the following. To receive these services, a patient must be in transition from the hospital, be ventilator dependent, or be a patient with a tracheostomy who is unable to manage secretions:

(a) tracheostomy care;

(b) total parenteral nutrition;

(c) intravenous therapy where a single intravenous therapy infusion takes at least four continuous hours and requires monitoring and treatment by a skilled nurse;

(d) decubitus ulcer care for stage three or four ulcers;

(e) colostomy or ileostomy care;

(f) suprapubic catheter care;

(g) continuous nasogastric or gastrostomy tube feeding;

(h) mechanical ventilator support;

(i) monitoring a patient on oxygen who experiences frequent oxygen desaturation.

] (4) After informing the recipient's family or similar representatives who live with the recipient and in coordination and consultation with the physician, the private duty nurse shall attempt to wean the patient from a device or service and identify new problems.

(5) Private duty nursing is not covered to provide services solely for the following:

(a) custodial or sitter care to ensure the patient is compliant with treatment;

(b) respite care;

(c) monitoring behavioral or eating disorders; and

(d) observation or monitoring medical conditions that do not require skilled nursing care.

(6) Private duty nursing service is not covered if the service is available from another funding source, agency, or program.

 

KEY: Medicaid

Date of Enactment or Last Substantive Amendment: [June 23, 2008]2011

Notice of Continuation: October 14, 2010

Authorizing, and Implemented or Interpreted Law: 26-1-5; 26-18-3