R414.  Health, Health Care Financing, Coverage and Reimbursement Policy.
R414-40.  Private Duty Nursing Service.
R414-40-1.  Introduction and Authority.
	(1)  This rule outlines eligibility, access requirements, coverage, limitations, and reimbursement for private duty nursing.  This rule is authorized by Sections 26-1-5 and 26-18-3.
	(2)  Private duty nursing service is an optional Title XIX program authorized by 42 U.S.C. Sec. 1396 et seq., 42 U.S.C. Sec. 1396d(a)(8) and 42 CFR 440.80.

R414-40-2.  Recipient Eligibility Requirements.
	ESPDT eligible children who are under age 21 and who are either in transition from the hospital to the home or who are ventilator dependent are eligible for private duty nursing service.  The recipient must require greater than four hours of continuous skilled nursing care per day.

R414-40-3.  Program Access Requirements.
	(1)  Only a licensed home health agency enrolled as a Medicaid provider may be reimbursed for private duty nursing service.
	(2)  A recipient must have a written physician order establishing the need for private duty nursing service.  The private duty nursing provider must develop a plan of care consistent with the recipient diagnosis, severity of illness, and intensity of service.  The patient must require more than four hours of skilled nursing service.  If medically necessary nursing service requires four hours or less of skilled nursing, the service is covered under the home health program.
	(3)  Medicaid providers shall submit an initial prior authorization request with medical documentation that demonstrates the need for nursing service.  The home health agency shall submit an initial certification and a recertification at least every 60 days as required by 42 CFR 440.70.
	(4)  Private duty nursing is only available if a parent, guardian, or primary caregiver is committed to and capable of performing the medical skills necessary to ensure quality care.
	(5)  The home health agency shall verify that the hospital has provided specialized training for the caregiver before patient discharge to enable the caregiver to provide hands-on care in the home.  The private duty nurse initially supervises the caregiver who provides this care to ensure that training has been assimilated to ensure safe, quality patient care.

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.
	(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.
	(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.

R414-40-5.  Reimbursement of Services.
	(1)  Medicaid reimburses nursing service in accordance with the Utah Medicaid State Plan, Attachment 4.19-B.
	(2)  A private duty nurse caring for two patients in the home shall bill with the UN modifier.
	(3)  A provider shall not charge the Department a fee that exceeds the provider's usual and customary charges for the provider's private pay patients.

KEY:  Medicaid
Date of Enactment or Last Substantive Amendment:  December 1, 2011
Notice of Continuation:  July 16, 2015
Authorizing, and Implemented or Interpreted Law:  26-1-5; 26-18-3