Current through Register Vol. 35, No. 18, September 24, 2024
MAD pays for private duty nursing (PDN) services as part of
the EPSDT program, see
42 CFR Section
441.57. Services must be accessed through the
tot to teen healthcheck screen. A MAP eligible recipient is under 21 years, who
has been referred for PDN services shift care (not intermittent care), must
meet the established medically fragile criteria and parameters that have been
approved by MAD.
A. EPSDT PDN eligible
providers: A nurse working for a MAD approved PDN agency must have
a RN or LPN on staff that meets MAD requirements. Services must be furnished
under the direction of the MAP eligible recipient's PCP. Certification for
participation as a medicare home health agency is not required. The following
agencies are eligible to be reimbursed for providing EPSDT PDN services:
(1) a licensed nursing agency; or
(2) a FQHC.
B. EPSDT PDN coverage criteria: PDN services
must be furnished by a RN or a LPN in the MAP eligible recipient's home or in
his or her school setting if it is medically necessary for school attendance.
The goal of the provision of care is to avoid institutionalization and maintain
the MAP eligible recipient's function level in a home setting.
(1) EPSDT PDN services are for a MAP eligible
recipient under 21 years of age who requires more individual and continuous
care than can be received through the MAD home health program.
(2) EPSDT PDN services must be ordered by the
MAP eligible recipient's PCP and must be included in his or her approved
treatment plan. Services furnished must be medically necessary and be within
the scope of the nursing profession. A MAP eligible recipient must have an
approved ISP before nursing services can begin. Prior authorization for these
services is required.
C.
EPSDT PDN treatment plan: The need for skilled nursing services must be
included in the MAP eligible recipient's ITP or ISP. The ISP meeting must have
been held and the ISP written by the RN or case manager must be approved before
nursing services can start. The plan must contain the following:
(1) statement of the nature of the specific
problem and the specific needs of the MAP eligible recipient;
(2) description of the functional level of
the MAP eligible recipient as documented by the PCP's clinical evaluation,
including social, emotional or behavioral health status, intellectual
functioning and medical necessity which identify and document the need for a
PDN;
(3) specific clinical problems
relating to:
(a) physical assessment needs
including the identification of durable medical equipment or medical supplies
needed by the MAP eligible recipient;
(b) psychosocial evaluation including level
of support from family in reaching projected clinical goals; and
(c) medication history including status of
compliance of the MAP eligible recipient;
(4) applicable clinical interventions related
to the identified clinical problem including measurable goals;
(5) statement of the least restrictive
conditions necessary to achieve the goals identified in the plan;
(6) description of intermediate and
long-range goals with the projected timetable for their attainment and duration
and scope of services, and strengths and priorities of the family and MAP
eligible recipient;
(7) statement
and rationale of the nursing care plan for achieving these intermediate and
long-range goals including provisions for the review and modification of the
plan;
(8) specification of nursing
responsibilities, description of the proposed nursing care, orders for
medication, treatments, restorative and rehabilitative services, activities,
therapies, social services, diet and special procedures recommended for the
health and safety of the MAP eligible recipient; and
(9) a transition plan that identifies what
the plan will be after discharge from PDN services.
D. EPSDT PDN covered services: MAD covers the
following PDN services:
(1) skilled nursing
services furnished to the MAP eligible recipient's at his or her home;
and
(2) skilled nursing services
which are medically necessary for attending school and furnished to the MAP
eligible recipient in the school setting. These services are an alternative to
his or her participation in a homebound program. Nursing services are furnished
only to a MAP eligible recipient and not to others in the school
setting.
E. EPSDT PDN
noncovered services: PDN services are subject to the limitations and coverage
restrictions which exist for other MAD services. See Section 14 of this rule
for general non-covered MAD EPSDT services or activities.
