DAR File No. 31135

Health, Health Care Financing, Coverage and Reimbursement Policy

R414-40

Nursing Service

NOTICE OF PROPOSED RULE

DAR File No.: 31135
Filed: 04/10/2008, 04:38
Received by: NL

RULE ANALYSIS

Purpose of the rule or reason for the change:

The current rule is repealed because it is necessary to delete inaccurate references to the Nurse Practitioner Prescriptive Practice Act and Nurse Practice Act. The new rule is reenacted to clarify authority, prior authorization, eligibility, access requirements, service coverage, and reimbursement for private duty nursing services to Medicaid recipients. The new rule allows for a better allocation of private duty nursing services among Medicaid recipients.

Summary of the rule or change:

The repealed rule contains antiquated references and citations. The new rule updates and restates the existing program in clearer, simpler language. For example, it clarifies prior authorization requirements and details coverage, limitations, and exclusions for private duty nursing service and establishes reimbursement methodology. The reenacted rule also clarifies that private duty nursing service is available to children under the age of 21 who are either in transition from the hospital to the home or who are ventilator dependent. The new rule further clarifies consultation procedures before the private duty nurse attempts to wean the patient from a device or service and identifies new problems.

State statutory or constitutional authorization for this rule:

Sections 26-18-3 and 26-1-5, and Title 58, Chapter 31b, and 42 CFR 440.80

Anticipated cost or savings to:

the state budget:

Medicaid currently hires all the private duty services available to it in the marketplace. This rule does not reduce or increase the amount of private duty nursing provided by Medicaid to the public. There is no budget impact because there is only a redistribution of resources to cover Medicaid recipients who do not have access to private duty nursing services. The amendments allow Medicaid to provide enhanced assessments and service to a greater number of Medicaid recipients and their families. The allocation of resources to provide these services is ongoing and there is no cost or savings to the state.

local governments:

There is no budget impact because local governments do not fund or provide private duty nursing services in the home.

small businesses and persons other than businesses:

Medicaid currently hires all the private duty services available to it in the marketplace. There is no impact to other persons and small businesses in the aggregate because the amendment only redistributes resources to cover Medicaid recipients who do not have access to private duty nursing services. This will require that some Medicaid recipients will receive less hours of private duty nursing than they currently receive. The amended rule allows Medicaid to provide enhanced assessments and service to a greater number of Medicaid recipients and their families. Some Medicaid recipients will receive less private duty services while others will receive more. The allocation of resources to provide these services is ongoing and there is no increase or loss in revenue to providers.

Compliance costs for affected persons:

There are no compliance costs because there is only a redistribution of resources to cover Medicaid recipients who do not have access to private duty nursing services. Some Medicaid recipients will receive less private duty services while others will receive more. The individual impact on any particular Medicaid recipient is highly variable and dependent on the recipient's medical condition and the ability of family caregivers to supplement the private duty nursing services currently provided. Medicaid believes that no Medicaid recipient will need to hire any independent private duty nurse to provide services that Medicaid reallocates because of the new rule.

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

Businesses providing private duty nursing are not expected to see a negative fiscal impact, but this will be carefully evaluated after public comment is received. David N. Sundwall, MD, 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:

06/02/2008

Interested persons may attend a public hearing regarding this rule:

5/29/2008 at 3:00 PM, Cannon Health Bldg, 288 N 1460 W, Room 125, Salt Lake City, UT

This rule may become effective on:

06/09/2008

Authorized by:

David N. Sundwall, Executive Director

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

R414-40. Private Duty Nursing Service.

[R414-40-1. Policy Statement.

A. Nursing encompasses care and services necessary to maintain or restore health; prevent illness; care for the sick, injured, infirm; and provide support and comfort for the dying patient and his family.

B. General and specialized nursing service is provided consistent with nursing practice as defined in Title 58, Chapter 31 and 31a, Utah Code Annotated, and with all relevant federal statutes, rules and regulations.

 

R414-40-2. Authority and Purpose.

A. Authority

1. Private duty nursing service is an optional Title XIX program authorized by Section 1901 et seq., of the Social Security Act, Section 1905(a)(8) of the Social Security Act and 42 CFR 440.80.

2. Nursing Service provided to an eligible pregnant woman or a child under the age of 21 by a certified pediatric or family nurse practitioner practicing within the scope of practice as defined by State Law is a mandatory Title XIX program authorized by The Omnibus Budget Reconciliation Act of 1989 (OBRA-89) section 6401 (H.R. 3299, P.L. 101-329).

3. This rule is also authorized by Utah Code Annotated (1953) Sections 26-1-5 and 26-18-3.

B. Purpose

1. Private Duty nursing service is designed to prevent prolonged institutionalization and meet the needs of a special group of ventilator dependent, EPSDT (CHEC) eligible children by providing this service in the home for a period of time essential to meet medically necessary care needs, and to supervise and develop confidence in family caregivers responsible for care of the child. The quality and cost effectiveness of home care and private duty nursing must be considered in relation to other alternatives for care.

2. Pediatric or family nurse practitioner services are authorized for the purpose of expanding the pool of obstetric and pediatric care providers to assure that adequate numbers of ambulatory (non-institutional) obstetric and pediatric care providers will be available to provide appropriate care to those pregnant women mandated for Medicaid coverage at specified poverty levels, and to children eligible to receive EPSDT (CHEC) services.

 

R414-40-3. Definitions.

A. In addition to the definitions related to nursing and nursing practice specified in the Nurse Practice Act and the Nurse Practitioner Prescriptive Practice Act, Title 58, chapters 31 and 31a, Utah Code Annotated, the following definitions apply specifically to this rule:

1. "Obstetric care" means ambulatory, non-institutional services covered by the State Plan which are provided to a pregnant woman by a certified family nurse practitioner.

2. "Pediatric care" means ambulatory, non-institutional services covered by the State Plan which are provided to a child under age 21 by a certified pediatric or family nurse practitioner.

3. "Pediatric or family nurse practitioner services" means service provided by a certified nurse practitioner who by reason of advanced education, experience, and licensure has an enhanced degree of knowledge, skill and competence necessary to provide specialized health care to women and children.

4. "Prescriptive Practice" means the ability to 'prescribe', within criteria established in protocols, during the course of diagnosis and treatment of common health problems. Prescriptive practice is authorized by Title 58, Section 31a Utah Code Annotated, and is a specialized nursing function which can be performed by an advance practice registered nurse licensed under Title 58 Section 31-9.1. Prescriptive practice is based on advanced education, experience, and licensure of the nurse practitioner; an agreement and consultive relationship with a physician who has agreed to provide direction and review on a continuing basis; and on protocols jointly developed by a nurse practitioner and the consulting physician.

5. "Private duty nursing service" means nursing services for patients who require more individual and continuous care than is available from a visiting nurse.

6. "Ventilator dependent" means reliance on a mechanical ventilator to compensate for decreased lung function as a result of respiratory distress syndrome requiring mechanical ventilation soon after birth. The infant is then unable to be weaned from the assisted ventilation during the first month after birth because a more complicated lung problem known as bronchopulmonary dysplasia (BPD) develops. The ventilator dependence is assumed to be prolonged, perhaps up to and beyond two years of age.

7. "Prior authorization" means that degree of approval of payment of services required to be obtained from the Division of Health Care Financing by a licensed provider before the service is provided.

 

R414-40-4. Eligibility Requirements/Coverage.

A. Private duty nursing service is available to categorically and medically needy children.

B. Pediatric or family nurse practitioner services are available to categorically eligible and medically needy children eligible to receive EPSDT (CHEC) services and to categorically eligible and medically needy pregnant women.

 

R414-40-5. Program Access Requirements.

A. Recipients seeking private duty nursing service must be Medicaid eligible, ventilator dependent children under age 21 who meet the criteria established and approved by the Division of Health Care Financing staff and physician consultants.

B. Recipients seeking ambulatory obstetrical care from a family nurse practitioner who is an accepted Medicaid provider must have a verifiable pregnancy and be in need of prenatal care.

C. Recipients seeking ambulatory pediatric care from a pediatric nurse practitioner or a family nurse practitioner who is an accepted Medicaid provider, must be under the age of 21.

 

R414-40-6. Service Coverage.

A. Private duty nursing provides for service to a special group of ventilator dependent, Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Child Health Evaluation and Care (CHEC) eligible children under age 21 who meet established criteria. A highly technical level of skilled nursing care based on specialized training, knowledge, judgment and skill is required to meet the needs of such children. However, such nursing care can be provided in the home by parents or other trained caregivers after learning and providing hands-on care while the child is hospitalized and after a period of orientation and supervision by a private duty nurse in the home.

B. Private duty nursing may be provided:

1. in the individual's home in order to prevent prolonged institutionalization. The service shall be based on a physician's order and a written plan of care specific to needs of the individual, and will be reviewed and recertified every 60 days consistent with Home Health requirements in 42 CFR 440.70, dated October 1988, hereby adopted and incorporated by reference;

2. for a period of time essential to meet medically necessary care needs and develop confidence in family caregivers. Private duty nursing service needs are expected to decrease over time to minimal, intermittent levels consistent with those in the regular home health program.

C. Certified Pediatric and family nurse practitioners are authorized to perform expanded role functions in addition to all functions appropriate for registered nurses. Pediatric and family nurse practitioner services include a broad range of primary health care services for the promotion and maintenance of health. Appropriate intervention for the management of patient care needs is essential, shall be based on established nursing or health care standards, and shall include but not be limited to:

1. establishing a medical, family and social history;

2. completing a physical examination;

3. ordering diagnostic and laboratory procedures;

4. assessing findings and complaints;

5. evaluating health status;

6. identifying problems;

7. establishing a diagnosis;

8. planning, implementing, and evaluating a treatment program according to established standards of health care;

9. prescribing drug therapy according to standard medical practice and in accordance with the Nurse Practitioner Prescriptive Practices Act;

10. providing emergency care;

11. collaborating with other health care professionals;

12. assisting clients to access community resources;

13. initiating and maintaining medical and legal records;

14. supporting and counseling clients on compliance with treatment plans; and

15. making appropriate referrals to meet client needs.

D. Pediatric and family nurse practitioners may provide service as independent or private practitioners or as part of a group practice in a private office, a community health center, or a local health department.

E. Prescriptive practice privileges must be part of the licensure of the pediatric nurse practitioner or the family nurse practitioner providing service in this program to assure a comprehensive level of service.

 

R414-40-7. Standards of Care.

A. Private duty nursing service shall be provided in accordance with 42 CFR 440.80, dated October 1988, which is hereby adopted and incorporated by reference.

B. High quality, cost-effective care and safe environment for the child in the home may be provided only through adequate training, knowledge, judgment, and skill of the registered nurse or licensed practical nurse licensed in the State of Utah in accordance with Title 58, Chapter 31 Utah Code Annotated.

C. Pediatric nurse practitioner and family nurse practitioner services shall be provided in accordance with standards of practice defined in the rules promulgated pursuant to the provisions of the Utah Nurse Practice Act, Title 58, Chapters 31 and 31a, Utah Code Annotated, "and to protect the public in relation to the practice of nursing."

 

R414-40-8. Limitations.

A. Private duty nursing service may be provided only through a certified home health agency or by a nurse properly licensed by the State of Utah and enrolled as a provider for the Utah Medicaid Program.

B. Private duty nursing service may be provided only to ventilator dependent, EPSDT (CHEC) eligible individuals under age 21 who meet established criteria.

C. Private duty nursing service may be provided only through a physician's written orders on which a plan of care specific to the needs of the individual is developed and prior authorized.

D. Private duty nursing service may be provided in the home for a period of time essential to meet medically necessary care needs, supervise and develop confidence in family caregivers.

E. Private duty nursing service may be provided on the basis of a reasonable expectation that the care and the service needs of the child can be met adequately by the private duty nurse in the recipient's home.

F. Private duty nursing hours will be monitored and approved through a weekly utilization review and evaluation, by telephone, with Division of Health Care Financing staff, the private duty nurse/home health agency and in consultation with the primary care pediatrician responsible for medical management of the patient.

G. Only approved services essential to the care of pregnant women and the care of children under the age of 21 may be provided as covered Medicaid services by pediatric and family nurse practitioners in private practice.

 

R414-40-9. Prior Authorization.

A. Prior authorization is required for private duty nursing service provided after January 1, 1989.

B. Prior authorization requests shall be evaluated through the use of criteria developed and approved by the Division of Health Care Financing staff and physician consultants.

 

R414-40-10. Reimbursement of Services.

A. Reimbursement for nursing services shall be provided as documented in the Utah State Medicaid Plan, Attachment 4.19-B.

B. When service is provided by a certified licensed nurse practitioner working under supervision in a group practice, in a private office, community health center, or local health department, the supervising provider shall bill according to his authorized fee schedule.

C. When service is provided by a certified licensed nurse practitioner working in a private or independent practice, the certified licensed nurse practitioner shall bill according to his authorized fee schedule.]

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 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) 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.

 

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: [m]Medicaid

Date of Enactment or Last Substantive Amendment: [1991]2008

Notice of Continuation: November 22, 2005

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