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.