Benefits Of Private Duty Vs Medicare/medicaid Home Care
As a care provider, working on a private-pay basis offers many advantages. Private duty home care agencies have complete control over their margins, which makes this service delivery model far more appealing than working as a government-contracted agency.
Private duty home care agencies are also free to offer a broad range of non-medical services to their clients, such as homemaking, companion care and ongoing personal care, regardless of whether or not the client is recovering from an injury or illness. Additionally, home care agencies are able to provide around-the-clock care upon request, which can mean increased revenue and better service delivery for clients who want to use home care services as an alternative to a senior care facility.
There are also financial benefits to take into account. Its a common misconception that not servicing Medicare/Medicaid can remove Private Duty agencies from earning profits from a larger home care market. While this may be the case for some, Nurse Next Door is a premium home care brand delivering a premium experience and our Franchise Partners are able to charge a premium price to provide it. When you consider that the profit margins on Medicare/Medicaid arent as substantial as some may believe, and that private duty home care agencies are able to set their own pricing, its clear that working on a private-pay basis can also have its financial advantages.
Pdn Mfca Program Fee Enhancements
- Fee enhancements applied for each component:
- Medically Fragile Children and Adult Training and Experience
- Already an option for medically fragile children. Nurse/Agency enrolls in the program by attesting to medically fragile children and adult training and/or experience
- 30% fee enhancement to be calculated at claims processing
Doh Increasing Private Duty Nursing Rate
Situation Report | September 14, 2020
The state Department of Health is making rate enhancements to fee-for-service Private Duty Nursing for medically fragile children.
The announcement was made during DOHs monthly Managed Care Policy and Planning meeting.
HCA has long worked to improve the rate that Medicaid pays for private duty nursing, working with our association pediatric home care services providers who have informed our advocacy seeking functional, sustainable and necessary rate updates.
HCA welcomes the Departments progress in this direction and will continue to consult with member providers on PDN rate adequacy.
Rate details
Beginning October 1, 2020, DOH will be moving from county-based fees to two regional fees. Eligibility has also been expanded to include all members up to the age of 23.
The Medically Fragile Childrens PDN program will now consist of two components with corresponding financial rate enhancements for provider participation beginning .
Providers of pediatric continuous PDN services will receive an enhanced rate of 30 percent added to the approved standard hourly rate for participation in the PDN Medically Fragile Children Training and Experience component.
Participation in the directory indicates the willingness to accept inquiries for providing care to medically fragile children. The directory, updated weekly, will be searchable by name, licensure, city and county.
For further background, see the DOH slide presentation here.
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Guide To Accessing Medicaid Private Duty Nursing Services In The Community
What are private duty nursing services?
Private duty nursing services are nursing services for Medicaid members who require more individual and continuous nursing care than is available from a certified home health agency . A CHHA may provide nursing services only on a part-time or intermittent basis, generally fewer than two hours per service authorization. A Medicaid member may be appropriate for private duty nursing services if he or she requires nursing services that exceed the amount and scope of nursing services that a CHHA may provide. Private duty nursing services are not warranted for non-skilled tasks such as, but not limited to, turning and positioning, ambulation, transferring, bathing, toileting, oral feeding, dressing, and household chores. The intention of PDN services is to support – not replace – the skilled care provided to a member by parents, family, and other responsible caregivers. Commitment by the family and community are necessary to meet the member´s needs and to ensure the member can remain safely at home.
Who can provide private duty nursing services?
Private duty nursing services may be provided by Licensed Home Care Agencies or independently practicing RNs or LPNs who are enrolled with New York State Medicaid.
How does a Medicaid member in the community obtain private duty nursing services?
Is there a list of Medicaid private duty nursing providers for medically fragile children and adults?
Medicaid Income Limits In New York
If you are disabled, blind, or 65 or older, you can qualify for Medicaid if your monthly income in 2018 is $842 or less for a household of one or $1,233 for a couple.
New York’s Excess Income Program does allow individuals to qualify for Medicaid by spending down their income on qualifying medical expenses until they reach Medicaid income limits. For example, if your income is $1,000/month, but you spend $300/month on medical expenses, then you qualify for Medicaid because you are spending down $300 to bring you under the $842 income cap.
New York also has a program in which you can pay your extra income to the Department of Social Services in order to maintain Medicaid eligibility. In addition, New York allows individuals of any age to establish pooled income trusts to set aside excess income and still qualify for Medicaid. For more information about pooled income trusts, read Nolo’s article on putting income in a pooled trust to qualify for Medicaid or consult an attorney.
If you are considering a nursing home stay, remember that New York Medicaid requires nursing home residents to contribute almost all of their monthly income to the cost of their nursing home care. The state allows Medicaid recipients in nursing homes to keep only $50 per month for themselves.
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The Need To Bill Third
Third-party insurers, including Medicare, provide reimbursement for various dental procedures. Since Medicaid is the payer of last resort, the provider must bill the memberâs third-party payers prior to requesting payment from Medicaid. If the third party is a commercial plan, Medicaid will reimburse the difference only if the total third-party payment is less than the lesser of the providerâs fee charged to the general public or the fee developed by New York State Department of Health for the specific procedure code. If the third party is a Medicare Advantage plan, Medicaid will reimburse eighty-five percent of the patient responsibility. Prior to initiating treatment which has been approved by a third-party insurance plan, the provider should obtain a prior approval from Medicaid to ensure that the treatment plan falls within the current guidelines of the Medicaid Program. Failure to do so may result in the denial of Medicaid benefits for these services.
Medicaid Resource Limits In New York
To qualify for non-MAGI Medicaid, the kind of Medicaid that will cover long-term care services, you must have few resources. Resources are assets, like money in the bank, retirement accounts, land, and personal property like cars. The resource limit for a single person to qualify for non-MAGI Medicaid is $15,150, and it is $22,200 for a married couple who both want to qualify.
Some property does not count toward the resource limit. For example, you are allowed to have up to $814,000 of equity in your home, and you are also allowed to exempt one vehicle.
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Doh Announces Private Duty Nursing Rate Enhancement Process For Serving Medically Fragile Children And Adults
Effective April 1, 2022, the New York State Fee-for-Service Medicaid Private Duty Nursing Medically Fragile Childrens Program transitioned to the Medically Fragile Children and Adult Program. FFS Medicaid will offer PDN fee enhancements to all enrolled Medicaid PDN providers and independent Registered Nurses and Licensed Practical Nurses ) who enroll in one or both components of the MFCA Program. The Department of Health advisory is available here.
The two components will consist of the MFCA Training and Experience component and the MFCA Provider Directory component. Enrollment is voluntary, and PDN providers may choose to participate in one or both components to receive the corresponding enhanced fee:
Component 1: FFS PDN MFCA Training and Experience
- Already an option for PDN providers serving medically fragile children
- A PDN provider must enroll in the program by attesting to having completed training and/or experience to care for children and adults in the PDN community
- 30 percent fee enhancement to be calculated at the time of claims processing
- Enrolled providers must indicate a Service Authorization Code of 7 on their claims
- Providers already enrolled in the Medically Fragile Childrens Training and Experience component will not need to re-enroll until they need to revalidate. Revalidation occurs every five years.
Component 2: FFS PDN MFCA Provider Directory
When To Submit A Prior Approval Change Of Request Form
If a change is needed or there exists a disagreement with a prior approval review and there is need to challenge a determination rendered by DOH on an existing finalized prior approval, a request may be submitted with supporting documentation and a detailed report using a âPrior Approval Change Request Formâ. This form may be submitted pre-operatively or post-operatively, if the requested change is submitted post-operatively, a copy of the treatment notes should be included with the request. The Prior Approval Change Request Form can be obtained at: or by calling eMedNY at 3439000.
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Doh Announces Adult Private Duty Nursing Temporary Ffs Medicaid Increase For The Time Period Of 11/1/21
Situation Report | October 25, 2021
The American Rescue Plan Act was signed into law on March 11, 2021. Section 9817 provides a financial increase in Federal Medical Assistance Percentage to state Medicaid programs from April 1, 2021 to March 31, 2022 to supplement existing state expenditures on Home and Community-based Services .
To support and strengthen the Private Duty Nursing direct care workforce, the state Department of Health is investing state and federal monies on a one-time basis to supplement Fee-for-Service Medicaid PDN reimbursement for adult members age 23 and over.
Effective November 1, 2021, FFS Medicaid PDN fees will be raised for members 23 and older for the time period of November 1, 2021 through March 31, 2022.
This increase will be applied to Prior Approvals that receive the current upstate/downstate regional fee . This increase ONLY applies to FFS members receiving PDN services.
The fee increase will be handled through an administrative process by the Office of Health Insurance Programs PDN PA Unit based on the following procedure:
For Prior Approvals that will receive fee increases:
Nursing providers do not need to provide any information or paperwork to receive this enhancement.
The temporary fee increases are as follows:
Questions And Additional Resources
- Enrollment and/or billing questions should be directed to the eMedNY Call Center at 3439000.
- FFS prior approval questions should be directed to the Office of Health Insurance Programs Call Center at 3425000, or via email at or .
- Program updates and news will be posted on the eMedNY website and in upcoming Medicaid Update editions.
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When A Nursing Home Is Medically Necessary In New York
Medicaid will pay for a nursing home only when having access to skilled care is medically necessary. In New York, when you are admitted to a nursing home, an evaluator will meet with you to review all of your medical conditions and your ability to do some activities of daily living like eating, moving between a bed and chair or wheelchair, using the bathroom, and getting around. The evaluator will use a form called a Hospital and Community Patient Review Instrument to assign a particular score to your need for nursing home care. Medicaid uses that information to decide whether you need a nursing home, what kind of nursing home is appropriate for you, and what services Medicaid will pay in the nursing home. In general, for a nursing home to be considered medically necessary, you must have a medical condition that is so serious that you need the level of nursing care that is only available in an institution.
Medicaid For New Yorkers In Nursing Homes
Nursing homes are residential facilities that offer round-the-clock skilled nursing care in addition to other supportive services. People who are sixty-five or older, disabled, or blind, can qualify for Medicaid that will cover a nursing home stay if they meet income and asset limits and if they need skilled nursing care.
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Limited Licensed Home Care Services Agencies
Limited LHCSAs are operated by the certified operator of an adult care facility to directly provide:
- personal care services and related nursing supervision which are not the responsibility of the adult care facility and/or
- application of sterile dressings by a registered professional nurse
- intramuscular and subcutaneous injections by a registered professional nurse and
- all other related nursing tasks associated with the administration of intramuscular and subcutaneous injections or application of sterile dressings.
These services must be pre-approved for each patient by the local Department of Social Services or the New York City Human Resources Administration .
Complaints, questions or concerns about any licensed home care services agencies should be directed to the Home Health Hotline . You can also submit a complaint at .
What Is Private Duty Home Care
Seniors, people living with disabilities and those who need help while recovering from an illness or injury often turn to private duty home care services for assistance. This type of care is provided through an agency, or directly from a private caregiver.
Private duty home care is home care that is delivered on a private-pay basis, which means clients or their families pay either the home care agency or the caregiver. Because the service works on an individual basis, private duty home care services can be customized to meet the unique needs of each client.
Clients who hire a private duty home care provider have the ability to access as much support as they feel they need, without seeking approval from their primary care physician or any other medical professional. With private duty care, there are no eligibility requirements, and clients are free to use the service on a short-term or long-term basis.
Another important distinction of private duty home care is that home care agencies have the flexibility to match caregivers with clients based on skills, preferences and overall compatibility. This flexibility leads to a high level of client satisfaction, and that can help increase profits for the home care agency.
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How Is Private Duty Home Care Different From Medicare And Medicaid
There are significant differences between the type of care available through a private duty home care agency and government-funded home care services.
From the perspective of the client, Medicare and Medicaid-funded home care can be difficult to qualify for, given that there are strict eligibility criteria that must be met. Government-funded home care clients have no say in who their caregiver is, how frequently the caregiver visits, or when visits are provided. In most cases, Medicare and Medicaid home care services are time-limited, and clients who require ongoing care are required to re-qualify for services frequently.
In terms of service delivery, agencies that provide contracted home care services under Medicare or Medicaid often have to deal with significant financial and logistical barriers that limit their ability to achieve and maintain profitability. Government-funded home care services are focused on delivering services at the lowest possible cost, and that often means caregivers cannot deliver the services that the client requires.
From the perspective of a caregiver or home care agency, working with Medicare or Medicaid-funded home care clients involves little to no control over profit margins. Obtaining reimbursement for services rendered can also be challenging, since payments are made through government departments that often involve multiple levels of bureaucracy.
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Eligible Direct Care Workers One
The Current Operations Appropriations Act of 2021 approved a Medicaid budget provision to give a one-time bonus to eligible direct care workers and support staff who provide services to Medicaid and NC Health Choice beneficiaries. The State budget also includes a provision to implement a home- and community-based services and intermediate care facility/individuals with intellectual disabilities DCW wage increase for eligible employees who provide services to Medicaid and NC Health Choice beneficiaries.
Details about the three categories of eligibility criteria can be found in the following NC Medicaid provider bulletins, posted Jan. 14, 2022:
- COVID-19 BULLETIN #212 One-Time Bonus: DCWs and support staff in waiver programs, personal care services, home health and others may be eligible for a one-time bonus.
- COVID-19 BULLETIN #213 ICF-IID Wage Increase: DCWs in Intermediate Care Facilities for Individuals with Intellectual Disabilities may be eligible for a wage increase.
- COVID-19 BULLETIN #214 HCBS Wage Increase: DCWs providing home- and community-based service may be eligible for a wage increase.
NC Medicaid will hold webinars from Jan. 19-25, 2022, to provide an overview of the wage increase and bonus program. Webinar information is located in the provider bulletins listed above.
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