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
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.
Medicaid Pharmacy Prior Authorization Programs Update
On July 23, 2020, the New York State Medicaid Drug Utilization Review Board recommended changes to the Medicaid pharmacy prior authorization programs. The Commissioner of Health has reviewed the recommendations of the Board and has approved changes to the Preferred Drug Program within the fee-for-service pharmacy program.
Effective October 8, 2020, prior authorization requirements will change for some drugs in the following PDP classes:
- Non-Steroidal Anti-Inflammatory Drugs
- Immunosuppressive, Oral
- Phosphate Binders/Regulators
- Hepatitis C Agents – In addition to the standard clinical criteria for non-preferred products, all products require prior authorization if there is no evidence of a Federal Drug Administration -approved or compendia-supported diagnosis in history or if the patient is being retreated.
Detailed information on the DUR Board can be found at: .
Information on the Medicaid FFS Pharmacy Prior Authorization Programs, including a full-listing of drugs subject to the Medicaid FFS Pharmacy Programs can be found at: .
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Private Duty Nursing Providers
Effective October 1, 2020, New York State Medicaid will increase private duty nursing fee-for-service rates for Licensed Home Care Agencies , Independent Registered Nurses and Licensed Practical Nurses who enroll in the Private Duty Nursing Directory for Medically Fragile Children . The enhanced fee will be implemented over a period of three years. These changes were authorized in the Fiscal Year 2021 enacted budget.
The enhancements include, but are not limited to:
- increasing Medicaid fee-for-service rates of payment over three years for providers who participate in the PDN Directory
- increasing the maximum age of coverage under the PDN program for MFC from 21 years to 23 years
- moving from county-based fees to State level-based fees
- establishing upstate and downstate regional fees and
- creating a new PDN Directory on the New York State Department of Health web site. The purpose of the Directory is to ensure adequate access to PDN services by promoting the availability and ensuring delivery of PDN services for MFC up to the age of 23.
In order to assist providers and interested parties in staying up-to-date on process changes related to the PDN program, all are encouraged to sign up for the LISTSERV which can be found on the eMedNY website at: . Information on training sessions can also be obtained on the website at: .
Legislative Changes To Private Duty Nursing
- Article VII Amendments to SSL 367r: Private duty nursing services worker recruitment and retention program for Medically Fragile Adults
- PDNs providing services to medically fragile adults will be included in a newly expanded Private Duty Nursing Medically Fragile Children and Adult’s Provider Directory
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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.
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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The Various Types Of Medicaid Home Care In New York State
New York State has a range of Medicaid home care service programs, each oriented toward slightly different needs and sometimes to different populations. These programs are listed below, with links to detailed information posted on this site.
Beginning in September 2012, for ADULTS age 21+ who have Medicare , some of the services listed below can only be accessed by enrolling in a Managed Long Term Care plan. The requirement to enroll in an MLTC plan if one needs long-term home care is being rolled out statewide on a gradual basis – first in New York City in September 2012, then in Long Island and Westchester in January 2013 and Orange and Rockland counties in approximately July 2013.
As of June 2013, most people who do not have Medicare, and who are enrolled in a mainstream Medicaid managed care plan, must access the following home care services through their managed care plan. This includes personal care, Consumer-directed personal assistance, certified home health care, and private duty nursing services.
The different home care services programs are as follows. Click on the hyperlinks for more information.
This chart summarizes some of the key differences between the programs.
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.
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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Documentation Of School Nurse Services On An Iep
When the student’s CPSE/CSE determines that school health services or school nurse services are a required related service for a particular student in order to allow such student to benefit from special education programs and services and enable the student to receive FAPE, those services must be documented within the student’s IEP and be provided at no cost to the parents. Depending on the nature of the nursing services, the documentation in the student’s IEP could, as appropriate to the individual student’s needs, be included as follows:
Due to the frequency of changes to orders for nursing treatment and/or medications, the specific nursing service and/or medication to be provided should not be detailed in the IEP. The nursing treatment and/or medication orders are documented on an Individualized Health Plan , which is a nursing care plan developed by an RN. The IHP is maintained in the student’s cumulative health record to direct nursing care provided and is updated as necessary.
New York State Assembly
|Amd §367-r, Soc Serv L amd §3614, Pub Health L|
|Provides increased rates for private duty nursing services that are provided to medically fragile adults to ensure adequate access to such services applies to private duty nursing services provided to medically fragile adults by fee-for-service private duty nursing services providers who enroll and participate in the applicable provider directory.|
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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 member’s 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 provider’s 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.
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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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 .
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 “Prior Approval Change Request Form”. 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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What Is The Difference Between Private Duty Home Care & Medicare/medicaid
As costs for in-patient health care services rise, there has been a systemic shift towards the use of private duty home care agencies. While the basic services offered through a private duty agency are similar to Medicare and Medicaid-funded home care services, there are some major differences in service delivery, revenue and the overall experience between private and government-funded care.
Medically Fragile Children And Adult Pdn Program
- Effective April 1, 2022, the PDN Medically Fragile Children´s Program expanded to the Medically Fragile Children and Adult Program. The Program consists of two components with corresponding financial enhancements for provider participation
- Private Duty Nursing Medically Fragile Children and Adult Training and Experience
- Private Duty Nursing Medically Fragile Children and Adult Provider Directory
- Providers can choose to enroll in one or both components of the Medically Fragile Children and Adult Private Duty Nursing Program
- Re-enrollment into each of these program components will be necessary every five years during a provider´s routine Provider Enrollment Revalidation Process
- Eligible providers:
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Fape Responsibility For School Nurse Services
The Individuals with Disabilities Education Act requires that FAPE be made available to students with disabilities through the provision of special education and related services, including school health services and school nurse services. For some students, nursing services, including the assignment of a full-day one-to-one nurse, may be a required related service for the student to receive FAPE footnote 2. Additionally, students may need nursing services to attend school in accordance with Section 504 of the Rehabilitation Act of 1973 and the Americans with Disabilities Act. If it is determined that school health services and/or school nurse services, including assignment of a full-day one-to-one nurse, are required related services for a student with a disability, those services must be provided at no cost to the parents and are the fiscal and programmatic responsibility of the school district of residence.
Considerations For Determining If A Student With A Disability Needs Full
The CPSE/CSE determination as to whether a student needs school health services or school nurse services as a required related service to receive FAPE must be made on an individual basis. This decision should include the student’s parent. The types and amounts of services to be provided must be individually determined based on each student’s unique needs and documented within the student’s IEP. In developing an IEP, the CPSE/CSE must consider current evaluation information about the student.
The decision to recommend a full-day one-to-one nurse must weigh the factors of both the student’s individual health needs and what specific school health and/or school nurse services are required to meet those needs. There are a number of important considerations that must be made by the CPSE/CSE in determining if a student needs a full-day one-to-one nurse. These include, but are not limited to, consideration of each of the following :
- The complexity of the student’s individual health needs and level of care needed during the school day to enable the student to attend school and benefit from special education
- The qualifications required to meet the student’s health needs
- The student’s proximity to a nurse
- The building nurse’s student case load and
- The extent and frequency the student would need the services of a nurse .
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