N.J. Admin. Code § 10:60-5.3

Current through Register Vol. 56, No. 21, November 4, 2024

Section 10:60-5.3 - Eligibility for Early and Periodic Screening Diagnosis and Treatment/Private Duty Nursing (PDN) Services

(a) Individuals under 21 years of age who are enrolled in the Medicaid/NJ FamilyCare programs, and who require private duty nursing services, which will allow them to be cared for in a community setting, may be referred for EPSDT/PDN services.

1. Individuals eligible for Medicaid services through the Medically Needy program are not eligible for EPSDT services, in accordance with 10:49-5.3(a)2.

2. For individuals who are enrolled in Medicaid/NJ FamilyCare managed care, private duty nursing is authorized and provided by the MCO.

(b) An individual must exhibit a severity of illness that requires complex skilled nursing interventions on an ongoing basis, to be considered in need of EPSDT/PDN services.

1. "Ongoing" means that the beneficiary needs skilled nursing intervention 24 hours per day/seven days per week.

2. "Complexity" means the degree of difficulty and/or intensity of treatment/procedures.

3. "Skilled nursing interventions" means procedures that require the knowledge and experience of licensed nursing personnel, or a trained primary caregiver.

(c) EPSDT/PDN services are only appropriate when the following requirements are satisfied:

1. There is a capable adult primary caregiver residing with the individual who accepts ongoing 24-hour responsibility for the health and welfare of the beneficiary;

2. The adult primary caregiver agrees to be trained or has been trained in the care of the beneficiary and agrees to receive additional training for new procedures and treatments, if directed to do so by a State agency; and

3. The home environment can accommodate the required equipment and licensed PDN personnel.

N.J. Admin. Code § 10:60-5.3

Amended by 50 N.J.R. 1992(b), effective 9/17/2018