N.J. Admin. Code § 10:60-5.4

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

Section 10:60-5.4 - Limitation, duration, and location of EPSDT/PDN

(a) The following requirements shall apply to EPSDT/PDN services:

1. Private duty nursing shall be provided for eligible FFS beneficiaries in the community only and not in hospital inpatient or nursing facility settings.

2. DMAHS shall determine and approve the total PDN hours for reimbursement, in accordance with N.J.A.C. 10:60-5.2(b).

3. The determination of the total EPSDT/PDN hours approved shall take into account the primary caretaker's ability to provide care, as well as alternative sources of PDN care available to the caregiver, such as medical day care or a school program.

4. In emergency situations, for example, when the sole caregiver has been hospitalized, DMAHS may authorize, for a limited time, additional hours beyond the authorized amount.

5. DMAHS may also approve, for a limited time, additional hours when a change in the child's medical condition requires additional training for the primary caregiver to address changes in the care needs of the beneficiary.

(b) Medical necessity for EPSDT/PDN services shall be based upon, but may not be limited to, the following criteria in (b)1 or 2 below:

1. A requirement for all of the following medical interventions:

i. Dependence on mechanical ventilation;

ii. The presence of an active tracheostomy; and

iii. The need for deep suctioning; or

2. A requirement for any of the following medical interventions:

i. The need for around-the-clock nebulizer treatments, with chest physiotherapy;

ii. Gastrostomy feeding when complicated by frequent regurgitation and/or aspiration; or

iii. A seizure disorder manifested by frequent prolonged seizures, requiring emergency administration of anti-convulsants.

(c) The following situational criteria shall be considered, once medical necessity has been established in accordance with (b) above, when determining the extent of the need for EPSDT/ PDN services and the authorized hours of service:

1. Available primary care provider support.

i. Determining the level of support should take into account any additional work related or sibling care responsibilities, as well as increased physical or mental demands related to the care of the beneficiary;

2. Additional adult care support within the household; and

3. Alternative sources of nursing care.

(d) Services that shall not, in and of themselves, constitute a need for PDN services, in the absence of the skilled nursing interventions listed in (b) above, shall include, but shall not be limited to:

1. Patient observation, monitoring, recording or assessment;

2. Occasional suctioning;

3. Gastrostomy feedings, unless complicated as described in (b)1 above; and

4. Seizure disorders controlled with medication and/or seizure disorders manifested by frequent minor seizures not occurring in clusters or associated with status epilepticus.

(e) Private duty nursing shall be a covered service only for those beneficiaries covered under EPSDT/PDN.

(f) Private duty nursing services shall not include respite or supervision, or serve as a substitution for routine parenting tasks.

(g) In the event that two Medicaid/NJ FamilyCare beneficiaries are receiving PDN services in the same household, the family may elect to have one nurse provide services for both children. The agency providing the nursing services shall document that having one nurse does not pose a health risk to either beneficiary in the plan of care which shall be signed by the physician/practitioner. At no time shall a nurse provide care for more than two beneficiaries at the same time in a single household.

N.J. Admin. Code § 10:60-5.4

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

Amended by 54 N.J.R. 1721(a), effective 9/6/2022