N.J. Admin. Code § 10:60-5.9

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

Section 10:60-5.9 - Limitation, duration, and location of MLTSS/PDN services

(a) MLTSS/PDN services shall be provided in the community only and not in an inpatient hospital or nursing facility setting. Services shall be provided by a registered nurse (RN) or a licensed practical nurse (LPN).

1. Private duty nursing services rendered during hours when the beneficiary's normal life activities take him or her outside the home will be reimbursed. If a beneficiary seeks to obtain MLTSS/PDN services to attend school or other activities outside the home, but does not need such services in the home, there is no basis for authorizing MLTSS/PDN services. Only those MLTSS/PDN beneficiaries who require, and are authorized by the MCO and the MLTSS care manager to receive, private duty nursing services in the home may utilize the approved hours outside the home during those hours when normal life activities take the beneficiary out of the home.

2. Due to safety concerns, the nurse shall not be authorized to engage in non-medical activities while accompanying the client, including the operation of a motor vehicle.

(b) Private duty nursing shall be a covered service only for those beneficiaries enrolled in MLTSS. Under MLTSS, when payment for private duty nursing services is being provided or paid for by another source (that is, insurance), MLTSS shall supplement payment up to a maximum of 16 hours per 24-hour period. The hours approved shall supplement alternative sources of PDN care available, such as medical day care or a school program, including services provided or paid for by the other sources or other insurance available to the beneficiary; shall be medically necessary; and, shall comply with the annual cost threshold.

(c) Private duty nursing services shall be limited to a maximum of 16 hours, including services provided or paid for by other sources, in a 24-hour period, per person in MLTSS. There shall be a live-in primary adult caregiver who accepts 24-hour per day responsibility for the health and welfare of the beneficiary unless the sole purpose of the private duty nursing is the administration of IV therapy.

1. The MLTSS care manager or DMAHS shall conduct an assessment to determine the need for MLTSS/PDN services, the required provider skill level (LPN or RN), and the amount of service required. The number of hours approved and the skill level of services shall be noted in the individual's service plan and be reviewed by the care manager and/or designated DMAHS staff person every six months.

2. The adult primary caregiver must be trained in the care of the individual and agree to meet the beneficiary's skilled needs during a minimum of eight hours of care to the individual during every 24-hour period.

3. In emergency circumstances, for example, when the sole caregiver has been hospitalized or brief post-hospital periods while the caregiver(s) adjust(s) to the new responsibilities of caring for the discharged beneficiary, the MCO or DMAHS may authorize, for a limited time, additional hours beyond the 16-hour limit.

(d) Medical necessity for MLTSS/PDN services shall be based upon the following criteria;

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;

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

iv. The need for other skilled nursing interventions on an ongoing basis.

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

1. Beneficiary observation, monitoring, recording, or assessment;

2. Occasional suctioning;

3. Gastrostomy feedings, unless complicated as described in (d)2ii 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.

(f) The following situational criteria shall be considered, once medical necessity has been established in accordance with (d) above, when determining the extent of the need for MLTSS/ PDN services in addition to the primary caregiver(s) eight-hour responsibility 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 dependent(s) care responsibilities, as well as increased physical or mental demands related to the care of the individual;

2. Additional adult care support within the household; and

3. Alternative sources of nursing care.

(g) In the event that two Medicaid/NJ FamilyCare MLTSS beneficiaries are receiving PDN services in the same household, the beneficiary or legal guardian may elect to have one nurse provide services for both beneficiaries. 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 § 10:60-5.9

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

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