N.M. Admin. Code § 8.320.2.19

Current through Register Vol. 35, No. 20, October 22, 2024

Section 8.320.2.19 - EPSDT PRIVATE DUTY NURSING SERVICES

MAD pays for private duty nursing (PDN) services as part of the EPSDT program, see 42 CFR Section 441.57. Services must be accessed through the tot to teen healthcheck screen. A MAP eligible recipient is under 21 years, who has been referred for PDN services shift care (not intermittent care), must meet the established medically fragile criteria and parameters that have been approved by MAD.

A. EPSDT PDN eligible providers: A nurse working for a MAD approved PDN agency must have a RN or LPN on staff that meets MAD requirements. Services must be furnished under the direction of the MAP eligible recipient's PCP. Certification for participation as a medicare home health agency is not required. The following agencies are eligible to be reimbursed for providing EPSDT PDN services:

(1) a licensed nursing agency; or

(2) a FQHC.

B. EPSDT PDN coverage criteria: PDN services must be furnished by a RN or a LPN in the MAP eligible recipient's home or in his or her school setting if it is medically necessary for school attendance. The goal of the provision of care is to avoid institutionalization and maintain the MAP eligible recipient's function level in a home setting.

(1) EPSDT PDN services are for a MAP eligible recipient under 21 years of age who requires more individual and continuous care than can be received through the MAD home health program.

(2) EPSDT PDN services must be ordered by the MAP eligible recipient's PCP and must be included in his or her approved treatment plan. Services furnished must be medically necessary and be within the scope of the nursing profession. A MAP eligible recipient must have an approved ISP before nursing services can begin. Prior authorization for these services is required.

C. EPSDT PDN treatment plan: The need for skilled nursing services must be included in the MAP eligible recipient's ITP or ISP. The ISP meeting must have been held and the ISP written by the RN or case manager must be approved before nursing services can start. The plan must contain the following:

(1) statement of the nature of the specific problem and the specific needs of the MAP eligible recipient;

(2) description of the functional level of the MAP eligible recipient as documented by the PCP's clinical evaluation, including social, emotional or behavioral health status, intellectual functioning and medical necessity which identify and document the need for a PDN;

(3) specific clinical problems relating to:

(a) physical assessment needs including the identification of durable medical equipment or medical supplies needed by the MAP eligible recipient;

(b) psychosocial evaluation including level of support from family in reaching projected clinical goals; and

(c) medication history including status of compliance of the MAP eligible recipient;

(4) applicable clinical interventions related to the identified clinical problem including measurable goals;

(5) statement of the least restrictive conditions necessary to achieve the goals identified in the plan;

(6) description of intermediate and long-range goals with the projected timetable for their attainment and duration and scope of services, and strengths and priorities of the family and MAP eligible recipient;

(7) statement and rationale of the nursing care plan for achieving these intermediate and long-range goals including provisions for the review and modification of the plan;

(8) specification of nursing responsibilities, description of the proposed nursing care, orders for medication, treatments, restorative and rehabilitative services, activities, therapies, social services, diet and special procedures recommended for the health and safety of the MAP eligible recipient; and

(9) a transition plan that identifies what the plan will be after discharge from PDN services.

D. EPSDT PDN covered services: MAD covers the following PDN services:

(1) skilled nursing services furnished to the MAP eligible recipient's at his or her home; and

(2) skilled nursing services which are medically necessary for attending school and furnished to the MAP eligible recipient in the school setting. These services are an alternative to his or her participation in a homebound program. Nursing services are furnished only to a MAP eligible recipient and not to others in the school setting.

E. EPSDT PDN noncovered services: PDN services are subject to the limitations and coverage restrictions which exist for other MAD services. See Section 14 of this rule for general non-covered MAD EPSDT services or activities.

N.M. Admin. Code § 8.320.2.19

8.320.2.19 NMAC - Rp, 8.323.4 NMAC, 1-1-14