Easy Choice Health Plan, Inc. Harmony Health Plan of Illinois, Inc. Missouri Care, Inc. Ohana Health Plan, a plan offered by WellCare Health Insurance of Arizona, Inc. WellCare Health Insurance of Illinois, Inc. WellCare Health Plans of New Jersey, Inc. WellCare Health Insurance of Arizona, Inc. WellCare of Florida, Inc. WellCare of Connecticut, Inc. WellCare of Georgia, Inc. WellCare of Kentucky, Inc. WellCare of Louisiana, Inc. WellCare of New York, Inc. WellCare of South Carolina, Inc. WellCare of Texas, Inc. WellCare Prescription Insurance, Inc. Windsor Health Plan for Medicare Advantage Part D Windsor Rx Medicare Prescription Drug Plan Private Duty Nursing (New Jersey) Policy Number: HS-253 Original Effective Date: 6/18/2014 Revised Date(s): 6/27/2014; 5/7/2015; 6/ /2015 APPLICATION STATEMENT The application of the Clinical Coverage Guideline is subject to the benefit determinations set forth by the Centers for Medicare and Medicaid Services (CMS) National and Local Coverage Determinations and state-specific Medicaid mandates, if any. Clinical Coverage Guideline page 1
DISCLAIMER The Clinical Coverage Guideline is intended to supplement certain standard WellCare benefit plans. The terms of a member s particular Benefit Plan, Evidence of Coverage, Certificate of Coverage, etc., may differ significantly from this Coverage Position. For example, a member s benefit plan may contain specific exclusions related to the topic addressed in this Clinical Coverage Guideline. When a conflict exists between the two documents, the Member s Benefit Plan always supersedes the information contained in the Clinical Coverage Guideline. Additionally, Clinical Coverage Guidelines relate exclusively to the administration of health benefit plans and are NOT recommendations for treatment, nor should they be used as treatment guidelines. The application of the Clinical Coverage Guideline is subject to the benefit determinations set forth by the Centers for Medicare and Medicaid Services (CMS) National and Local Coverage Determinations and state-specific Medicaid mandates, if any. Note: The lines of business (LOB) are subject to change without notice; consult www.wellcare.com/providers/ccgs for list of current LOBs. BACKGROUND Private-duty nursing (PDN), provided by licensed nurses, is defined as individual and continuous care, in contrast to part-time or intermittent care. Nurses can be employed by a licensed, certified home health agency or a licensed, accredited health care service firm. PDN is limited for each beneficiary to a maximum of 16 hours per day from all payment sources. It is to be provided only when there is a live-in primary caregiver (adult relative or significant other adult) who accepts 24-hour responsibility for the health and welfare of the beneficiary. PDN is also a benefit for Core Medicaid in New Jersey for Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) members. For adults, Members must be considered in Managed Long Term Services and Supports (MLTSS) to receive PDN benefits. The purpose of the program is to accommodate long-term chronic or maintenance health care, as opposed to shortterm skilled care as is provided under Medicaid s home health program. PDN services provide individual and continuous nursing care, as different from part-time intermittent care, provided by licensed nurses in the home to beneficiaries under Community Resources for People with Disabilities (CRPD), Home and Community-Based Waiver for Medically Fragile Children (ABC Program), AIDS Community Care Alternatives Program Waiver (ACCAP), as well as eligible EPSDT beneficiaries. PDN services shall be provided by a licensed home health agency, voluntary non-profit homemaker agency, private employment agency and temporary-help service agency approved by the Department of Medical Assistance and Health Services (DMAHS). The voluntary nonprofit homemaker agency, private employment agency and temporary help-service agency shall be accredited, initially and on an ongoing basis, by the Commission on Accreditation for Home Care, Inc., the Community Health Accreditation Program, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) or the National Association for Home Care and Hospice. (New Jersey State Legislature, 2014, 10:60-5.1 Purpose and scope). According to New Jersey MLTSS, PDN shall be a covered service only for those beneficiaries enrolled in MLTSS. When payment for private duty nursing services is being provided or paid for by another source, the MLTSS benefit of private duty nursing hours shall supplement the other source up to a maximum of 16 hours per day, including services provided or paid for by the other sources, if medically necessary, and if cost of service provided is less than institutional care. Service Limitations Per Medical Necessity as defined in the contract. Adult PDN services are provided in the community only (the home or other community setting of the individual), and not in hospital inpatient or nursing facility settings. PDN services are a State Plan benefit for children under the age of 21. For adults over the age of 21, PDN is provided under the MLTSS benefit. Persons meeting nursing facility (NF) level of Care are eligible to receive PDN. PDN criteria are based on medical necessity and is prior approved by the MCO in a plan of care. Home and community-based services waiver / PDN is individual, continuous nursing care in the home, and is a service available to a beneficiary only after enrollment in MLTSS. Clinical Coverage Guideline page 2
POSITION STATEMENT Applicable To: Medicaid (Plan A) New Jersey Medicaid (MLTSS) New Jersey MLTSS Private Duty Nursing is a covered benefit when the following criteria are met: 1. Member is enrolled in Medicaid Plan A or MLTSS; AND, 2. There is a doctor's order to receive this service*; AND, 3. Live in a community based residence (e.g., private home, apartment, rooming house, or boarding home) or group home, skill development home, supervised apartment or other congregate living program where personal care is not provided as a part of the service package included in the living arrangement; AND, 4. Have a documented need for hands-on personal care. * To receive PDN services, the member does not have to be permanently disabled. Services for Children Through Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Legislature, 2014 New Jersey State To be considered for EPSDT / PDN services, the member must meet the following criteria ( 10:60-5.2): Shall be under 21 years of age; AND, Enrolled in the Medicaid / NJ FamilyCare fee-for-service program; AND, Referred by a parent, primary physician, hospital discharge planner, Special Child Health Services case manager, Division of Developmental Disabilities (DDD), Division of Disability Services (DDS), Division of Youth and Family Services (DYFS), Division of Mental Health Services (DMHS) or current PDN provider; AND, Exhibits a severity of illness that requires complex skilled nursing interventions on an ongoing basis, to be considered in need of EPSDT/PDN services. "Ongoing" means that the beneficiary needs skilled nursing intervention 24 hours per day/seven days per week. "Complexity" means the degree of difficulty and/or intensity of treatment/procedures. "Skilled nursing interventions" means procedures that require the knowledge and experience of licensed nursing personnel, or a trained primary caregiver. Requests for services shall be submitted to the using a "PDN Services" form, incorporated herein by reference. The Request shall be completed signed by the referring physician and agreed to and signed by a parent or guardian. All sections of the Request shall be completed and a current comprehensive medical history and current treatment plan, completed by the referring physician, shall be attached. The comprehensive medical history, current treatment plan and other documents submitted with the request shall reflect the current medical status of the individual and shall document the need for ongoing (not intermittent) complex skilled nursing interventions by a licensed nurse. Incomplete requests shall be returned to the referral source for completion prior to further action by. Upon receipt of the fully completed Request, a of the need for PDN services, as well as the level (LPN or RN) and amount of service required. When the is found to be eligible for EPSDT/PDN services, the number of hours approved, the level of services, and the length of time of the approval (up to a maximum of six months) shall be noted. Requests for continuation, or modification of PDN services during the treatment period, shall be submitted by the Clinical Coverage Guideline page 3
PDN agency, in writing, to on the "Prior Authorization Request Form" In an emergency, requests for modification of services may be made by telephone but shall be followed immediately by a written prior authorization (PA) request. EPSDT/PDN services are only appropriate when all of the following requirements are satisfied: 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; AND, The adult primary caregiver agrees to be trained or has been trained in the care of the individual and agrees to receive additional training for new procedures and treatments, if directed to do so by a State agency; AND, The primary caregiver agrees to provide a minimum of eight hours of hands-on care to the individual during every 24-hour period; AND, The home environment can accommodate the required equipment and licensed PDN personnel. NOTE: Individuals eligible for Medicaid services through the Medically Needy program are not eligible for EPSDT services, in accordance with N.J.A.C. 10:49-5.3(a)2. NOTE: For individuals who are enrolled in Medicaid managed care, PDN is authorized and provided by the HMO. The following requirements apply to for EPSDT/PDN services ( 10:60-5.4): PDN shall be provided for eligible beneficiaries in the community only and not in hospital inpatient or nursing facility settings. shall determine and approve the total PDN hours for reimbursement, in accordance with N.J.A.C. 10:60-5.2(b). A maximum of 16 hours of PDN services may be provided in any 24-hour period. The determination of the total EPSDT/PDN hours approved, up to the maximum 16 hours per 24-hour period, shall take into account alternative sources of PDN care available to the caregiver, such as medical day care or a school program. In emergency situations, for example, when the sole caregiver has been hospitalized, may authorize, for a limited time, additional hours beyond the 16-hour limit. Medical necessity for EPSDT/PDN services shall be based upon, but may not be limited to, one of the following: 1. A requirement for all of the following medical interventions: Dependence on mechanical ventilation; The presence of an active tracheostomy; and The need for deep suctioning; or OR, 2. A requirement for any of the following medical interventions: The need for around-the-clock nebulizer treatments, with chest physiotherapy; Gastrostomy feeding when complicated by frequent regurgitation and/or aspiration; or A seizure disorder manifested by frequent prolonged seizures, requiring emergency administration of anti-convulsants. the following situational criteria shall be considered, once medical necessity has been established in accordance with items #1 or #2 above, when determining the extent of the need for EPSDT/PDN services and the authorized hours of service: Available parental support; AND, Additional sibling care responsibilities; AND, Alternative sources of nursing care. Clinical Coverage Guideline page 4
Exclusions Services that shall not, in and of themselves, constitute a need for PDN services, in the absence of the skilled nursing interventions listed above, shall include, but shall not be limited to: Patient observation, monitoring, recording or assessment; Occasional suctioning; Gastrostomy feedings, unless complicated as described in (b)1 above; and Seizure disorders controlled with medication and/or seizure disorders manifested by frequent minor seizures not occurring in clusters or associated with status epilepticus. NOTE: PDN shall be a covered service only for adults those beneficiaries covered under EPSDT/PDN. While PDN is a form of respite service available under the Division of Development Disabilities - Community Care Waiver (CCW-DDD), respite services are distinct from EPSDT/PDN services and are not eligible for reimbursement as EPSDT/PDN services. Respite care is not a covered service under Medicaid/NJ FamilyCare. CODING CPT * Codes No applicable codes HCPCS * Codes T1000 Private duty/independent nursing service(s), licensed, up to 15 minutes ICD-9 Codes No applicable codes ICD-10 Codes No applicable codes *Current Procedural Terminology (CPT ) 2015 American Medical Association: Chicago, IL. REFERENCES 1. Title 10, chapter 60: home care services. New Jersey State Legislature Web site. http://www.lexisnexis.com/hottopics/njcode/. Published 2014. Accessed May 1, 2015. MEDICAL POLICY COMMITTEE HISTORY AND REVISIONS Date Action 6/16/2015 Approved by MPC. 5/7/2015 Approved by MPC. No changes. 6/27/2014 Approved by MPC. Clarified language. 6/5/2014 Approved by MPC. Clinical Coverage Guideline page 5