PROVIDER POLICIES & PROCEDURES EXTENDED NURSING SERVICES The purpose of this document is to provide guidance to providers enrolled in the Connecticut Medical Assistance Program (CMAP) on the requirements for the prior authorization of extended nursing services. This includes the applicable coverage guidelines and limitations for HUSKY Health Program members as well as the procedures for requesting authorization for this service. Extended nursing services, more commonly known as complex or private duty nursing, are nursing care services provided by a Registered Nurse (RN) or Licensed Practical Nurse (LPN) that are required for more than two continuous, consecutive hours on any given day. Extended nursing services are typically provided in the member s home under the direction of a written individualized plan of care by the member s attending physician. A home is defined as the member s place of residence including but not limited to, a boarding home, residential care home or community living arrangement. The term home does not include facilities such as hospitals, nursing facilities, chronic disease hospitals, intermediate cate care facilities for individuals with intellectual disabilities (ICFs/MR) or other facilities that are paid an all inclusive rate for the care of the member. Extended nursing services provide more individual and continuous skilled care than can be provided in an intermittent skilled nursing visit (up to two hours) through a home health agency. The intent of extended nursing services is to assist the member with complex direct skilled nursing care, to develop caregiver competencies through training and education, and to optimize member health status and outcomes. The skilled nursing tasks must be done so frequently that the need is continuous. The frequency and duration of extended nursing services is intermittent (less than twenty-four hours of care in a twenty-four hour period) and typically temporary in nature and is generally not intended to be provided on a permanent ongoing basis. CLINICAL GUIDELINE Coverage guidelines for extended nursing services are made in accordance with the Department of Social Services (DSS) Definition of Medical Necessity. The following criteria are guidelines only. Coverage determinations are based on an individual assessment of the member and his or her clinical needs. Coverage of extended nursing services is considered medically necessary when: 1. The services are ordered as medically necessary by a licensed physician (MD or DO) as part of a written treatment plan with short and long term goals for a covered medical condition; AND 2. Placement of a nurse in the home to provided extended nursing services is done solely to meet the skilled needs of the member by providing skilled constant attention and observation to a seriously ill member; AND 3. The services are performed by a licensed nurse (i.e., Registered Nurse or Licensed Practical Nurse) who is employed by a licensed home care agency; AND 1
4. The member s condition is unstable and requires frequent nursing assessments and changes in the plan of care; AND 5. The member s needs could not be met through a skilled nursing visit(s), but only through extended care nursing services in the home; AND 6. The need for, and the length of, service is determined by the condition of the member and the level of care required rather than the nature of the disease, illness, or condition. Examples of extended nursing services in the home may include: 1. New ventilator dependent members; OR 2. New tracheotomy members; OR 3. Members who are dependent on other device-based respiratory support, including tracheostomy care, suctioning to manage secretions, and oxygen support; OR 4. Members who are chronically ill and who require extensive skilled nursing care to remain at home; OR 5. Members who require prolonged intravenous nutrition (total parenteral nutrition) or drug therapy with needs beyond those provided by Home Infusion Therapy services; OR 6. Continuous nasogastric or gastrostomy tube feeding. Note: In most cases, more than 12 hours per day of skilled nursing care in the home is not considered medically necessary. The goal should be to assist the member and primary caregivers to achieve as much independence as possible and to decrease the level of nursing care as the member's medical condition stabilizes. However, more than 12 hours per day of skilled nursing care in the home may be considered medically necessary in any of the following circumstances: 1. Member is being transitioned from an inpatient setting to home; OR 2. Member becomes acutely ill and the additional skilled nursing care in the home will prevent a hospital admission; OR 3. The member meets the clinical criteria for confinement in a skilled nursing facility (SNF), but a SNF bed is not available. In this situation additional skilled nursing may be provided until a SNF bed becomes available; OR 4. For members on a ventilator, extended nursing services up to 24 hours per day, on a temporary basis, upon initial discharge from an inpatient setting to allow for safe transition to the home environment. Thereafter, up to 16 hours of extended nursing services per day is considered medically necessary. Extended nursing services in the home are typically not considered medically necessary: 1. When the member s medical condition is stable; OR 2. When the nurse is in the home to ensure that the member is compliant with treatment; OR 3. For a member who receives bolus nasogastric (NG) or gastrostomy tube (GT) feeds and does not have other skilled needs; OR 4. When the nurse is the member s spouse, natural or adoptive child, parent, or sibling, grandparent or grandchild. This also includes any person with an equivalent step or in-law relationship to the member; OR 5. When the nurse would be providing respite care for caregivers or family members, OR 6. When the nurse would be acting as a sitter when the caregiver is absent from the home (e.g. allowing family members to work or attend school); OR 2
7. When the nurse would be monitoring for behavioral or eating disorders; OR 8. When the nurse would be providing care that is primarily social or recreational in nature; OR 9. For services normally provided by an immediate relative, legally responsible adult or other willing and capable caregiver. Services to Children Extended nursing services are not intended to relieve a parent of their child care responsibilities e.g. providing personal care for a child that is not of an age to be expected to perform their own personal care. NOTE: The following limitations shall apply when extended nursing services are required to care for multiple clients in the same household: 1. If one nurse is required, the department shall pay the full unit fee for the primary client and a reduced unit fee for the unit of time during which the nurse is providing care to one subsequent client. No payment shall be made for additional subsequent clients. The care plans shall support the ability of one nurse to provide services safely to multiple clients. 2. If more than one nurse is required, the department shall pay the fee described in section 17b-262-734(b)(3)(A) of the Regulations of Connecticut State Agencies for each nurse. The care plans shall support the need for multiple nurses. NOTE: Extended nursing services shall be cost effective as described in section 17b-262-730 of the Regulations of Connecticut State Agencies. Extended nursing services must be cost effective. For all extended nursing services a cost effectiveness test is applied. Services will only be approved if the total monthly cost of extended nursing services is less than the monthly cost of services provided at the appropriate institution. Note, the cost effectiveness test is not applied during the first week after hospital discharge (REF: Section 17b-262-730 of the Regulations of Connecticut State Agencies). NOTE: EPSDT Special Provision Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) is a federal Medicaid requirement that requires the Connecticut Medical Assistance Program (CMAP) to cover services, products, or procedures for Medicaid enrollees under 21 years of age where the service or good is medically necessary health care to correct or ameliorate a defect, physical or mental illness, or a condition identified through a screening examination. The applicable definition of medical necessity is set forth in Conn. Gen. Stat. Section 17b-259b (2011) [ref. CMAP Provider Bulletin 2011-36]. PROCEDURE Prior authorization of extended nursing services is required. Requests for coverage of extended nursing services will be reviewed in accordance with procedures in place for reviewing requests for home health services. Coverage determinations will be based upon a review of requested and/or submitted case-specific information. Initial requests are authorized for a period of up to 3 months Reauthorization requests are authorized for a period of up to 6 months Information Required for Review - Initial Request 1. Fully completed authorization request via on-line web portal. 2. Copy of physician s verbal order signed by the Registered Nurse (RN) who obtained the order. 3
3. Fully completed Physician s Request Form for Extended Nursing Services. 4. Comprehensive Start of Care Assessment that includes: A. Current clinical status; B. Medical history related to current condition; C. List of required skilled nursing interventions; and D. List of family members and caregivers available to furnish care and description of the training they will receive. 5. Date of next scheduled appointment with primary care provider (PCP) or treating specialist. 6. Home health Certification and Plan of Care form -CMS 485 (if available at time of submission). 7. Additional information as requested. Information Required for Review Reauthorization Request 1. Fully completed authorization request via on-line web portal. 2. Fully completed Physician s Request Form for Extended Nursing Services. 3. An updated Home Health Certification and Plan of Care Form (CMS 485) indicating specific recertification dates and frequency and duration of extended nursing services being requested. 4. A copy of the previous Home Health Certification and Plan of Care Form (CMS 485), that is now signed and dated by the attending physician. 5. An updated comprehensive nursing assessment that includes: A. Changes in clinical status; B. New orders or changes in existing medication orders; C. Emergency department visits since previous assessment; D. Hospitalizations since previous assessment; E. A list of skilled nursing interventions being provided; and F. Documentation of the training provided to the member, family and caregivers and documentation of member/caregiver competency. NOTE: Requests for extended nursing services missing any of the above information will be pended. Missing documentation will be requested from the provider and the information must be submitted before a medical necessity review can be completed. As part of the prior authorization review process, the HUSKY Health Program may contact the ordering provider s office to verify any and all of the above information. If the specific number of hours or days requested appears greater than would normally be expected given the member s cognitive, intellectual and physical limitations, the member s current status and capabilities will be verified with the ordering provider. EFFECTIVE DATE This Policy is effective for prior authorization requests for extended nursing services for HUSKY Health Program members beginning July 1, 2015. LIMITATIONS Extended nursing services are not a covered benefit under the HUSKY B Program. Supplemental coverage may be available under HUSKY Plus for medically eligible children in Band 1 or Band 2. 4
CODES: Code S9123 S9124 Description Nursing care, in the home; by registered nurse, per hour Nursing care, in the home; by licensed practical nurse, per hour DEFINITIONS 1. HUSKY A: Connecticut children and their parents or a relative caregiver; and pregnant women may qualify for HUSKY A (also known as Medicaid). Income limits apply. 2. HUSKY B: Uninsured children under the age of 19 in higher income households may be eligible for HUSKY B (also known as the Children s Health Insurance Program) depending on their family income level. Family cost-sharing may apply. 3. HUSKY C: Connecticut residents who are age 65 or older or residents who are ages 18-64 and who are blind, or have another disability, may qualify for Medicaid coverage under HUSKY C (this includes Medicaid for Employees with Disabilities (MED-Connect), if working). Income and asset limits apply. 4. HUSKY D: Connecticut residents who are ages 19-64 without dependent children and who: (1) do not qualify for HUSKY A; (2) do not receive Medicare; and (3) are not pregnant, may qualify for HUSKY D (also known as Medicaid for the Lowest-Income populations). 5. HUSKY Health Program: The HUSKY A, HUSKY B, HUSKY C, HUSKY D and HUSKY Limited Benefit programs, collectively. 6. HUSKY Plus Physical Program (or HUSKY Plus Program): A supplemental physical health program pursuant to Conn. Gen. Stat. 17b-294, for medically eligible members of HUSKY B in Income Bands 1 and 2, whose intensive physical health needs cannot be accommodated within the HUSKY Plan, Part B. 7. Medically Necessary or Medical Necessity: (as defined in Connecticut General Statutes 17b- 259b) Those health services required to prevent, identify, diagnose, treat, rehabilitate or ameliorate an individual's medical condition, including mental illness, or its effects, in order to attain or maintain the individual's achievable health and independent functioning provided such services are: (1) Consistent with generally-accepted standards of medical practice that are defined as standards that are based on (A) credible scientific evidence published in peer-reviewed medical literature that is generally recognized by the relevant medical community, (B)recommendations of a physicianspecialty society, (C) the views of physicians practicing in relevant clinical areas, and (D) any other relevant factors; (2) clinically appropriate in terms of type, frequency, timing, site, extent and duration and considered effective for the individual's illness, injury or disease; (3) not primarily for the convenience of the individual, the individual's health care provider or other health care providers; (4) not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of the individual's illness, injury or disease; and (5) based on an assessment of the individual and his or her medical condition. 8. Prior Authorization: A process for approving covered services prior to the delivery of the service or initiation of the plan of care based on a determination by CHNCT as to whether the requested service is medically necessary. 9. Skilled Care: Skilled care is defined as medically necessary services that can only be rendered under state law or regulation by licensed health professionals such as a medical doctor, physician's assistant, physical therapist, occupational therapist, speech therapist, certified clinical social worker, certified nurse midwife, licensed practical nurse or registered nurse 5
10. Unstable Medical Condition: Instability of the member's condition is characterized by frequent or rapid changes, so that constant monitoring or frequent adjustments of treatment regimens are required. ADDITIONAL RESOURCES AND REFERENCES: 1. Centers for Medicare and Medicaid Services (CMS), Health Care Procedural Coding System Level II Manual, 2015 2. Connecticut Medical Assistance Program Home Health Regulation/Policy Chapter 7, dated January 1, 2008 3. North Carolina Division of Medical Assistance. Medicaid and Health Choice. Clinical Coverage Policy No: 3G. Private Duty Nursing (PDN) retrieved on April 20, 2015 from http://www.ncdhhs.gov/dma/mp/3g.pdf 4. Oregon Department of Human Services. Health Services. Office of Medical Assistance Programs (OMAP). Private Duty Nursing Program Rulebook retrieved on April 20, 2015 from http://www.oregon.gov/oha/healthplan/policies/132rb120105.pdf 5. State of Nevada. Department of Health and Human Services. Division of Health Care Financing and Policy. Medicaid Services Manual. Private Duty Nursing retrieved on April 20, 2015 from http://www.dhcfp.nv.gov/msm/archives/ch0900/ch%20900%2011-13-07.pdf 6. Regulations of Connecticut State Agencies: 17b-262-734(b)(3)(A) Requirements for Payment of Home Health Agencies, Payments 7. Regulations of Connecticut State Agencies: 17b-262-730 Requirements for Payment of Home Health Agencies, Cost effectiveness test PUBLICATION HISTORY Status Date Action Taken Original publication July 1, 2015 Approved by DSS on May 18, 2015 Reviewed June 15, 2015 Clinical Quality Subcommittee Review. Approved at the June 15, 2015 Clinical Quality Subcommittee meeting. Updated August 2015 Updated definitions of HUSKY A, B, C and D programs at request of DSS 6