23 Miss. Code. R. 223-4.3 - Covered Services
A. The Division of
Medicaid covers medically necessary private duty nursing (PDN) services only
for early and periodic screening, diagnosis and treatment (EPSDT)-eligible
beneficiaries when:
1. Ordered and directed by
the beneficiary's primary physician or appropriate physician
specialist.
2. Prior authorized by
the Division of Medicaid or designee.
3. The required service(s) exceed the level
of services provided through the home health benefit.
4. Post-acute inpatient skilled nursing care
is not appropriate, does not meet the beneficiary's care needs, or is not
available.
5. Provided in a setting
in which the beneficiary's normal life activities take place.
6. All medical and home environment criteria
are met.
7. Are directly related to
the beneficiary's illness or disability.
8. Services can be safely provided by only
one (1) nurse and do not require the assistance of a second
(2nd) nurse.
9. The plan of care (POC) includes multiple
skilled nursing functions and is not limited to just one (1) skilled nursing
function, such as for the administration of a nasogastric or gastrostomy
feeding.
10. The beneficiary:
a) Is medically stable to receive nursing
care managed safely in a non-institutional setting where normal life activities
take place,
b) Has a documented
illness or disability of such severity and/or complexity that it requires
prescribed care that can only be provided by an RN or LPN, and
c) Requires more individual and continuous
care than is available from a visiting nurse through intermittent home health
care or custodial care.
11. The home environment is conducive to
appropriate growth and development for the beneficiary's age group and is
conducive to the provision of appropriate medical care.
12. There must be at least one (1) parent or
other caregiver capable of and willing to be trained to assist in the provision
of care for the beneficiary and the parent or caregiver must:
a) Provide evidence of parental or family
involvement, and an appropriate home situation including, but not limited to, a
physical environment and geographic location for the beneficiary's medical
safety.
b) Have a reasonable plan
for an emergency situation including, but not limited to:
1) Power and equipment backup for those with
a life-support device,
2) Access to
a working telephone, and
3)
Available transportation adequate to safely transport the
beneficiary.
c) Comply
with the plan of care, physician office appointments and/or other ancillary
services.
B.
The level of care required to meet the beneficiary's needs is determined by the
referring physician.
C. PDN
services are covered only when provided:
1. By
an RN or LPN:
a) With a current Mississippi
license acting within the scope-of-practice, and
b) Employed by a PDN provider,
2. Under the direction of the
beneficiary's physician, and
3. In
a non-institutional setting where normal life activities take place.
D. PDN services are covered:
1. On short-term basis for beneficiaries in
need of parent and/or caregiver training in order to reside in the home and
community, or
2. On a long-term
basis for beneficiaries that require substantial and complex care that exceeds
the level of service available from the home health benefit in order to remain
in the home and community setting.
Notes
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No prior version found.