388-106-1010 - Am I eligible for medicaid-funded private duty nursing services?

388-106-1010. Am I eligible for medicaid-funded private duty nursing services?

In order to be eligible for medicaid-funded private duty nursing (PDN):

(1) You must be eighteen years of age or older and financially eligible, which means you:

(a) Meet medicaid requirements under the categorically needy program or the medically needy program; and

(b) Use private insurance as first payer, as required by medicaid rules. Private insurance benefits, which cover hos-pitalization and in-home services, must be ruled out as the first payment source to PDN.

(2) You must be medically eligible, which means:

(a) The department has received the skilled nursing task log or ADSA-approved equivalent completed by a nurse licensed under chapter 18.79 RCW.

(b) You have been assessed by an ADSA community nurse consultant (CNC) or nursing care consultant (NCC) and determined medically eligible for PDN.

(3) The department must assess you using the CARE assessment tool, as provided in chapter 388-106 WAC to determine that you:

(a) Require care in a hospital or meet nursing facility level of care, as defined in WAC 388-106-0310; and

(b) Have unmet skilled nursing needs that cannot be met in a less costly program or less restrictive environment; and

(c) Are not able to have your care tasks provided through nurse delegation, WAC 246-840-910 through 246-840-970; COPES skilled nursing, WAC 182-515-1505; DDD waiver skilled nursing, WAC 388-845-0215 or self-directed care RCW 74.39.050; and

(d) Have a complex medical need that requires four or more hours every day of continuous skilled nursing care that can be safely provided outside a hospital or nursing facility; and

(e) Require skilled nursing care that is medically necessary, per WAC 182-500-0070; and

(f) Are able to supervise your care or have a guardian who is authorized and able to supervise your care; and

(g) Have a family member or other appropriate informal support who is responsible for assuming a portion of your care; and

(h) Are medically stable and appropriate for PDN services, as reflected by your primary care provider's:

(i) Orders for medical services; and

(ii) Documentation of approval for the service provider's PDN care plan.

(i) Do not have any other resources or means to obtain PDN services; and

(j) Are dependent upon technology every day with at least one of the following skilled care needs:

(i) Mechanical ventilation which takes over active breathing due to your inability to breathe on your own due to injury or illness. A tracheal tube is in place and is hooked up to a ventilator that pumps air into the lungs; or

(ii) Complex respiratory support, which means that you require two of the following treatment needs:

(A) Postural drainage and chest percussion;

(B) Application of respiratory vests;

(C) Nebulizer treatments with or without medications;

(D) Intermittent positive pressure breathing;

(E) O2 saturation measurement with treatment decisions dependent on the results; or

(F) Tracheal suctioning.

(iii) Intravenous/parenteral administration of multiple medications, and care is occurring on a continuing or frequent basis; or

(iv) Intravenous administration of nutritional substances, and care is occurring on a continuing or frequent basis.

(Amended by WSR 15-03-038, Filed 1/12/2015, effective 2/12/2015)

Reviser's note:RCW 34.05.395 requires the use of underlining and deletion marks to indicate amendments to existing rules. The rule published above varies from its predecessor in certain respects not indicated by the use of these markings.

Statutory Authority: RCW 74.08.090, 74.09.520. 11-05-079, § 388-106-1010, filed 2/15/11, effective 3/18/11. Statutory Authority: RCW 74.08.090, 74.09.520 and 42 C.F.R. 440.80. 05-24-091, § 388-106-1010, filed 12/6/05, effective 1/6/06.

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