2018 Special Session I

Budget Amendments - HB5002 (Committee Approved)

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Private Duty Nursing Medical Necessity Review (language only)

Item 303 #12h

Item 303 #12h

Health and Human Resources
Department of Medical Assistance Services


Page 278, after line 4, insert:

"PPP.1.  The Department of Medical Assistance Services shall work with stakeholders to review and adjust medical necessity criteria for Medicaid-funded nursing services including private duty nursing, skilled nursing, and home health. The department shall adjust the medical necessity criteria to reflect advances in medical treatment, new technologies, and use of integrated care models including behavioral supports. The department shall have the authority to amend the necessary waiver(s) and the State Plan under Titles XIX and XXI of the Social Security Act to include changes to services covered, provider qualifications and medical necessity criteria.  The adjustments to these services shall meet the needs of members and maintain budget neutrality by not requiring any additional expenditure of general fund beyond the current projected appropriation for such nursing services.

2. The department shall have authority to implement these changes to be effective October 1, 2018. The department shall also have authority to promulgate any emergency regulations required to implement these necessary changes within 280 days or less from the enactment dated of this act. The department shall submit a report and estimates of any projected cost savings to the Chairmen of the House Appropriations and Senate Finance Committees 30 days prior to implementation of such changes."


(This amendment authorizes the Department of Medical Assistance Services to review and adjust private duty nursing services as a part of Medicaid home and community-based services (HCBS) waivers and the Medicaid Early, Periodic Screening, Diagnosis and Treatment (EPSDT) benefit. The medical necessity criteria for private duty nursing services for individuals in HCBS waivers and those who use the EPSDT benefit has not been evaluated for many years. This review is necessary to ensure that DMAS is applying updated medical necessity criteria that reflects the advances in medical treatment, new technologies, and use of integrated care models that allow medically complex individuals to live longer, healthier lives in their homes and communities. It will also ensure this service is being utilized in a clinically appropriate and cost effective manner for all Medicaid and FAMIS members and that lower costs services such as skilled nursing, home health nursing, personal care, and behavioral supports are utilized when clinically appropriate.)