Controlling the cost of Medicaid private duty nursing services : final report to the Joint Legislative Program Evaluation Oversight Committee - Page 6 |
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Private Duty Nursing Report No. 2008- 12- 05 Page 2 of 22 Scope The North Carolina General Assembly’s Joint Legislative Program Evaluation Oversight Committee directed1 the Program Evaluation Division to evaluate the cost of alternatives to the private duty nursing benefit currently provided under the North Carolina Medicaid Program. The Division examined how North Carolina and other states structure their private duty nursing benefit and identified options for containing the cost of care for Medicaid recipients who require continuous, complex, and substantial nursing services. The Program Evaluation Division collected data from several sources including • the Division of Medical Assistance, the Division of Health Service Regulation, and the Division of Vocation Rehabilitation; • states that offer private duty nursing under their state Medicaid plans and states that offer private duty nursing through Medicaid waivers; • interviews of ten private duty nursing recipients and/ or their families; • the North Carolina Health Care Facilities Association and the Association for Home and Hospice Care of North Carolina; • the United States Center for Medicare and Medicaid Services; • the Kaiser Family Foundation; and • the Center for Personal Assistance Services. Background The United States Centers for Medicare and Medicaid Services ( CMS) defines private duty nursing services as nursing services provided by a registered nurse or a licensed practical nurse under the direction of a physician for recipients who require more individual and continuous care than is available from a visiting nurse or routinely provided by the nursing staff of a hospital or skilled nursing facility. 2 Private duty nursing is an optional3 Medicaid service for adults; therefore, states do not have to cover it. Thirty- five states, including North Carolina, have chosen to cover private duty nursing. States that choose to cover private duty nursing offer it either under their state Medicaid plan, through 1915( c) Home and Community- Based Services Medicaid waivers, or both. The North Carolina Medicaid Program began offering private duty nursing services under its state plan in 1988. The benefit covers medically necessary continuous, complex, and substantial nursing services provided by a licensed nurse in a recipient’s home. 4 Recipients choose private duty nursing services over nursing facility services because they prefer to be 1 The Joint Legislative Program Evaluation Oversight Committee establishes the Program Evaluation Division’s work plan in accordance with N. C. Gen. Stat. § 120- 36.13. 2 CMS allows states to determine whether private duty nursing services are provided in a recipient’s home, a hospital, and/ or a skilled nursing facility. 3 Federal law ( 42 CFR § § 440.210, 440.220) requires state Medicaid programs to cover mandatory services, including nursing home care and home health care for recipients entitled to nursing home care. States may elect to cover any of the optional services listed in 42 CFR § 440.80, and then they must provide the service statewide to all beneficiaries. 4 Recipients must live in private residences to receive private duty nursing services. A nurse may accompany the recipient outside of the home when the recipient’s normal life activities take the recipient away from the home during the day. For example, a private duty nurse can accompany a child to school.
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Title | Controlling the cost of Medicaid private duty nursing services : final report to the Joint Legislative Program Evaluation Oversight Committee - Page 6 |
Full Text | Private Duty Nursing Report No. 2008- 12- 05 Page 2 of 22 Scope The North Carolina General Assembly’s Joint Legislative Program Evaluation Oversight Committee directed1 the Program Evaluation Division to evaluate the cost of alternatives to the private duty nursing benefit currently provided under the North Carolina Medicaid Program. The Division examined how North Carolina and other states structure their private duty nursing benefit and identified options for containing the cost of care for Medicaid recipients who require continuous, complex, and substantial nursing services. The Program Evaluation Division collected data from several sources including • the Division of Medical Assistance, the Division of Health Service Regulation, and the Division of Vocation Rehabilitation; • states that offer private duty nursing under their state Medicaid plans and states that offer private duty nursing through Medicaid waivers; • interviews of ten private duty nursing recipients and/ or their families; • the North Carolina Health Care Facilities Association and the Association for Home and Hospice Care of North Carolina; • the United States Center for Medicare and Medicaid Services; • the Kaiser Family Foundation; and • the Center for Personal Assistance Services. Background The United States Centers for Medicare and Medicaid Services ( CMS) defines private duty nursing services as nursing services provided by a registered nurse or a licensed practical nurse under the direction of a physician for recipients who require more individual and continuous care than is available from a visiting nurse or routinely provided by the nursing staff of a hospital or skilled nursing facility. 2 Private duty nursing is an optional3 Medicaid service for adults; therefore, states do not have to cover it. Thirty- five states, including North Carolina, have chosen to cover private duty nursing. States that choose to cover private duty nursing offer it either under their state Medicaid plan, through 1915( c) Home and Community- Based Services Medicaid waivers, or both. The North Carolina Medicaid Program began offering private duty nursing services under its state plan in 1988. The benefit covers medically necessary continuous, complex, and substantial nursing services provided by a licensed nurse in a recipient’s home. 4 Recipients choose private duty nursing services over nursing facility services because they prefer to be 1 The Joint Legislative Program Evaluation Oversight Committee establishes the Program Evaluation Division’s work plan in accordance with N. C. Gen. Stat. § 120- 36.13. 2 CMS allows states to determine whether private duty nursing services are provided in a recipient’s home, a hospital, and/ or a skilled nursing facility. 3 Federal law ( 42 CFR § § 440.210, 440.220) requires state Medicaid programs to cover mandatory services, including nursing home care and home health care for recipients entitled to nursing home care. States may elect to cover any of the optional services listed in 42 CFR § 440.80, and then they must provide the service statewide to all beneficiaries. 4 Recipients must live in private residences to receive private duty nursing services. A nurse may accompany the recipient outside of the home when the recipient’s normal life activities take the recipient away from the home during the day. For example, a private duty nurse can accompany a child to school. |