Controlling the cost of Medicaid private duty nursing services : final report to the Joint Legislative Program Evaluation Oversight Committee

              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.