Private Duty Nursing (PDN) Quarterly Stakeholder Session Long-Term - - PowerPoint PPT Presentation

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Private Duty Nursing (PDN) Quarterly Stakeholder Session Long-Term - - PowerPoint PPT Presentation

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NC Department of Health and Human Services Private Duty Nursing (PDN) Quarterly Stakeholder Session Long-Term Services and Supports December 13, 2019 NCDHHS, NC Medicaid | Private Duty Nursing (PDN) Quarterly Stakeholder Session | December 13,

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NCDHHS, NC Medicaid | Private Duty Nursing (PDN) Quarterly Stakeholder Session | December 13, 2019 1

NC Department of Health and Human Services

Private Duty Nursing (PDN)

Quarterly Stakeholder Session

Long-Term Services and Supports

December 13, 2019

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NCDHHS, NC Medicaid | Private Duty Nursing (PDN) Quarterly Stakeholder Session | December 13, 2019 2

Agenda

  • Welcome and Introductions
  • Managed Care Update
  • Quality Initiatives
  • PDN and CAP/C Respite
  • Proposed PDN

Policy Revisions

  • Timeline
  • Q & A
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NCDHHS, NC Medicaid | Private Duty Nursing (PDN) Quarterly Stakeholder Session | December 13, 2019 3

Managed Care Update

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NCDHHS, NC Medicaid | Private Duty Nursing (PDN) Quarterly Stakeholder Session | December 13, 2019 4

Managed Care Update

  • General Assembly adjourned without providing

required new spending and program authority for transition to managed care

  • Managed care implementation and open

enrollment suspended

  • NC Medicaid is continuing to operate under

current fee-for-service model (Medicaid Direct)

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NCDHHS, NC Medicaid | Private Duty Nursing (PDN) Quarterly Stakeholder Session | December 13, 2019 5

Quality Improvement Initiatives

  • CMS-485 audit
  • Third party insurance
  • Requests for

Additional Information

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NCDHHS, NC Medicaid | Private Duty Nursing (PDN) Quarterly Stakeholder Session | December 13, 2019 6

CMS-485 Audit

  • PDN Clinical Coverage policies

3G-1 and 3G-2 require that CMS- 485s be uploaded to NCTracks every 60 days

  • Audit initiated for claims

submitted Nov. 1, 2017 – April 30, 2019

  • Results
  • Documentation reviewed for

191 PDN cases

  • All required CMS-485s were

noted in 70% of cases

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NCDHHS, NC Medicaid | Private Duty Nursing (PDN) Quarterly Stakeholder Session | December 13, 2019 7

Third Party Insurance

  • Medicaid is the payer of last

resort

  • Private health insurance

coverage for nursing services or denial documentation for the prior approval period must be submitted to Medicaid

  • Monitoring for compliance

with this requirement has been initiated

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NCDHHS, NC Medicaid | Private Duty Nursing (PDN) Quarterly Stakeholder Session | December 13, 2019 8

Requests for Additional Information

  • Issued by PDN Consultant

when documents required by policy are missing or incomplete

  • Information due within 10

business days from date of letter

  • Reminder call or email made

at 5 business days

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NCDHHS, NC Medicaid | Private Duty Nursing (PDN) Quarterly Stakeholder Session | December 13, 2019 9

Requests for Additional Information (cont’d)

  • If information not received by

business day 10, PDN services will only be authorized for 30 days – final chance for agency to correct deficiency

  • Formal notification of agency

non-compliance with PDN policy and referral to OCPI

  • In-person meeting required for

recurrent non-compliance

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NCDHHS, NC Medicaid | Private Duty Nursing (PDN) Quarterly Stakeholder Session | December 13, 2019 10

PDN and CAP/C Respite

  • Respite intended to provide

temporary support to primary unpaid caregiver(s) while ensuring beneficiary’s needs are still met

  • Caregiver determines need for

respite

  • Not used to supplement weekly

authorized PDN hours

  • Submit prior approval request to

PDN if additional hours needed

(emergency, short-term intensive, ongoing)

  • Coordinate with CAP/C case

manager

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NCDHHS, NC Medicaid | Private Duty Nursing (PDN) Quarterly Stakeholder Session | December 13, 2019 11

Proposed PDN Clinical Coverage Policy 3G-1 and 3G-2 Revisions

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NCDHHS, NC Medicaid | Private Duty Nursing (PDN) Quarterly Stakeholder Session | December 13, 2019 12

Proposed PDN 3G-1 and 3G-2 Policy Revisions

  • Reauthorization process timeline
  • Short-Term Increase
  • Emergency Change timeline
  • Change in Service Providers
  • Missed Shift Hours
  • Provider to Beneficiary Relationship
  • Therapeutic Leave
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NCDHHS, NC Medicaid | Private Duty Nursing (PDN) Quarterly Stakeholder Session | December 13, 2019 13

Reauthorization Process Timeline

Prior approval timeline for reauthorization requests adjusted to offer a more utilized timeframe and still allow for due process

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NCDHHS, NC Medicaid | Private Duty Nursing (PDN) Quarterly Stakeholder Session | December 13, 2019 14

  • Current

reauthorization timeline

“at least 30 calendar days”

Proposed PDN 3G-1 and 3G-2 Policy Revisions

  • Proposed

reauthorization timeline

“at least 15 business days”

Note: This change would make it consistent with a more utilized timeframe for preparation of required documentation and due process.

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NCDHHS, NC Medicaid | Private Duty Nursing (PDN) Quarterly Stakeholder Session | December 13, 2019 15

Short-Term Increase in PDN Services

Covered when one of the following is met:

  • Caregiver training needed on new technology
  • Acute, temporary change in condition
  • Family emergency, additional support needed
  • Beneficiary out of school, used up allotted hours
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NCDHHS, NC Medicaid | Private Duty Nursing (PDN) Quarterly Stakeholder Session | December 13, 2019 16

Proposed PDN 3G-1 and 3G-2 Policy Revisions

  • Current allowable

short-term increase in hours

“a maximum of 4 calendar weeks”

  • Proposed allowable

short-term increase in hours

“a maximum of 6 calendar weeks”

Note: This change would be consistent with research suggesting 6 weeks is a more utilized recovery period from a variety of procedures.

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NCDHHS, NC Medicaid | Private Duty Nursing (PDN) Quarterly Stakeholder Session | December 13, 2019 17

Emergency Change in PDN Services

Sudden changes in the amount, scope, frequency or duration of services are based

  • n true emergent medical necessity of the

beneficiary or their primary caregiver

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NCDHHS, NC Medicaid | Private Duty Nursing (PDN) Quarterly Stakeholder Session | December 13, 2019 18

Proposed PDN 3G-1 and 3G-2 Policy Revisions

  • Current emergency

change timeline

Physician-signed order “within 15 business days”

  • Proposed emergency

change timeline

Physician-signed order “within 5 business days”

Note: This change would be consistent with reporting other changes within the policy.

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NCDHHS, NC Medicaid | Private Duty Nursing (PDN) Quarterly Stakeholder Session | December 13, 2019 19

Changing service providers

Transfer of care

The new PDN service provider shall facilitate the change by coordinating the transfer of care with the beneficiary’s attending physician, the current PDN service provider, and others who are involved in the beneficiary’s care.

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NCDHHS, NC Medicaid | Private Duty Nursing (PDN) Quarterly Stakeholder Session | December 13, 2019 20

Proposed PDN 3G-1 and 3G-2 Policy Revisions

  • Current transfer of

care process

1) Within 5 business days

  • f request

2) No provisional review 3) No continuation review

  • Proposed transfer of

care process

1) Within 5 business days PRIOR to anticipated transfer 2) Initial provisional approval for 30 calendar days only 3) Continuation for remainder

  • f 180-day period

Note: This change would decrease administrative burden for the provider and provide clarification on the information needed for the transfer.

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NCDHHS, NC Medicaid | Private Duty Nursing (PDN) Quarterly Stakeholder Session | December 13, 2019 21

Missed Shift Hours

Reporting structure for shift hours that are missed within the preceding 180-day period

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NCDHHS, NC Medicaid | Private Duty Nursing (PDN) Quarterly Stakeholder Session | December 13, 2019 22

Proposed PDN 3G-1 and 3G-2 Policy Revisions Proposed PDN 3G-1 and 3G-2 Policy Revisions

  • Current missed

shift hours process

  • No requirement for

reporting of missed shift hours

  • Proposed missed

shift hours process

  • PDN providers disclose

missed shifts in past 180 days and/or upon termination

  • Provide report to beneficiary
  • r legal guardian upon

request

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NCDHHS, NC Medicaid | Private Duty Nursing (PDN) Quarterly Stakeholder Session | December 13, 2019 23

Provider to Beneficiary Relationship

Clarification on the relationship of provider to beneficiary, and who may be employed to provide services

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NCDHHS, NC Medicaid | Private Duty Nursing (PDN) Quarterly Stakeholder Session | December 13, 2019 24

Proposed PDN 3G-1 and 3G-2 Policy Revisions

  • Current provider/

beneficiary relationship

  • No immediate relative
  • No legally responsible

person who lives with beneficiary

  • PDN nurse cannot live with

beneficiary in any capacity

  • Proposed provider/

beneficiary relationship

  • No immediate relative
  • No one who shares primary

private residence

  • No PDN provider who is

employed by, owned by or has financial relationship to immediate relative

  • No one who is legally

responsible for beneficiary

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NCDHHS, NC Medicaid | Private Duty Nursing (PDN) Quarterly Stakeholder Session | December 13, 2019 25

Therapeutic Leave

Addition of 14 days per calendar year of physician-ordered, non-medical therapeutic leave

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NCDHHS, NC Medicaid | Private Duty Nursing (PDN) Quarterly Stakeholder Session | December 13, 2019 26

Proposed PDN 3G-1 and 3G-2 Policy Revisions

  • Current therapeutic

leave

  • No therapeutic leave
  • Proposed therapeutic

leave

  • 14 days of attending physician-
  • rdered non-medical leave per

calendar year

  • Leave defined as non-medical
  • Cannot exceed approved hours
  • Beneficiary cleared for travel

(requiring nurse) by physician

  • Documentation of necessity for

nurse to accompany

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NCDHHS, NC Medicaid | Private Duty Nursing (PDN) Quarterly Stakeholder Session | December 13, 2019 27

Timeline

  • March 2020

Proposed PDN policy revisions to Physician Advisory Group

  • April 1 – May 15, 2020

45-day public comment period

  • June 1, 2020

Final posting

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NCDHHS, NC Medicaid | Private Duty Nursing (PDN) Quarterly Stakeholder Session | December 13, 2019 28

Q & A

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NCDHHS, NC Medicaid | Private Duty Nursing (PDN) Quarterly Stakeholder Session | December 13, 2019 29

Mark your calendars!

Spring PDN Stakeholder session scheduled for Friday March 27, 2020 2-3:30 p.m.

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NCDHHS, NC Medicaid | Private Duty Nursing (PDN) Quarterly Stakeholder Session | December 13, 2019 30

Additional Questions

Please email additional PDN-related questions to:

Medicaid.homecareservice@dhhs.nc.gov

  • Current PDN policy links:

https://files.nc.gov/ncdma/documents/files/3G-1_1.pdf https://files.nc.gov/ncdma/documents/files/3G-2_0.pdf

  • PDN website:

https://medicaid.ncdhhs.gov/providers/programs-and- services/long-term-care/private-duty-nursing-pdn

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NCDHHS, NC Medicaid | Private Duty Nursing (PDN) Quarterly Stakeholder Session | December 13, 2019 31

Thank You!