37.86.2217    EARLY AND PERIODIC SCREENING, DIAGNOSTIC AND TREATMENT SERVICES (EPSDT), PRIVATE DUTY NURSING SERVICES

(1) Private duty nursing services are limited to:

(a) skilled nursing services provided directly to a child; and

(b) patient-specific training provided to a registered nurse or licensed practical nurse when a child is new to the nursing agency, when a change in the condition of a child requires additional training for the current nurse, or when a change in nursing personnel requires a new nurse to be trained to care for a child.

(2) Private duty nursing services do not include:

(a) psychological or mental health counseling;

(b) nurse supervision services including chart review, case discussion, or scheduling by a registered nurse;

(c) travel time to and from the recipient's place of service;

(d) services provided to allow the client's family or caregiver to work or to go to school; or

(e) services provided to allow respite for caregivers or the client's family.

(3) Private duty nursing services must be authorized prior to the initial provision of services and any time the condition of the client changes resulting in a change to the amount of skilled nursing services being provided. Authorization must be renewed with the department, or the department's designated review agent, every 90 days during the first six months of services, and every six months thereafter.

(a) Authorization for private duty nursing services provided through school districts may be authorized for the duration of the regular school year. Services provided during the summer months are additional services that require separate prior authorization.

(4) Authorization is based on approval of a plan of care by the department or department's designated review agent.

(5) A provider of private duty nursing services must be an incorporated entity meeting the legal criteria for independent contractor status that either employs or contracts with nurses for the provision of nursing services. The department does not contract with or reimburse individual nurses as providers of private duty nursing services.

(6) Private duty nursing services provided to an eligible client by a person who is the client's legally responsible person as that term is used in this rule must be prior authorized by the department or its designee.

(a) For purposes of this rule, "legally responsible person" means a person who has a legal obligation under the provisions of Montana law to care for another person. Legally responsible person includes the parents (natural, adoptive, or foster) of minor children, legally assigned caretaker relatives of minor children, and spouses.

(b) For private duty nursing services provided to a Medicaid client by a person who is legally responsible for the Medicaid client, the department will approve no more than 40 hours of services under the EPSDT program in a seven day period. The legally responsible person must meet the department's criteria for providing PDN services. The individual must be a licensed RN or LPN and be employed by an agency enrolled to provide private duty nursing services.

History: 53-2-201, 53-6-113, MCA; IMP, 53-2-201, 53-6-101, 53-6-111, 53-6-113, MCA; NEW, 2001 MAR p. 27, Eff. 1/12/01; AMD, 2006 MAR p. 1894, Eff. 7/28/06.