Revision 22-3; Effective Dec. 1, 2022

Medicaid managed care organizations (MCOs) must follow all federal and state laws, rules and the provisions of the Texas Medicaid Provider Procedures Manual (TMPPM) and their contracts regarding Private Duty Nursing (PDN) services.

PDN services are a Texas Medicaid Texas Health Steps-Comprehensive Care Program (THSteps-CCP) benefit for STAR Kids members. PDN services are nursing services, described by the Texas Nursing Practice Act and its implementing regulations, for clients who meet the medical necessity criteria and who require individualized, continuous, skilled care beyond the level of skilled nursing (SN) visits normally authorized under Texas Medicaid Home Health SN and Home Health Aide (HHA) services.

PDN is a THSteps-CCP benefit per the Code of Federal Regulations, Title 42, Section 440.80, relating to PDN services, and Section 440.40(b), relating to Early Periodic Screening, Diagnostic and Treatment (EPSDT) services. THSteps-CCP is an expansion of the EPSDT service mandated by the Omnibus Budget Reconciliation Act (OBRA) of 1989, which requires all states to provide all medically necessary treatment for correction or amelioration of physical or mental illnesses and conditions to THSteps eligible clients when federal financial participation (FFP) is available, even if the services are not covered under the Medicaid state plan.

MCOs must follow all EPSDT requirements, including the provision of PDN services, for STAR Kids members.

State rules governing PDN are found at Texas Administrative Code (TAC) Title 1, Part 15, Chapter 363, Subchapter C. These rules and related policies, including rules and policy related to past authorization, apply to HHSC or its designees, which include MCOs (see 1 TAC Section 363.301(c), Section 363.303(6), and Section 363.311(b)). MCOs are must follow all policies governing PDN services in the TAC, as well as the latest edition of the TMPPM. Find Texas Medicaid’s THSteps-CCP PDN policy in Section 4 of the TMPPM’s Home Health and Private Duty Nursing Services Handbook. Find more Information about the THSteps-CCP Program in Section 2 of the TMPPM’s Children’s Services Handbook.

These rules and TMPPM policy provisions are the result of the final settlement agreement in the Alberto N., Et. Al. v. Albert Hawkins, Et. Al. lawsuit.

Because PDN is a Texas Medicaid THSteps-CCP service, the rules and related policies cited above apply directly to the STAR Kids program. See 8.1.2 Covered Services of Attachment B-1 of the STAR Kids Contract. MCOs must ensure that if their internal policy and procedure manuals contain language and guidance for processing PDN service requests, these documents are updated to align with all federal and state laws and rules, as well as the Texas Medicaid medical policy guidance available in the latest version of the TMPPM. See 7.02 MCO responsibility for compliance with laws and regulations of Attachment A of the STAR Kids Contract.

4310 Private Duty Nursing and Prescribed Pediatric Extended Care Center Services

Revision 20-2; Effective September 1, 2020

Private duty nursing (PDN) services and nursing services provided through a Prescribed Pediatric Extended Care Center (PPECC), as described in Section 4400 that follows, are considered to be an equivalent level of nursing care. An individual who qualifies for PDN will qualify for PPECC.

An individual has a choice of PDN, PPECC, or a combination of both PDN and PPECC for ongoing skilled nursing. Members must be informed of their service options for ongoing skilled nursing (PDN or PPECC) when PPECC services are available in the service delivery area. A member may receive both PDN and PPECC on the same day, but not at the same time (e.g., PDN may be provided before or after PPECC services are provided). The combined total hours between PDN and PPECC services is not anticipated to increase unless there is a change in the individual's medical condition or the authorized hours are not commensurate with the individual's medical needs. Per §363.209 (c)(3), PPECC services are intended to be a one-to-one replacement of PDN hours unless additional hours are medically necessary.

Because the total number of approved skilled nursing hours do not decrease, the Texas Health and Human Services Commission (HHSC) views a shift from PDN to PPECC as a provider change, and not an adverse action. The fee-for-service Nursing Addendum to the Plan of Care for PPECCs and PDN includes updated individual acknowledgements, including an acknowledgement that PDN hours may decrease if shifting the hours to the PPECC, or vice versa.

Achieving a one-to-one replacement of existing PDN hours with PPECC (or vice versa) to prevent service duplication will require an examination of authorizations for both PDN and PPECC services, including a review of the 24-hour flow sheet for nursing care. For example, when an individual with PDN decides to shift hours to a PPECC, then the PDN authorized hours will be decreased by the amount of hours shifted to a PPECC, unless there is a change in the individual’s medical condition requiring additional hours, or the authorized hours are not commensurate with the individual's medical needs. The PDN provider would be notified by the managed care organization of the revised (decreased) authorized hours. The PDN provider may submit a revision request with documentation to justify medical necessity for any additional hours requested. The PPECC and PDN providers are expected to coordinate on the respective plan of care for the individual. The service coordinator is expected to play a role in ensuring the coordination between PPECC and PDN service providers and authorized services.