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Florida Administrative Code (Last Updated: July 17, 2024) |
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59. Agency for Health Care Administration |
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59G. Medicaid |
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59G-4. Medicaid Policy |
1(1) This rule applies to all providers rendering Florida Medicaid private duty nursing services to recipients.
17(2) All providers must be in compliance with the provisions of the Florida Medicaid Private Duty Nursing Services Coverage Policy, November 2016, incorporated by reference. The policy is available on the Agency for Health Care Administration’s website at http://ahca.myflorida.com/Medicaid/review/index.shtml, 56and available at 59https://www.flrules.org/Gateway/reference.asp?No=Ref-0749561.
62(3) Florida Medicaid reimburses for medically necessary private duty nursing services provided to recipients under the age of 21 years. Rule 8359G-1.010, 84Florida Administrative Code (F.A.C.), defines “medically necessary” or “medical necessity” as follows:
96“[T]he medical or allied care, goods, or services furnished or ordered must:
108(a) Meet the following conditions:
1131. Be necessary to protect life, to prevent significant illness or significant disability, or to alleviate severe pain;
1312. Be individualized, specific, and consistent with symptoms or confirmed diagnosis of the illness or injury under treatment, and not in excess of the patient’s needs;
1573. Be consistent with generally accepted professional medical standards as determined by the Medicaid program, and not experimental or investigational;
1774. Be reflective of the level of service that can be safely furnished, and for which no equally effective and more conservative or less costly treatment is available statewide; and,
2075. Be furnished in a manner not primarily intended for the convenience of the recipient, the recipient’s caretaker, or the provider.
228(b) “Medically necessary” or “medical necessity” for inpatient hospital services requires that those services furnished in a hospital on an inpatient basis could not, consistent with the provisions of appropriate medical care, be effectively furnished more economically on an outpatient basis or in an inpatient facility of a different type.
278(c) The fact that a provider has prescribed, recommended, or approved medical or allied care, goods, or services does not, in itself, make such care, goods or services medically necessary or a medical necessity or a covered service.”
316(4) Subparagraph (3)(a)5. of the medical necessity definition, as described above, shall not be applicable when determining the medical necessity of private duty nursing services. All other medical necessity criteria apply and must be met in order to receive reimbursement from Florida Medicaid.
359Rulemaking Authority 361409.919, 362409.961 FS. 364Law Implemented 366409.902, 367409.905, 368409.907, 369409.908, 370409.9081, 371409.912, 372409.913, 373409.973 FS. 375History–New 11-17-16.
