The purpose of Rule 59G-4.261 is to clarify the application of the Florida Medicaid definition of “medical necessity” or “medically necessary” as it relates to private duty nursing services, and to incorporate by reference the Florida Medicaid ...

AGENCY FOR HEALTH CARE ADMINISTRATION
Medicaid

RULE NO.: RULE TITLE:
59G-4.261: Private Duty Nursing Services
PURPOSE AND EFFECT: The purpose of Rule 59G-4.261 is to clarify the application of the Florida Medicaid definition of “medical necessity” or “medically necessary” as it relates to private duty nursing services, and to incorporate by reference the Florida Medicaid Private Duty Nursing Services Coverage Policy, __________. The incorporated coverage policy will specify recipient eligibility, provider requirements, service coverage, and reimbursement information.
SUBJECT AREA TO BE ADDRESSED: Rules 59G-4.261, Private Duty Nursing Services, 59G-4.130, Home Health Services, and 59G-4.215, Personal Care Services.
An additional area to be addressed during the workshop will be the potential regulatory impact Rules 59G-4.261, 59G-4.130, and 59G-4.215, Florida Administrative Code, will have as provided for under sections 120.54 and 120.541, Florida Statutes.
RULEMAKING AUTHORITY: 409.919 FS.
LAW IMPLEMENTED: 409.902, 409.905, 409.907, 409.908, 409.9081, 409.912, 409.913 FS.
A RULE DEVELOPMENT WORKSHOP WILL BE HELD AT THE DATE, TIME AND PLACE SHOWN BELOW:
DATE AND TIME: October 30, 2015 from 10:00 a.m. to 12:00 p.m.
PLACE: Agency for Health Care Administration, 2727 Mahan Drive, Building 3, Conference Room D, Tallahassee, Florida 32308-5407.
Pursuant to the provisions of the Americans with Disabilities Act, any person requiring special accommodations to participate in this workshop/meeting is asked to advise the agency at least 48 hours before the workshop/meeting by contacting: Claire Anthony-Davis. If you are hearing or speech impaired, please contact the agency using the Florida Relay Service, 1(800)955-8771 (TDD) or 1(800)955-8770 (Voice).
THE PERSON TO BE CONTACTED REGARDING THE PROPOSED RULE DEVELOPMENT AND A COPY OF THE PRELIMINARY DRAFT, IF AVAILABLE, IS: Claire Anthony-Davis, Bureau of Medicaid Policy, 2727 Mahan Drive, Mail Stop 20, Tallahassee, Florida 32308-5407, telephone: [phone], e-mail: [e-mail].
Please note that a preliminary draft of the reference material, if available, will be posted prior to the workshop at http://ahca.myflorida.com/Medicaid/review/index.shtml. Comments will be received until 5:00 p.m., on the day of the workshop.

THE PRELIMINARY TEXT OF THE PROPOSED RULE DEVELOPMENT IS:

59G-4.261    Private Duty Nursing Services.

(1) This rule applies to any person or entity prescribing or reviewing a request for private duty nursing services and to all providers of private duty nursing services who are enrolled in or registered with the Florida Medicaid program.

(2) All providers of private duty nursing services must comply with the provisions of the Florida Medicaid Private Duty Nursing Services Coverage Policy, __________, incorporated by reference. The policy is available from the Florida Medicaid fiscal agent’s Web site at http://portal.flmmis.com/flpublic.

(3)  Florida Medicaid reimburses for medically necessary private duty nursing services provided to recipients under the age of 21 years. Rule 59G-1.010, Florida Administrative Code (F.A.C.) defines “medically necessary” or “medical necessity” as follows:

“[T]he medical or allied care, goods, or services furnished or ordered must:

(a) Meet the following conditions:

1. Be necessary to protect life, to prevent significant illness or significant disability, or to alleviate severe pain;

2. 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;

3. Be consistent with generally accepted professional medical standards as determined by the Medicaid program, and not experimental or investigational;

4. 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

5. Be furnished in a manner not primarily intended for the convenience of the recipient, the recipient's caretaker, or the provider.

(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.

(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.”

(3) Paragraph (a)(5) of the medical necessity definition, as described above, shall not be applied 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.

Rulemaking Authority 409.919 FS. Law Implemented 409.902, 409.905, 409.907, 409.908, 409.9081, 409.912, 409.913 FS. History–New, _______.