The purpose of the amendment to Rule 59G-4.261, Florida Administrative Code, (F.A.C.), is to incorporate by reference the Florida Medicaid Private Duty Nursing and Family Home Health Aide Services Coverage Policy, __________, ....

 

AGENCY FOR HEALTH CARE ADMINISTRATION

Medicaid

RULE NO.:RULE TITLE:

59G-4.261Private Duty Nursing Services

PURPOSE AND EFFECT: The purpose of the amendment to Rule 59G-4.261, Florida Administrative Code, (F.A.C.), is to incorporate by reference the Florida Medicaid Private Duty Nursing and Family Home Health Aide Services Coverage Policy, __________, and change the rule title to Private Duty Nursing and Family Home Health Aide Services. The revised coverage policy includes new definitions, makes technical changes, and updates policy language to align with the requirements of section 400.4765, Florida Statutes (F.S.).

SUBJECT AREA TO BE ADDRESSED: Private Duty Nursing and Family Home Health Aide Services.

An additional area to be addressed during the workshop will be the potential regulatory impact Rule 59G-4.261, Florida Administrative Code, will have as provided for under sections 120.54 and 120.541, Florida Statutes.

RULEMAKING AUTHORITY: 409.919, 409.961 FS.

LAW IMPLEMENTED: 400.4765, 409.902, 409.905, 409.907, 409.908, 409.9081, 409.912, 409.913, 409.973 FS.

A RULE DEVELOPMENT WORKSHOP WILL BE HELD AT THE DATE, TIME AND PLACE SHOWN BELOW:

DATE AND TIME: April 18, 2024 from 2:00 p.m. to 3:00 p.m.

PLACE: Agency for Health Care Administration, 2727 Mahan Drive, 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 7 days before the workshop/meeting by contacting: [e-mail]. 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: [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. Official comments to be entered into the rule record will be received until 5:00 p.m., April 19, 2024, and may be emailed to [e-mail].

 

THE PRELIMINARY TEXT OF THE PROPOSED RULE DEVELOPMENT IS:

 

59G-4.261 Private Duty Nursing and Family Home Health Aide Services.

(1) This rule applies to all providers rendering Florida Medicaid private duty nursing and family home health aide services to recipients.

(2) All providers must be in compliance with the provisions of the Florida Medicaid Private Duty Nursing and Family Home Health Aide 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, and available at https://www.flrules.org/Gateway/reference.asp?No=Ref-______07495.

(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.”

(4) Paragraph (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.

(3)  This rule is in effect for five years from its effective date.

Rulemaking Authority 409.919, 409.961 FS. Law Implemented 400.4765, 409.902, 409.905, 409.907, 409.908, 409.9081, 409.912, 409.913, 409.973 FS. History–New 11-17-16,                 .