The purpose of Rule 59G-4.261, Florida Administrative Code, 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 ...

 

AGENCY FOR HEALTH CARE ADMINISTRATION

Medicaid

RULE NO.:RULE TITLE:

59G-4.261Private Duty Nursing Services

PURPOSE AND EFFECT: The purpose of Rule 59G-4.261, Florida Administrative Code, 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, __________.

SUMMARY: The incorporated coverage policy will specify recipient eligibility, provider requirements, service coverage, and reimbursement information, and clarify the application of “medical necessity” or “medically necessary” for private duty nursing services.

SUMMARY OF STATEMENT OF ESTIMATED REGULATORY COSTS AND LEGISLATIVE RATIFICATION: The Agency has determined that this will not have an adverse impact on small business or likely increase directly or indirectly regulatory costs in excess of $200,000 in the aggregate within one year after the implementation of the rule. A SERC has not been prepared by the Agency.

The Agency has determined that the proposed rule is not expected to require legislative ratification based on the statement of estimated regulatory costs or if no SERC is required, the information expressly relied upon and described herein: A checklist was prepared by the Agency to determine the need for a SERC. Based on this information at the time of the analysis and pursuant to section 120.541, Florida Statutes, the rule will not require legislative ratification.

Any person who wishes to provide information regarding a statement of estimated regulatory costs, or provide a proposal for a lower cost regulatory alternative must do so in writing within 21 days of this notice.

RULEMAKING AUTHORITY: 409.919, 409.961 FS.

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

A HEARING WILL BE HELD AT THE DATE, TIME AND PLACE SHOWN BELOW:

DATE AND TIME: September 13, 2016, 11:30 a.m. to 12:00 p.m.

PLACE: Agency for Health Care Administration, 2727 Mahan Drive, Building 3, 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: Shameria 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 IS: Shameria 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 public hearing at http://ahca.myflorida.com/Medicaid/review/index.shtml. Official comments to be entered into the rule record will be received from the date of this notice until 5:00 p.m. on September 14, 2016. Comments may be e-mailed to [e-mail]. For general inquiries and questions about the rule, please contact the person specified above.

 

THE FULL TEXT OF THE PROPOSED RULE IS:

 

59G-4.261 Private Duty Nursing Services.

(1) This rule applies to all providers rendering Florida Medicaid private duty nursing services to recipients.

(2) All providers must be in compliance with the provisions of the Florida Medicaid Private Duty Nursing Services Coverage Policy, __________, 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 [DOS place holder Ref-_______].

(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.

Rulemaking Authority 409.919, 409.961 FS. Law Implemented 409.902, 409.905, 409.907, 409.908, 409.9081, 409.912, 409.913, 409.973 FS. History–New, _______.

 

NAME OF PERSON ORIGINATING PROPOSED RULE: Shameria Davis

NAME OF AGENCY HEAD WHO APPROVED THE PROPOSED RULE: Elizabeth Dudek

DATE PROPOSED RULE APPROVED BY AGENCY HEAD: August 08, 2016

DATE NOTICE OF PROPOSED RULE DEVELOPMENT PUBLISHED IN FAR: October 16, 2015