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.

SUMMARY: 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.).

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: 400.4765, 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: July 31, 2024, from 1:00-2:00 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 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 IS: [e-mail]. Please note that a preliminary draft of the reference material, if available, will be posted prior to the hearing 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. August 1, 2024, and may be emailed to [e-mail].

 

THE FULL TEXT OF THE PROPOSED RULE 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) This rule is in effect for five years from its effective date.

  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 400.4765, 409.902, 409.905, 409.907, 409.908, 409.9081, 409.912, 409.913, 409.973 FS. History–New 11-17-16,                 .

 

NAME OF PERSON ORIGINATING PROPOSED RULE: Christine Pawelczyk

NAME OF AGENCY HEAD WHO APPROVED THE PROPOSED RULE: Jason Weida

DATE PROPOSED RULE APPROVED BY AGENCY HEAD: June 24, 2024

DATE NOTICE OF PROPOSED RULE DEVELOPMENT PUBLISHED IN FAR: April 3, 2024