Covered Services

Covered Services A. The Division of Medicaid covers medically necessary private duty nursing (PDN) services only for early and periodic screening, diagnosis and treatment (EPSDT)-eligible beneficiaries when: 1. Ordered and directed by the beneficiary’s primary physician or appropriate physician specialist. 2. Prior authorized by the Division of Medicaid or designee. 3. The required service(s) exceed the level of services provided through the home health benefit. 4. Post-acute inpatient skilled nursing care is not appropriate, does not meet the beneficiary's care needs, or is not available. 5. Provided in a setting in which the beneficiary’s normal life activities take place. 6. All medical and home environment criteria are met. 7. Are directly related to the beneficiary's illness or disability. 8. Services can be safely provided by only one (1) nurse and do not require the assistance of a second (2nd) nurse. 9. The plan of care (POC) includes multiple skilled nursing functions and is not limited to just one (1) skilled nursing function, such as for the administration of a nasogastric or gastrostomy feeding. 10. The beneficiary: a) Is medically stable to receive nursing care managed safely in a non-institutional setting where normal life activities take place, b) Has a documented illness or disability of such severity and/or complexity that it requires prescribed care that can only be provided by an RN or LPN, and c) Requires more individual and continuous care than is available from a visiting nurse through intermittent home health care or custodial care. 11. The home environment is conducive to appropriate growth and development for the beneficiary’s age group and is conducive to the provision of appropriate medical care. 12. There must be at least one (1) parent or other caregiver capable of and willing to be trained to assist in the provision of care for the beneficiary and the parent or caregiver must: a) Provide evidence of parental or family involvement, and an appropriate home situation including, but not limited to, a physical environment and geographic location for the beneficiary’s medical safety. b) Have a reasonable plan for an emergency situation including, but not limited to: 1) Power and equipment backup for those with a life-support device, 2) Access to a working telephone, and 3) Available transportation adequate to safely transport the beneficiary. c) Comply with the plan of care, physician office appointments and/or other ancillary services. B. The level of care required to meet the beneficiary's needs is determined by the referring physician. C. PDN services are covered only when provided: 1. By an RN or LPN: a) With a current Mississippi license acting within the scope-of-practice, and b) Employed by a PDN provider, 2. Under the direction of the beneficiary’s physician, and 3. In a non-institutional setting where normal life activities take place. D. PDN services are covered: 1. On short-term basis for beneficiaries in need of parent and/or caregiver training in order to reside in the home and community, or 2. On a long-term basis for beneficiaries that require substantial and complex care that exceeds the level of service available from the home health benefit in order to remain in the home and community setting.