DEPARTMENT OF HEALTH AND SOCIAL SERVICES

Division of Social Services

Statutory Authority: 31 Delaware Code, Chapter 5, Section 512 (31 Del.C. Ch.5, §512)

ORDER

Private Duty Nursing Services

Nature Of The Proceedings

Delaware Health and Social Services (“Department”) / Division of Social Services initiated proceedings to amend the provider manual of the Delaware Medicaid/Medical Assistance Program and the Title XIX Medicaid State Plan to revise and clarify the criteria and reimbursement methodology for Private Duty Nursing (PDN) services. The Department’s proceedings to amend its regulations were initiated pursuant to 29 Delaware Code Section 10114 and its authority as prescribed by 31 Delaware Code Section 512.

The Department published its notice of proposed regulation changes pursuant to 29 Delaware Code Section 10115 in the January 2005 Delaware Register of Regulations, requiring written materials and suggestions from the public concerning the proposed regulations to be produced by January 31, 2005 at which time the Department would receive information, factual evidence and public comment to the said proposed changes to the regulations.

Citations

• Section 1905(a)(8) of the Social Security Act, includes private duty nursing services in the definition of medical assistance

• 42 CFR §440.80, defines Private Duty Nursing Services

• 42 CFR 447.205, defines requirement for Public Notice of Statewide Methods and Standards for Setting Payment Rates

Background

Coverage practices not specified by the Delaware Medicaid/Medical Assistance Program (DMAP) policy includes: serving multiple clients in a congregate setting; self-employed individual providers enrolled independently of a nursing agency; multiple nurses providing service to a single client, congregate group of clients, or when the PDN provider is a caretaker not legally responsible for the client.

Currently, DMAP enrolls multiple nurses to serve one or more clients in a home setting at negotiated rates. Rates negotiated for independent nurses are intended to be lower than the PDN rate paid to nursing agencies. Independent nurses were also intended to assure service when agencies were unreliable or unavailable. DSS staff prepares claims for reimbursement based on time logs submitted by independent PDN providers. This practice has provided adequate nursing care for clients, but has exposed DSS to possible billing issues and overpayments, and may not be consistent with current DMAP policy.

Summary of Proposed Changes

1. Private Duty Nursing may be provided by a single nurse to an individual or to multiple clients in a group setting. Private Duty Nursing is NOT necessarily defined as one-on-one nursing care, and may apply to services provided by a single nurse to multiple clients. This will be referred to as “Shared Nursing Services” because no single client is receiving the total attention of the nurse.

2. Special arrangements for other than one-on-one service for children in home settings will be considered if Shared Nursing Services are medically appropriate, advantageous to the client and to DMAP. Private Duty Nursing or Shared Nursing Services may supplement the care provided by a parent.

3. Private Duty Nursing reimbursement rates will be set at a One Nurse to One Client baseline. Shared Nursing Services will be reimbursed at a reduced or discounted rate per client, and will be limited to a maximum of three clients per nurse at one time.

4. Clients authorized for Private Duty Nursing may change from “private” services to Shared Nursing Services at the discretion of the DMAP Medical Director with no change to their medical condition. Areas considered by the Medical Director’s decision include availability of nursing staff, the housing situation of the client, the medical needs of the client, and the economic advantage of DMAP.

5. Referring physicians must be informed when DMAP has determined that Shared Nursing Services are appropriate. Referring physicians may object to Shared Nursing Services for their client if their interpretation of Private Duty Nursing is one-on-one nursing care.

6. Reimbursement rates will be based on the individual client, rather than the provider. A fixed rate will be established for each unit of client service for PDN. A reduced rate will be established for each unit of client service for shared nursing care for up to three clients. For example, a client who is authorized 8 hours of PDN per day may share a nurse with another client also authorized 8 hours of PDN per day. They will each be billed as 8 hours of Shared Nursing Service, at the discounted rate, rather than each 4 hours of PDN.

7. The maximum number of hours provided by an individual nurse will be restricted to a level that can safely and reasonably be provided. No single nurse should be expected to provide routinely or on a sustained basis more than 16 hours of service per day.

8. Neither DMAP Policy nor the State Plan makes a distinction between agency PDN and nursing services provided by independent contract nurses. Shared Nursing Service policy will apply to both, and will depend upon provider availability, the needs of the client, and the economic advantages of DMAP.

9. DHSS/DSS or their fiscal agent should not be involved in preparing, altering, revising, submitting, or correcting provider claims. Submission of claims for reimbursement is the responsibility of the provider. Retroactive adjustments for rate updates adjust the fee file and the reimbursement, not the claim.

10. A Prior Authorization template will be established for each client to display the authorized hours for the provider, and for the DSS staff to monitor claims. The template will document the authorized hours of service for each client, and coordinate the amount of service available from each provider. The Prior Authorization number will be entered in the MMIS, so edits/audits and payments can be automated. Billing will be oriented to the client, not to the provider.

Reimbursement Methodology

The baseline PDN reimbursement rate will normally represent services provided by one nurse to one client. An adjusted reimbursement rate per client will be established for medically appropriate PDN services provided by a single nurse for up to three clients. Maximum rates are established according to the following table:

One client: Rate for One = 100% of established

baseline rate

Two clients Rate for Each = 50% of 143% of

baseline rate

Three clients Rate for Each = 33% of 214% of

baseline rate

For example, if the baseline rate for one client is $21.00 per hour, the reimbursement rate for multiple client settings is as follows:

One Client: Rate for each client = $21.00 per hour

(Baseline)

Two Clients Rate for each client = $15.00 per hour

Three Clients Rate for each client = $15.00 per hour

The proposed provisions are subject to approval by the Centers for Medicare and Medicaid Services (CMS).

Summary Of Comments Received With Agency Response With Explanation Of Changes

The Governor's Advisory Council for Exceptional Citizens (GACEC), the Delaware Developmental Disabilities Council (DDDC), and the State Council for Persons with Disabilities (SCPD) offered the following summarized observations:

First, in Section 1.0, the last bullet indicates that the Provider Manual standards do not apply to “waiver group homes”. We believe the DDDC HCBS waiver also covers foster homes. The sentence could either be amended to include such settings or deleted altogether since the first bullet already covers beneficiaries enrolled in waivers.

Agency Response: Accepted comment and change made.

Second, in Section 1.1.1, the inclusion of the word “skilled” imposes a higher standard than the Federal PDN regulation, 42 CFR 440.80, which does not use the term “skilled”. The State cannot adopt a definition of a Medicaid service which is narrower than the Federal standard. Moreover, the reference to 42 CFR 440.80 should be 42 CFR 440.70.

Agency Response: Accepted comment and change made.

Third, in Section 1.1.4.1, we recommend adding “or community settings” after the word “home”. CMS modified its policy to permit PDN services to be provided in other community settings. Moreover, the limited reference to “home” in Section 1.1.4 is inconsistent with Sections 5.2.5 and 5.2.6 which authorize PDN in the contexts of accompaniment to medical appointments, accompaniment to school, and in-school settings.

Agency Response: Added the phrase, “or other DMAP approved community setting”.

Fourth, in Section 1.1.4, we recommend deletion of the second sentence which recites that “(g)enerally, the total cost of PDN services shall not exceed the cost of care provided in an institutional setting.” This is not a waiver program in which the cost of services are subject to an aggregate or individual cap. Moreover, it is inconsistent with the ADA and Olmstead which encourages states to review and revamp policies which encourage unnecessary institutionalization.

Agency Response: PDN is included in Delaware’s 1115(c) waiver. No change.

Fifth, Section 4.1.3 suggests that DSS will pay less to self-employed nurses than agency-based nurses. Given the nursing shortage, this approach may discourage individual nurses from providing PDN services. It would be preferable to establish compensation standards which attract, not deter, self-employed nurse participation in the Medicaid program.

Agency Response: The difference in the rates takes into account the fact that agencies have higher costs than self-employed nurses. No change.

Sixth, the regulations are unduly constrictive in the context of “carryover”. See Sections 5.1.5 and 5.2.9. The standards explicitly disallow carryover even to the next day. A completely rigid and inflexible system is simply not realistic and will result in hardship to families. Recognizing that a weekly schedule is developed at a minimum, consider the following alternative to Section 5.2.9:

DSS projects a sufficient amount of hours per day. If the hours authorized are not used on a particular day, the hours do not generally carry over to the next day or weekend nor can the hours be “banked” to be used at a later time. Occasional variations of 3 hours or less within a week based on unexpected or extenuating circumstances may be acceptable.

Agency Response: If a situation arises that necessitates the use of additional hours, the nurse or facility may seek prior approval from DMAP. No change.

Seventh, Section 5.2.3 is objectionable. This establishes a categorical requirement that no one (adult or child) is eligible for PDN unless they have a least 2 independent caregivers. This is not authorized by Federal law. If a single parent with a medically fragile child has no relatives in the area, she would be precluded from obtaining PDN to which her child is otherwise entitled. Moreover, the implication of the sentence is that if an agency nurse does not appear as scheduled, the agency need not arrange for s substitute. Rather, the primary caretaker or back-up caregiver would be expected to “cover” for the defaulting nurse to the exclusion of the provider. The sentence should be deleted.

Agency Response: The phrase, “and one back-up caregiver”, has been removed.

Eighth, Section 5.2.4 recites as follows: “DSS cannot guarantee that PDN services will be available from a specific home health agency.” The reference to “home health agency” is problematic since it suggests that PDN is a “home health service”. PDN is a distinct service. At a minimum, we recommend substituting “provider” for “home health agency”. Moreover, the sentence could be construed to mean that PDN may not be available based on a lack of participating providers or openings. DSS has a duty to ensure the ready availability of participating providers throughout the State. Therefore, Section 5.2.4 could be improved as follows:

Although a sufficient network of PDN providers will be enrolled to ensure statewide availability, DSS cannot guarantee that PDN services will be available from a specific provider.

Agency Response: The phrase, “home health agency” has been removed and replaced with the word, “provider”.

Ninth, there is some “tension” between Section 5.2.5 (which categorically prohibits a PDN accompanying a caregiver to a medical appointment or hospital) and Section 5.3.1 (which contemplates that some caregivers may not be sufficiently trained/skilled to care for a Medicaid beneficiary (e.g. with new trach or vent). Section 5.2.5 should be revised to permit such accompaniment when the beneficiary’s health and safety would be compromised by transport without a private duty nurse. This is similar to the authorization of accompaniment in the school transit context authorized by Section 5.2.6.

Agency Response: The intent of this section is to clarify that DMAP will not pay for a PDN when a parent/caregiver is available. No change.

Tenth, Section 5.2.6 should be revised to clarify that the “compromised airway” is only one of multiple medical conditions which may justify nurse accompaniment. Consider inserting “or other high risk condition” after the word “airway”.

Agency Response: Accepted comment. Added the phrase “or other DMAP approved high risk condition”.

Eleventh, for similar reasons, Section 5.3.4 could be revised by substituting “due to compromised airway (trach/vent) or other high risk condition” for “with a compromised airway (trach/vent)”.

Agency Response: Accepted comment. Added the phrase “or other DMAP approved high risk condition”.

Twelfth, the regulations establish a utilization cap of 16 hours/day for children. See Section 5.3.1. Under EPSDT, utilization limits may be used as guides but not absolute caps. Section 5.3.3 ostensibly recognizes that the utilization standard is a guide and not an absolute cap by authorizing more hours to avoid hospitalization. At a minimum, we therefore recommend substitution of “upper utilization guideline” for “maximum number of hours a day” in Section 5.3.1.

Agency Response: Section 5.3.1 - no change.

Thirteenth, for similar reason, we recommend the following substitute for the first sentence in Section 5.3.1:

In absence of compelling circumstances (e.g. unavailability of other appropriate options), DSS does not approve 24 hour on-going PDN services.

Agency Response: Refer to Section 5.3.3.

Fourteenth, for similar reasons, we recommend inserting “or institutional placement” after the word “hospitalization”. There are non-hospital settings (e.g. Voorhees) which should be disfavored over community settings.

Agency Response: Accepted comment and change made.

DSS Note: In addition to the above changes, please be notified of the following change. To indicate the appropriate number of units to bill based on the minutes of service provided, a new section numbered 4.2.1 has been added to clarify how to calculate units of PDN service.

Findings Of Fact

The Department finds that the proposed changes as set forth in the January 2005 Register of Regulations should be adopted.

THEREFORE, IT IS ORDERED, that the proposed regulation to amend the policies for Private Duty Nursing Services is adopted and shall be final effective March 10, 2005.

Vincent P. Meconi, Secretary, DHSS, 2/15/05

DSS FINAL ORDER REGULATIONS #05-12a

REVISIONS:

Private Duty Nursing Program Provider Specific Policy

1.0 Overview

Up to 28 hours of private duty nursing (PDN) per week are included in the Managed Care Organization (MCO) benefit package for both the Diamond State Health Plan (DSHP) and the Delaware Healthy Children Program (DHCP). Additional private duty nursing hours may be covered as a wrap-around service for the DSHP. No additional private duty nurse hours are covered for the DHCP.

Medicaid clients age 21 years and over are eligible for up to eight hours of PDN daily. Children under age 21 are covered under the Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) Program and may exceed this limit if medically necessary.

Providers shall refer to the Managed Care section of the General Policy for the required forms and procedures related to Diamond State Partners (DSP).

This manual reflects the policies as they relate to:

• Medicaid clients who are exempt from managed care coverage (see list of those exempt from managed care coverage in the Managed Care section of the General Policy)

• Medicaid clients enrolled in the DSHP whose medical need for private duty nursing has been determined by the Delaware Medical Assistance Program (DMAP) to exceed 28 hours per week.

Medicaid clients whose medical need requires private duty nursing services in a non-institutional setting. [This policy does not apply to waiver group homes.]

1.1 Service Definition

1.1.1 Private duty nursing PDN services are available through the Delaware Medical Assistance Program (DMAP) DMAP for clients who require more individual and continuous [skilled] care than is available from a visiting nurse or than is required to be provided in an inpatient setting by the nursing staff of a hospital or skilled nursing facility [home health services] as defined in 42 CFR 440.80.

1.1.2 PDN services may be provided by a single nurse to an individual or to multiple clients in a non-institutional group setting as described above. The nurse-client ratio will not exceed 3 clients per nurse. unless authorized by the Medical Review Team.

1.1.3 Special aArrangements for multiple clients in non-institutional settings may be considered if such arrangements are medically appropriate and advantageous to both the client and to DMAP.

1.1.4 PDN services are provided to Medicaid clients in their home [or other DMAP approved community setting] as an alternative to more expensive institutional care. Generally, the total cost of PDN services shall not exceed the cost of care provided in an institutional setting.

2.0 Qualified Providers

2.1 General Criteria

2.1.1 Private duty nursing may be provided by any registered nurse (RN), licensed practical nurse (LPN) or certified registered nurse practitioner (CNP) (CRNP) who has a professional license from the State to provide nursing services.

2.1.2 Home health agencies that employ and provide qualified nursing staff as described above or self-employed qualified nursing staff are considered qualified providers and may enroll as PDN providers.

2.1.2.1 Individual nurses, either employed by an agency or self-employed may provide no more than 16 hours of PDN services in a 24-hour period except in an emergency situation which will be reviewed by the Medical Review Team.

3.0 Documentation

3.1 Provider Requirements

3.1.1 The private duty nursing provider is required to keep the following documentation in the patient’s record:

3.1.1.1 Documentation of orientation to client’s care needs and demonstration of nursing skills necessary to deliver prescribed care.

3.1.1.2 Maintain A written plan of care that is established, signed and dated by the attending practitioner which includes orders for medications, treatments, nutritional requirements, activities permitted, special equipment and other ordered therapies.

3.1.1.3 Renew Orders renewed, signed and dated at least once every 60 days or as often sooner as the severity of the client’s conditions requires.

3.1.1.4 Documentation that the nurse promptly alerts the practitioner to any changes that suggest a need to alter the plan of care.

3.1.1.5 Adequate documentation dated and signed by the nurse performing the service.

4.0 Reimbursement

4.1 Methodology

4.1.1 Private duty nursing services provided to eligible DMAP clients are reimbursed using prospectively determined at a rates representing hourly or 15 minute units. The unit of service for agency providers is one hour, and for self-employed nurses is 15 minutes. A weekly maximum limit is established for each client by the DMAP based on the authorized services. This limit is defined as the product of the hourly rate and the minimum number of hours necessary to maintain the client in the home as an alternative to institutionalization. Hours will not exceed eight hours daily for clients age twenty-one years and over.

4.1.2 Hourly Hourly rrates Rates for agency services are reviewed annually. The rate represents the will relate to the lowest prevailing usual and customary charge, as determined by a survey of all private duty nursing service providers agencies. Providers Agencies will be reimbursed the lower of their usual and customary charges or the maximum rate.

4.1.3 Rates for self-employed nurses will be individually negotiated, but will not exceed a predetermined percentage of the agency rate. Rates may not be renegotiated more than once annually except in extenuating circumstances. Increases will be limited to the normal medical inflation used by DMAP. Self-employed nurses will be reimbursed the lower of their usual and customary charges or the maximum rate.

4.1.3 4.1.4 Providers are not required to submit cost reports to the DMAP. There are no retrospective settlements on claims paid.

4.1.5 The baseline PDN reimbursement rate will normally represent services provided by one nurse to one client. An adjusted reimbursement rate per client will be established for medically appropriate PDN services provided by a single nurse for up to three clients. Maximum rates are established according to the following table:

One client: Rate for One = 100% of established

baseline rate

Two clients Rate for Each = 50% of 143% of

baseline rate

Three clients Rate for Each = 33% of 214% of

baseline rate

For example, if the baseline rate for one client is $21.00 per hour, the reimbursement rate for multiple client settings is as follows:

One Client: Rate for each client = $21.00 per hour

(Baseline)

Two Clients Rate for each client = $15.00 per hour

Three Clients Rate for each client = $15.00 per hour

[4.2 Counting of 15-Minute Increments

4.2.1 Visits are to be rounded to the nearest 15-minute increment. The following chart is to be used to assist providers in determining the number of units to be billed:

1 unit 1 minute to <23 minutes

2 units >23 minutes to <38 minutes

3 units >38 minutes to <53 minutes

4 units >53 minutes to <68 minutes

5 units >68 minutes to <83 minutes

6 units >83 minutes to <98 minutes

7 units >98 minutes to <113 minutes

8 units >113 minutes to <128 minutes

NOTE: Unless prior authorized, providers cannot exceed the limited number of units assigned to each private duty nursing service.]

5.0 Prior Authorization

5.1 Requirements

5.1.1 Private duty nursing services must be prior authorized by DMAP before payment from the DMAP is made available the services are rendered.

5.1.2 Private duty nursing services for clients who are eligible for the Elderly and Disabled HCBS Waiver program or the Assisted Living Medicaid Waiver program must be prior authorized by the nursing staff of the Division of Services for Aging and Adults with Physical Disabilities (DSAAPD). See the Index in back of General Policy for appropriate address and telephone number.

5.1.3 All other requests for prior authorization should be directed to the Medical Review Team Prior Authorization Units. located in the Robscott Building The New Castle County unit is located in the Robscott Building and the Kent/Sussex County unit is located in Georgetown (see the Index section in the back of General Policy for the address and telephone number of each Prior Authorization Unit).

5.1.4 The maximum number of hours provided by an individual nurse will be restricted to a level that can safely and reasonably be provided. No individual nurse will be authorized to work more than a 16 hour shift per day except in an emergency situation which will be reviewed by the Medical Review Team.

5.1.5 PDN hours must be used for the period of time in which they are authorized. If the authorized hours are not used they cannot be carried over into another time period.

5.2 General Guidelines for Private Duty Nursing Authorization

5.2.1 Initially, a DSS Medical Services Nurse completes a face-to-face medical assessment. The client will receive a written notice of approval or non-approval for PDN services.

5.2.2 The on-going need for PDN care is routinely/periodically re-evaluated. DSS may determine that because of parent/caregiver work schedule, stability of the patient, and other factors, that PDN hours may be reduced or increased.

5.2.3 PDN will only be authorized when there is at least one caregiver [and one back-up caregiver] willing and able to accept responsibility for the client’s care when the nurse is not available. DSS expects that parents/caregivers be willing and capable to accept responsibility for their relative/child’s care. If the parent/caregiver cannot or will not accept responsibility for the client’s care when PDN is not authorized or available, the client is deemed not to be in a safe environment and PDN will not be authorized.

5.2.4 DSS cannot guarantee that PDN services will be available from a specific [home health agency provider].

5.2.5 DSS reimburses for medically necessary transportation through a Medicaid transportation broker. DSS expects the parent/caregiver to accompany the client in transport. If, because of employment or school, the parent/caregiver cannot accompany the client, the prior authorized PDN may accompany the client. If the client is transported to a medical appointment or the hospital with the PDN, as soon as the parent/caregiver arrives, the PDN service is no longer required. PDN will not be authorized for a nurse to accompany a client to a medical appointment or hospital stay when the parent/caregiver is available.

5.2.6 PDN may be approved to accompany school-age children with a compromised airway [or other DMAP approved high risk condition] in transport to school and to provide medically necessary care during school hours.

5.2.7 DSS may approve PDN when a child is home sick with a cold, virus or normal childhood disease or there are unplanned school closures or inclement weather days. However, additional hours must be prior authorized. Home health agencies may not be able to provide “on demand or same day service.” Families should contact DSS as soon as they know about an unplanned school closure, etc. and find a willing and available provider.

5.2.8 DSS may approve PDN to cover summer vacation as well as scheduled school year holiday vacations for school age children if parent/caregiver requests the coverage timely. Absence of parents/guardian from the home for employment or work-related education reasons must be documented.

5.2.9 DSS projects a sufficient amount of hours per day. If the hours authorized are not used on a particular day, the hours do not carry over to the next day or weekend nor can the hours be “banked” to be used at a later time.

5.3 Determination of Hours Needed

5.3.1 DSS does not approve 24 hour on-going PDN services. DSS may approve 24 hours PDN for 3-4 days (trach and vent child/adult) to help parents/caregivers adjust and ensure all equipment is functioning. PDN reduces to 20 hours for 1-2 days. PDN then reduces to 18 hours then reduces to 16 hours, the maximum number of hours a day authorized for children (8 hours for adults).

5.3.2 PDN may be reduced further by school enrollment or attendance at a Prescribed Pediatric Extended Care (PPEC) facility. A home health aid or Certified Nursing Assistant (CNA) may be approved for some clients in lieu of PDN when appropriate and cost effective.

5.3.3 An increase in hours may be approved if additional hours will avoid hospitalization as a cost effective measure. This will depend on the medical necessity, the amount of additional hours needed and the letter of medical necessity from the admitting physician.

5.3.4 If a parent/caregiver needs hours for sleep and skilled care is required for a client with a compromised airway (trach/vent) [or other DMAP approved high risk condition] during this sleep time, PDN is approved for a maximum of up to eight hours, generally eight hours within the range of 10 pm through 8 am.

5.3.5 PDN is adjusted to cover work and travel time of the parent/caregiver or to cover education (class schedule) and travel time of the parent, if there is not another parent/caregiver in the home. PDN is authorized for up to 40 hours per week plus an additional five hours for travel to and from work or school. Parent/guardian work hours/schedule must be verified. PDN for education is for employment related classes, vo-tech, GED, high school, college, etc. and must be documented.

5.3.6 If medical care is needed, but it is less than skilled care, DSS may authorize a CNA or home health aid to provide medically necessary care if it is deemed to be the most appropriate and cost effective.

DSS FINAL ORDER REGULATIONS #05-12b

REVISIONS:

STATE PLAN UNDER TITLE XIX UNDER THE SOCIAL SECURITY ACT

STATE OF DELAWARE

ATTACHMENT 3.1-A

Page 3a Addendum

AMOUNT, DURATION AND SCOPE OF MEDICAL

AND REMEDIAL CARE AND SERVICES PROVIDED TO THE CATEGORICALLY NEEDY

LIMITATIONS:

8. Private Duty Nursing Services: All requests for private duty nursing services must be prior authorized. Private duty nursing is available only for recipients who require more individual and continuous skilled care than is available from a visiting nurse or routinely provided by the nursing staff of a hospital or nursing facility home health services as defined in 42 CFR 440.80.

DSS FINAL ORDER REGULATIONS #05-12c

REVISIONS:

STATE PLAN UNDER TITLE XIX UNDER THE SOCIAL SECURITY ACT

STATE OF DELAWARE

ATTACHMENT 4.19-B

Page 10

DELAWARE RATES FOR PRIVATE DUTY NURSING

Private Duty Nursing Services, whether performed by a provider located in Delaware or a provider with an out-of-state location are reimbursed at a capped unit rate with weekly maximum dollar limit per client, as set by the Delaware Medicaid Program. The unit rates are reviewed whenever a rate increase is requested by a provider, but no more frequently than annually, by conducting a survey of agencies that provide private duty nursing services and capping the rate at the lowest level available of these prevailing rates. The weekly maximum dollar limit is derived by multiplying the capped unit rate by the minimum number of units necessary to maintain the client in the home as an alternative to institutionalization, but not to exceed eight (8) hours daily.

Private duty nursing services provided to eligible DMAP clients are reimbursed using prospectively determined rates. The unit of service for agency providers is one hour, and for self-employed nurses is 15 minutes. A weekly maximum limit is established for each client by the DMAP based on the authorized services.

Rates for agency services are reviewed annually. The rate will relate to the lowest prevailing usual and customary charge, as determined by a survey of all private duty nursing service agencies. Agencies will be reimbursed the lower of their usual and customary charges or the maximum rate.

Rates for self-employed nurses will be individually negotiated, but will not exceed a predetermined percentage of the agency rate. Rates may not be renegotiated more than once annually except in extenuating circumstances. Increases will be limited to the normal medical inflation used by DMAP. Self-employed nurses will be reimbursed the lower of their usual and customary charges or the maximum rate.

Providers are not required to submit cost reports to the DMAP. There are no retrospective settlements on claims paid.

The baseline PDN reimbursement rate will normally represent services provided by one nurse to one client. An adjusted reimbursement rate per client will be established for medically appropriate PDN services provided by a single nurse for up to three clients. Maximum rates are established according to the following table:

One client: Rate for One = 100% of established

baseline rate

Two clients Rate for Each = 50% of 143% of

baseline rate

Three clients Rate for Each = 33% of 214% of

baseline rate

For example, if the baseline rate for one client is $21.00 per hour, the reimbursement rate for multiple client settings is as follows:

One Client: Rate for each client = $21.00 per hour

(Baseline)

Two Clients Rate for each client = $15.00 per hour

Three Clients Rate for each client = $15.00 per hour

8 DE Reg. 1303 (3/1/05)