SECTION 363.309. Benefits and Limitations

(a) PDN services are a benefit of the Texas Medicaid Program in accordance with the Code of Federal Regulations, Title 42, §440.80, relating to PDN services, and §440.40(b), relating to EPSDT services.

(b) EPSDT recipients are eligible for all PDN services that are medically necessary to correct or ameliorate the recipient's disability and physical and mental illnesses and conditions.

(c) The provider requesting PDN services must supply documentation to support the medical need for a private duty nurse. The documentation must also support the number of PDN hours that are medically necessary to correct or ameliorate the recipient's disability and physical and mental illnesses and conditions.

(d) EPSDT recipients are eligible for all medically necessary PDN services that are required to meet the recipient's documented PDN needs over the span of time the needs arise, as the needs occur over the course of a 24-hour day.

(e) PDN services must be:

(1) prescribed by and provided under the direction of a treating physician;

(2) included in a plan of care, as described in §363.313 of this subchapter (relating to Plan of Care);

(3) delivered by a Texas Medicaid Program-enrolled PDN services provider; and

(4) provided in compliance with all applicable state and federal laws and regulations.

(f) PDN services are available when an individual:

(1) is eligible for EPSDT services;

(2) has a treating physician who:

(A) issues a prescription or physician's order for PDN services;

(B) reviews and approves an established and maintained plan of care in accordance with §363.313 of this subchapter; and

(C) provides continuing care and medical supervision, including examination or treatment, within 30 days prior to the start of PDN services. This physician visit may be waived when a diagnosis has already been established by the physician, and the client is under the continuing care and medical supervision of the physician. The waiver must be based on the physician's written statement that an additional evaluation visit is not medically necessary. This documentation must be maintained by the physician and the provider in the client's medical record; and

(3) has a responsible adult who resides in the recipient's residence when the recipient is a minor under the age of 18 years or when the recipient is 18 years of age or older with a managing conservator or legal guardian.

(g) HHSC may not:

(1) require a recipient's responsible adult(s) to provide PDN services to the recipient;

(2) require a recipient or a recipient's responsible adult(s) to designate an alternate caregiver to provide PDN services; or

(3) deny or reduce the amount of requested PDN services because the recipient's responsible adult(s) is trained and capable of performing such services, but chooses not to do so.

(h) HHSC may require providers to instruct and train responsible adults to perform PDN services should an emergency arise, or if the responsible adults voluntarily choose to provide part of the recipient's PDN themselves.

(i) The amount of medically necessary PDN services available to recipients will not be capped.

(j) PDN services must be provided in a place of service consistent with the requirements in the Code of Federal Regulations, Title 42, §440.80, relating to PDN.

(k) PDN services may be provided only by an RN or by an LVN who is under the supervision of an RN.

(l) PDN services must be prior authorized by HHSC. PDN may be authorized for a period of up to six months.

(m) The PDN services provider is notified in writing by HHSC of the approval, reduction, or denial of requested PDN services.

(n) PDN services limitations.

(1) PDN is considered only when the services are consistent with the definition of "nursing" as described in the Texas Nursing Practice Act or its implementing regulations. PDN services will not be considered for reimbursement if the services are intended solely to provide respite care or child care, or do not directly relate to the recipient's nursing needs.

(2) A responsible adult is not eligible for reimbursement for delivering PDN services through the Texas Medicaid Program if he or she is the parent of a recipient who is under the age of 18 or the spouse of the recipient. A responsible adult who is the managing conservator or legal guardian of a recipient over 18 years of age is not eligible for reimbursement.

(o) HHSC may deny or reduce PDN hours if the recipient's PDN needs decrease.

(p) HHSC may not deny or reduce PDN when the recipient's nursing needs have not decreased.

Source Note: The provisions of this §363.309 adopted to be effective October 15, 2015, 40 TexReg 7056