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(a) A medicaid recipient under 21 years of age who meets the criteria of this section will, in the division's discretion, be eligible for private duty nursing services in order to live in a family setting and prevent admission to, or promote early discharge from, an acute care or long-term care institution.
(b) To be eligible for reimbursement for private duty nursing services, a recipient under 21 years of age must
(1) have a full or partial EPSDT screening as specified in 7 AAC 43.452 on file with the division that was completed within 12 months before or one month after each use of private duty nursing services;
(2) need medical services that can only be provided by a registered nurse, licensed practical nurse, or an advanced nurse practitioner, including a nurse midwife; and
(3) repealed 6/26/98;
(4) have been recently discharged from an acute care or long-term care facility, or have a physical health status that the division, in its discretion, determines would justify admission to an acute care or long-term care facility.
(c) The department may enroll as a private duty nursing provider a hospice agency in accordance with 7 AAC 43.458, or a home health agency in accordance with 7 AAC 43.800 - 7 AAC 43.820.
(d) The employee of an enrolled private duty nursing agency who furnishes services directly to a recipient shall separately enroll with the division as a rendering provider and must have a valid license or authorization to practice in the state as a registered nurse, practical nurse, or advanced nurse practitioner, including a nurse midwife.
(e) The division will, in its discretion, reimburse for private duty nursing services if
(1) the division authorized the services before the services were provided;
(2) the services are provided under a plan of care approved by a physician;
(3) the services are provided by a rendering provider licensed to perform the tasks specified by the plan of care;
(4) the services provided are skilled nursing services that cannot be performed by a personal care attendant, a home health aide, or members of the immediate family; skilled nursing services do not include housekeeping, laundry, shopping, meal preparation, or transportation;
(5) a competent person residing with the recipient agrees to participate in the child's care; and
(6) the services are required less than 24 hours per day, at a total daily cost that, when combined with the costs of all other medicaid-reimbursable services provided to the recipient, does not exceed the cost of the institutional care for which the recipient would qualify if private duty nursing services were not provided.
(f) The division will reimburse for in-state private duty nursing services at the lesser of the amount charged to the general public or $80 per hour for registered nurse or advanced nurse practitioner services and $75 per hour for licensed practical nurse services.
(g) To be reimbursed by the division, an out-of-state private duty nursing agency and its employees who are rendering providers must be licensed to practice and enrolled in the medicaid program in the state in which service is provided, and enrolled in the medicaid program in Alaska. The division will reimburse an out-of-state private duty nursing agency and its employees at the lesser of amount charged the general public or the medicaid rate for such services in the state in which service is provided.
History: Eff. 12/31/92, Register 124; readopt 8/7/96, Register 139; am 6/26/98, Register 146; am 4/28/2005, Register 174
Authority: AS 47.05.010
Editor's note: Effective 8/7/96, Register 139, the Department of Health and Social Services readopted 7 AAC 43.456 in its entirety, without change, under AS 47.05 and AS 47.07. Executive Order No. 72 transferred certain rate-setting authority to the department.
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Last modified 7/05/2006