Section R414-40-4 - Service Coverage for Private Duty Nursing(1) Private duty nursing services are a limited benefit that is provided with the expectation that the member's need for private duty nursing services will decrease over time.(2) Medicaid covers medically necessary and appropriate private duty nursing services for a limited time to provide skilled nursing care in the home. Medicaid covers private duty nursing services while the agency trains the member's caregivers to provide the necessary care. Once the caregivers have been given sufficient training for the member's needs, the private duty nursing services end. A member, however, who still requires more than four hours of ongoing skilled nursing services may receive private duty nursing services as provided in this rule.(3) The number of private duty nursing (PDN) hours that a member may receive is based on how the member scores on the PDN Acuity Grid. The PDN provider shall provide supporting documentation to justify the member's score. The PDN Acuity Grid must reflect the average daily care given by the nurse during the previous certification period.(4) After informing the member's family or similar representatives who live with the member and in coordination and consultation with the physician, the private duty nurse shall attempt to wean the member from a device or service and identify new problems.(5) Medicaid does not cover the following as private duty nursing services: (a) custodial or sitter care to ensure the patient is compliant with treatment;(c) monitoring behavioral or eating disorders; and(d) observation or monitoring medical conditions that do not require skilled nursing care.(6) Medicaid does not cover private duty nursing services if the services are available from another funding source, agency, or program.Utah Admin. Code R414-40-4
Amended by Utah State Bulletin Number 2022-17, effective 8/24/2022