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Private Duty Nursing: A Medicaid Covered Service
June 2024
Skilled nursing services at home allow children with complex medical needs to get the care they need safely in a familiar and loving environment. For children covered by Wisconsin Medicaid including Badgercare Plus, Katie Beckett Medicaid or SSI Medicaid, their ForwardHealth card may cover the cost of having a nurse come into their home. This benefit is called private duty nursing (PDN) services.
Qualifying for PDN Services
If your child needs at least eight hours of skilled nursing services in a 24-hour period, they may qualify for PDN services. If your child has less than eight hours of nursing-needs each day they may qualify for another service, called intermittent nursing care but they likely will not qualify for PDN services. When you’re figuring out if your child qualifies for PDN think about the time it takes for all the skilled nursing care they need each day. Your child’s medical providers may be able to help you in this process.
Below are a few examples of what Wisconsin DHS considers to be a skilled nursing-level service:
- Tracheostomy management
- Continuous infusions or oxygen that will result in hospitalization if stopped for more than one hour
- Giving medications or nutrition through a central line
- Frequent suctioning to maintain their airway
- Mechanical Ventilation (ventilator or CPAP)
Care that does not qualify as skilled level nursing under Wisconsin Medicaid rules:
- Gastrostomy feedings (include the time needed to begin, disconnect, and flush – not the entire time the feeding is dispensing)
- Managing chronic vomiting
- Managing common or non-significant wounds
For more information on this topic read the ForwardHealth handbook section, qualifying for private duty nursing.
Make Sure Your PDN Services are Approved by Wisconsin Medicaid
While some private insurance plans will pay for PDN, Wisconsin Medicaid will only pay for the service if it is provided by a Medicaid-certified home health agency or a Medicaid-approved nurse. It is important to confirm that the agency or individual nurse you work with is authorized to bill Medicaid, so that your child’s ForwardHealth card fully covers the cost of these services.
Before services begin, you’ll need to contact an agency or an independent nurse. They will develop a plan of care and submit a Prior Authorization (PA) request to Wisconsin Medicaid that must be approved before services can start.
Tip for Families
We know the shortage of direct care providers is impacting Wisconsin families’ ability to find private duty nurses. Many agencies cannot hire enough nurses to fill open positions. Talk with other families, your child’s school district nurse and staff at the hospital or health system where your child receives care. They may be able to connect you with an agency or independent nurse. Another option is to find a nurse willing to work with your family who can then take the needed training, complete the required paperwork and become a Medicaid provider.
Getting Started
- Your child’s medical providers may be able to recommend home health agencies or independent nurses. You can also ask your local hospital or one of Wisconsin’s children’s hospitals and their complex-care program staff.
- Once you have decided on a PDN provider, they will work with you and your child’s medical providers to develop a care plan. The care plan will include: a medical assessment, medication and treatment orders, treatment goals, what care will be provided, and other related information.
If you are working with an independent nurse, you can make them your child’s Prior Authorization Liaison (PAL). (Note that a PAL’s time to complete the required paperwork is not covered by Medicaid.)
- The PDN provider will also talk with you about your other responsibilities and your family support needs. They will ask about your ability to provide medical care and treatment, your daily schedule including your work hours, school, sleep and the care you need to provide for your other children or family members.
- Once the care plan is completed, the home health agency or PAL will:
- prepare a prior authorization (PA) request,
- have you sign that you have read and approve the care plan and prior authorization request, and,
- submit the PA request and care plan to WI Medicaid for review and approval.
- If Medicaid staff members have questions, they may send the PA request back to the home health agency or PAL for more information or documentation.
- You will then receive a letter from the Department of Health Services letting you know if your request was approved, modified or denied. A PA is modified when less nursing time is approved than was originally requested.
What if PDN Services are Modified or Denied? Your Appeal Rights
Families have the right to appeal denied or modified PDN services. Start by calling the home health agency or independent nurse who submitted the plan of care and PA request. Ask if there are details, additional documents or medical information that may have been left out. If you feel the denial isn’t the right decision, your family can appeal the denial or modification by requesting a fair hearing. This is usually a phone call with an Administrative Law Judge (ALJ) and does not require hiring an attorney. We have more detail about this process in the Family Voices fact sheet on appealing a Medicaid denial, Medicaid: How Do I Appeal a Denial.
PDN Outside Your Home
While PDN services are generally provided in your home, if your child spends time each day at school or in other community settings, nursing services can be provided outside your home. However, Medicaid will only cover the cost of nursing services OUTSIDE your home if your child is approved for PDN WITHIN your home and their plan of care authorizes nursing services in other locations, like school.
INFORMATION AND RESOURCES
Wisconsin Wayfinder: Children’s Resource Network, 877-WiscWay (877-947-2929): Wisconsin Wayfinder offers families one name and phone number to find services for children with special health care needs. Wayfinder connects you to a resource guide at one of the five Children’s Resource Centers in your area.
Family Voices of Wisconsin, 2024© | familyvoiceswi.org