Guide to Accessing Medicaid Private Duty Nursing Services in the Community

What are private duty nursing (PDN) services?

Private duty nursing services are nursing services for Medicaid members who require more individual and continuous nursing care than is available from a certified home health agency (CHHA). A CHHA may provide nursing services only on a part-time or intermittent basis, generally fewer than two hours per service authorization. A Medicaid member may be appropriate for private duty nursing services if he or she requires nursing services that exceed the amount and scope of nursing services that a CHHA may provide. Private duty nursing services are not warranted for non-skilled tasks such as, but not limited to, turning and positioning, ambulation, transferring, bathing, toileting, oral feeding, dressing, and household chores. The intention of PDN services is to support - not replace - the skilled care provided to a member by parents, family, and other responsible caregivers. Commitment by the family and community are necessary to meet the member´s needs and to ensure the member can remain safely at home.

Who can provide private duty nursing services?

Private duty nursing services may be provided by Licensed Home Care Agencies (LCHSAs) or independently practicing RNs or LPNs who are enrolled with New York State Medicaid.

All nurses providing PDN services must possess a current RN or LPN registration with the New York State Department of Education. Independent enrollment with Medicaid and any approval for PDN services does not constitute an exception to, or expansion of, any scope of practice defined by New York State Education Law. PDN services provided by an independently enrolled LPN must be overseen by a licensed physician. PDN providers, whether independent providers or licensed agencies, are not employees of the Department of Health.

How does a Medicaid member in the community obtain private duty nursing services?

PDN services require prior approval and must be submitted by an enrolled servicing provider (LHCSA or independent RN or LPN) under the direction of a Medicaid enrolled physician or nurse practitioner. For further instruction on submitting a prior approval and documentation requirements, please refer to the Private Duty Nursing Policy Manual.

Under federal law, the Medicaid program is the payer of last resort. All third-party obligations must be exhausted before claims can be submitted to Medicaid. It is the responsibility of the member (family) and provider to investigate and exhaust all other insurance sources prior to billing Medicaid.

Is there a list of Medicaid private duty nursing providers for medically fragile children and adults?

Based on Article VII amendments to SSL 367r; the Department of Health has implemented a PDN directory for medically fragile children and adults. The directory will list the names and contact information of independently enrolled RNs, independently enrolled LPNs, and nursing agencies who are interested in providing PDN services to medically fragile children and adults. Participation by providers in the directory indicates the willingness to accept inquiries for providing care to medically fragile children and adults.