Investing in Medically Fragile Children

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Information for Providers on New York State´s Initiative

September 2020

Private Duty Nursing (PDN) Services

  • Private duty nursing services (PDN) are nursing services for NYS Medicaid fee for service (FFS) members who require continuous skilled nursing care in a non-institutional setting
  • Medically fragile children are at risk of hospitalization or institutionalization but are capable of being cared for at home if provided with appropriate home care services

2020 Legislative Changes to Private Duty Nursing

  • Article VII Amendments to SSL 367r: Private duty nursing services worker recruitment and retention program for Medically Fragile Children (MFC)
    • Authorizes the NYS Medicaid FFS program to reimburse noninstitutional pediatric continuous private duty nursing provided to medically fragile children at an enhanced fee
      • PDNs will be included in a newly created Private Duty Nursing Medically Fragile Children´s Provider Directory (up to age 23)
  • The responsibility of setting PDN fees will be under the authority of the Commissioner of Health
    • Transition from county PDN fees to regional PDN fees

Medically Fragile Children´s PDN Program

  • The Medically Fragile Children´s Private Duty Nursing Program consists of two components with corresponding financial enhancements for provider participation
    1. Private Duty Nursing Medically Fragile Children Training and Experience (expanded to include up to age 23)*
    2. Private Duty Nursing (PDN) Medically Fragile Children´s (MFC) Provider Directory (up to age 23)
      • *Training and Experience enhancement to age 23 allows alignment of both components to service the entire span of the member´s eligibility in the Program
  • Providers can choose to enroll in one or both components of the Medically Fragile Children´s Private Duty Nursing Program
  • Re-enrollment into each of these program components will be necessary every five years during a provider's routine Provider Enrollment Revalidation Process
  • Eligible providers:
    • Licensed Home Care Services Agency (LHCSA)
    • Independently enrolled nurse providers (RNs and LPNs)

What is the Medically Fragile Children´s Provider Directory?

Medically Fragile Children´s Provider Directory

  • Lists private duty nurses and nurse agencies that serve Medicaid members, up to age 23, receiving FFS private duty nursing services
  • Searchable by name, licensure, city, county
  • Identifies providers enrolled in Medically Fragile Children Training and Experience
  • Directory will be available to the public
  • Directory will be updated on a weekly basis
  • A PDN´s participation in the directory indicates the willingness to accept inquiries for providing care to medically fragile children
  • Inquiries will be received from family members or representatives, discharge planners and case managers
  • Directory participants are expected to respond to all inquiries received
  • Enhanced fees will be applied to PDN cases for dates of service 10/1/2020 and after
  • Active participation in the Directory is required for enhanced reimbursement
  • Listing in the Directory does not guarantee employment

Benefits of Participation

PDN MFC Program Fee Enhancements

  • Fee enhancements applied for each component:
    1. Medically Fragile Children Training and Experience
      • Already an option. Nurse/Agency enrolls in the program by attesting to medically fragile children training and/or experience
      • 30% fee enhancement to be calculated at claims submission
    2. PDN Medically Fragile Children´s (MFC) Provider Directory
      • Fee enhancement percentages applied to regional base fees
        • October 1, 2020 - 15%
        • April 1, 2021 - 30%
        • April 1, 2022 - 45%
  • If provider is eligible for both enhancements – stacked payment upon claims processing
  • Directory enhancement will be added after the current Training and Experience enhancement

PDN Regions

  • Effective 10/1/20
  • Two regions:
    1. Downstate:
      • Bronx, Dutchess, Kings, Nassau, New York, Orange, Putnam, Queens, Richmond, Rockland, Suffolk, Sullivan, Ulster and Westchester counties
    2. Upstate:
      • Albany, Allegany, Broom, Cattaraugus, Cayuga, Chautauqua, Chemung, Chenango, Clinton Columbia, Cortland, Delaware, Erie, Essex, Franklin, Fulton, Genesee, Greene, Hamilton, Herkimer, Jefferson, Lewis, Livingston, Madison, Monroe, Montgomery, Niagara, Oneida, Onondaga, Ontario, Orleans, Oswego, Otsego, Rensselaer, St. Lawrence, Saratoga, Schenectady, Schoharie, Schuyler, Seneca, Steuben, Tioga, Tompkins, Warren ,Washington, Wayne, Wyoming, Yates counties

PDN Base Fees Effective October 1, 2020

  • Upstate Region
    • RN: $27.30
    • High-Tech RN: $31.31
    • LPN: $22.92
    • High-Tech LPN: $25.93
  • Downstate Region
    • RN: $30.90
    • High-Tech RN: $33.99
    • LPN: $24.72
    • High-Tech LPN: $28.84
  • Fees based on the highest current county fee
  • Ontario County current cases will be grandfathered to continue current fee

Conversion of Current Prior Approvals to New Regional Fees

  • All PAs approved with a date span of service AFTER October 1, 2020 will be approved at the new regional fees
  • All PAs approved in September 2020 with date span of service that includes dates of service BEFORE and AFTER October 1, 2020 will have TWO PA numbers:
  • One PA for dates of service BEFORE September 30, 2020 at the current fees
  • One PA for dates of service AFTER October 1, 2020 at the new regional fees
  • PAs that are in process at the time of the new regional fees will be end-dated September 30, 2020
    • A new PA will be created based on regional fees for approved hours
    • A new PA letter will be sent to the provider/member for use AFTER October 1, 2020
  • Providers will need to put the appropriate PA number on claims based on date of service to be reimbursed the appropriate fee

Medically Fragile Children´s PDN Program
Provider Enrollment Process

Provider Enrollment Process

  • Access forms on eMedNY in the "Provider Enrollment" section
    • Forms are provider type specific:
      • Agency Providers: follow "Nurse Registry" instructions
      • Independent Providers: follow "Nurse (LPN/RN)" instructions
  • Providers may participate in one or both programs
  • Complete Section One for Certification of Nurse Training and Experience
    • Form no longer requires listing training or experience.
    • Documentation to support training and experience must be kept by the independent nurse/agency and presented to the Department on request
  • Complete Section Two for Private Duty Nursing Provider Directory
  • Sign and date certification(s)
  • Mail to eMedNY, PO Box 4610, Rensselaer NY 12144-4610

Provider Enrollment MFC Form

Requirements & Additional Forms

✓ Proof of current licence / registration
  1. Copy of license with future expiration date,
  2. Copy of license registration/renewal, or
  3. Printout of your license status from the licensing agency´s website.
✓ Electronic Funds Transfer (EFT) Authorization - form #701101
(NOT REQUIRED for revalidation if EFT is already in place and no change is requested). If you answered "No" to the Enrollment Form´s Group question (Line 4 of page 2), EMEDNY -701101 is NOT required. Also not required for revalidation or reinstatement/reactivation.
✓ ETIN Certification Statement for New Enrollments - form #490602
(NOT REQUIRED for revalidation or reinstatement/reactivation). If you already have an existing ETIN that you wish to affiliate with, submit the Certification Statement for Existing ETINs (EMEDNY 490601) after you receive your Provider ID. This form is available on eMedNY under "Maintenance Forms".
✓ Medically Fragile Children Program - form #432301
To apply for the Medically Fragile Children PDN Enhancement, complete this form.
✓ Prior Conduct Questionnaire - form #431001
(If you answer "Yes" to questions 1-4 in section 6 of the enrollment application, you must complete this form).

OMIG Provider Compliance Certification - Confirmation notice for the OMIG Provider Compliance Program may be required. Visit OMIG to determine if the Applicant / Provider must comply. If yes, a copy of the confirmation notice (printed from the website) must be included with this application.


Questions and Answers