RD65 - Community-Based Nursing Transformation in the Medicaid Program – December 15, 2018

Executive Summary:

Nursing is an important component of a continuum of supports designed to allow eligible Medicaid recipients to live within their communities. “Skilled nursing" is a level of care that includes services that can only be performed safely and properly by either a registered nurse (RN) or a licensed practical nurse (LPN). Medicaid currently covers several skilled nursing services (dependent on eligibility), including Home Health, Skilled Nursing (SN), and Private Duty Nursing (PDN). PDN services are skilled nursing services for eligible individuals with complex medical needs who require more individual and continuous care than is available from an intermittent visiting nurse, such as those available in the Home Health and Skilled Nursing services.

Per the direction of the 2018 Appropriations Act, the Department of Medical Assistance Services (DMAS) is conducting a review of the complicated system for provision of nursing services to Medicaid recipients. This delivery system has not been reviewed in upwards of 15 years, and it has not kept up with changes in the practice of medicine and in demand for services.

This report details the work already completed and an initial set of recommendations for the further transformation of these services. Among the recommendations updates to the medical necessity criteria used to determine the amount of services that are appropriate to meet recipients’ clinical needs and a simplification of the billing codes and rates for these services. DMAS also recommends a new methodology for reimbursement of these services that will allow CNAs to function as nurse-extenders in a team-based approach to care delivery. Doing so would simultaneously address workforce concerns through the use of assistive personnel, allow higher-level skilled professionals to practice at the top of their licenses and provide a de facto rate increase for community-based nursing providers without a formal rate increase with budgetary impacts.