To:                   Ms. Emily McClellan

                        Department of Medical Assistance Services

FROM:             Colleen Miller

RE:                   Draft EPSDT Provider Manual

DATE:              September 1, 2021

Dear Ms. McClellan,

Thank you for the opportunity to comment on the Draft EPSDT (Private Duty Nursing Services) Provider Manual (Draft PDN Manual). As the protection and advocacy organization for the Commonwealth, the disAbility Law Center of Virginia (dLCV) has an interest in ensuring that children with disabilities receive those services that are necessary for them to live safely in the community, including Private Duty Nursing (PDN) services.

dLCV is concerned that some of the proposed amendments in the Draft PDN Manual reflect, and will exasperate, problematic trends in the Private Duty Nursing (PDN) service authorization and reauthorization process. dLCV has represented multiple Medicaid beneficiaries whose PDN services have been reduced or revoked in recent months, and we have heard from others who have experienced similar reductions or revocations of previously approved PDN services. Frequently, the Medicaid members involved have similar nursing needs: They have complex comorbid developmental and medical conditions; their need for discreet nursing interventions is inconstant and unpredictable; and their PDN services were previously authorized, in part, based on their need for ongoing monitoring and assessment to determine when a discreet nursing intervention is needed and to intervene as necessary.

At a recent DMAS Fair Hearing involving the revocation of previously approved PDN services, a Managed Care Organization (MCO) representative testified that the PDN Medical Needs Assessment (DMAS-62) form does not allow for consideration of the need for ongoing monitoring and assessment when determining the medical necessity of PDN services. This testimony was surprising, given that the currently effective EPSDT PDN Manual instructs providers to document the need for “medical monitoring” in the individual’s Plan of Care, as well as on the Medical Needs Assessment form;^[1] and the service description of Private Duty Nursing in the Manual explains that the service must be “deemed medically necessary by an attending physician to assess, monitor, and provide medical interventions….”^[2] Both of these references to the need for medical “monitoring” as a component of the PDN medical necessity calculus, however, are stricken from the Draft PDN Manual.^[3]

The exclusion of the need for ongoing monitoring and assessment from the PDN medical necessity calculus poses special risks for children whose medical conditions are characterized by the need for medical interventions that are unpredictable in their timing. Denying, reducing, or revoking PDN services for these children, because their need for discreet nursing interventions is not constant, places them at greater risk of institutionalization, or of heightened risk of serious illness, injury, or death if they remain in the community without adequate nursing supports. Many of these children are also on one of Virginia’s Developmental Disabilities Waivers (DD Waivers) and would have been eligible for PDN services through the DD Waiver prior to a policy change in 2017 requiring all PDN service authorization requests for children to be processed as EPSDT PDN. Consistent with the currently effective PDN Manual, the DD Waiver regulations included in their list of allowable activities, inter alia: “On-going monitoring of an individual’s medical status as it relates to specified medical and nursing needs.”^[4] As Virginia continues to work towards coming into compliance with the DOJ Settlement Agreement, this is not the time to make it more difficult for Virginians in the Settlement Agreement population to obtain the services that they need to live safely in the community, rather than in an institutional setting.

dLCV urges DMAS to restore and strengthen language in the Draft PDN Manual clarifying that ongoing monitoring and assessment are components of the PDN service; that providers should document the need for ongoing monitoring and assessment in the comments section to the “other” category on the Medical Needs Assessment form (DMAS-62); and that the need for ongoing monitoring and assessment is a component of the PDN medical necessity calculus to be taken into consideration during the service authorization process.

Thank you for this opportunity to comment on the Draft EPSDT Provider Manual. If you have any questions about these comments or otherwise wish to discuss this matter further, please contact Robert Gray, dLCV Director for Compliance and Quality Assurance, at robert.gray@dlcv.org or 804-225-2042.

Sincerely,

Colleen Miller

Executive Director

The Arc of Virginia appreciates the opportunity to review and comment on the Draft EPSDT Private Duty Nursing Services Provider Manual.  The Arc of Virginia is an advocacy organization representing people of all ages with developmental disabilities and their families.

Families of children/young adults who use PDN are often faced with service authorization issues that put their children at risk and poses undue pressure on families.  Some have had services reduced.  Many have complex developmental and medical conditions.  Due to their conditions it is often impossible to predict when the need for discreet nursing interventions will occur.  In addition to nursing interventions they need continuous monitoring and assessment so that when a discreet nursing service is necessary the intervention takes place.   

The Arc of Virginia strongly recommends that the Dept. of Medical Assistance Services include language in the PDN Manual that explicitly states that ongoing monitoring and assessment are activities of private duty nursing. 

Thank you for your consideration of this comment.  

Sincerely,
Lucy Cantrell
The Arc of Virginia