This amendment authorizes the Department of Medical Assistance Services to review and adjust private duty nursing services, rates and rate methodologies as a part of Medicaid home and community-based services (HCBS) waivers and the Medicaid Early, Periodic Screening, Diagnosis and Treatment (EPSDT) benefit. The medical necessity criteria for private duty nursing services for individuals in HCBS waivers and those who use the EPSDT benefit has not been evaluated for many years. This review is necessary to ensure that DMAS is applying updated medical necessity criteria that reflects the advances in medical treatment, new technologies, and use of integrated care models that allow medically complex individuals to live longer, healthier lives in their homes and communities. It will also ensure this service is being
utilized in a clinically appropriate and cost effective manner for all Medicaid and FAMIS members and that lower costs services such as skilled nursing, home health nursing, personal care, and behavioral supports are utilized when clinically appropriate.