Many people with disabilities need nursing care for a medical condition. People who are enrolled in the Medicaid program can get nursing services in their own homes. With a doctor’s prescription, you can get nursing care on a part-time (or intermittent) basis, which generally means no more than 14 hours a week and visits that last no more than four hours. With approval (called “prior authorization”) from the Ohio Department of Medicaid (“ODM”), you can get private duty nursing (“PDN”) services. These are continuous nursing services that can be more than 14 hours a week and for longer than four hours at a time.
Recently, many people getting PDN services have learned that their services will be reduced or even eliminated. This creates many problems for people and their families and may even be illegal under Medicaid law and the Americans with Disabilities Act (ADA).
What are some of the reasons why my PDN services would be reduced or eliminated?
The ODM could give any of the following as a reason. This does not mean that the reason is factually accurate or legally appropriate:
- a parent or other family member, instead of a nurse, can provide nursing services for you;
- an aide can perform the nursing services instead of a nurse (this is called “delegated nursing”);
- you do not need “continuous” nursing services, only part-time or intermittent; or
- your condition has improved.
Can a decision to reduce or eliminate my PDN services be challenged?
Yes. Before proposing to reduce or eliminate your PDN services, the ODM must provide you 15 days advance written notice explaining the reason for the decision and giving you the opportunity to request a Medicaid state hearing to challenge the decision. You have 90 days from the date of the notice to request a hearing, but if you request a hearing within 15 days of the notice, your PDN services must be maintained until a hearing is held and a state hearing decision is issued. This is called a “stay put.”
What should I do if my PDN services are reduced or eliminated?
In addition to requesting a Medicaid state hearing, you should contact Disability Rights Ohio immediately. Our phone number is 800-282-9181, and select option 2 for the intake department. At Disability Rights Ohio, we will provide you guidance on the Medicaid state hearing process and how to prepare for the hearing.
Are nursing services available through other Medicaid programs?
Yes, including the federal Early and Periodic Screening, Diagnostic and Treatment (“EPSDT”) program (known in Ohio as “Healthchek”) for individuals under age 21, as well as home and community-based services waiver programs, like the Ohio Home Care waiver. Contact Disability Rights Ohio for more information on these and other programs.