Program Evaluation Division

Controlling the Cost of Medicaid Private Duty Nursing Services (December 2008)

Summary

The North Carolina Medicaid Program covers private duty nursing—medically necessary continuous, complex, and substantial nursing services provided by a licensed nurse in a recipient's home. Under federal law, private duty nursing is an optional Medicaid service for adults and a required Medicaid service for children. The Division of Medical Assistance should adopt the cost-containment mechanisms used by other states for its private duty nursing benefit for adults. The Division of Medical Assistance should modify the Community Alternatives Program for Children, which is subject to budget limits, to encourage use of the waiver program by children in need of continuous skilled nursing.

Relevant Legislation:

S.L. 2010-31, Section 10.35: Directed the Division of Medical Assistance to limit its private duty nursing service by restricting it to individuals under 21, capping the amount of care at 16 hours unless more are required under federal law, and requiring needs assessments be performed by independent entities; and required the Division of Medical Assistance to submit a technology-dependent waiver and subsequently transition individuals age 21 and over to receiving services under the waiver.

Agency Actions:

The group of stakeholders working toward a technology-dependent waiver for adults determined the Division of Medical Assistance could not meet the waiver’s cost neutrality requirement.
A policy enforcing a 16-hour limit on services for adults was implemented on December 1, 2012.

Press Coverage:

Related Reports:

Cost Savings:

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