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Nursing

People with complex medical needs may require nursing services that are typically provided through Medicaid State Plan services.

Medicaid’s State Plan Home Health Nursing can be used to meet intermittent skilled nursing needs. Intermittent  meaning each visit is four hours or less in duration. If the nursing need exceeds the four-hour limitation of home health nursing, Medicaid’s State Plan Private Duty Nursing may be authorized if medical necessity is established. If the person’s nursing needs cannot be met through State Plan Home Health and/or Private Duty Nursing, and the person is enrolled in the Individual Options Waiver, then waiver nursing could be authorized to meet the nursing needs if medically necessary. 

State Plan Home Health Nursing

Available through the Ohio Medicaid State Plan using the Ohio Medicaid card, the Home Health Nursing service can only be provided by Medicare-certified home health agencies. This service is for people with nursing needs that can be met in shifts that are four hours long or less, defined by Medicaid as intermittent services.

This service is not authorized by county boards of developmental disabilities but requires an assessment by a Medicare-certified home health agency and physician orders.

People can receive up to 14 hours per week of this service.

  • Children younger than 21 can receive more than 14 hours per week, when needed.
  • For those 21 years old or older, a prior authorization request may be submitted to ask for additional hours if needed. Prior authorization requests are submitted by the home health agency providing services.

A service and support administrator from a county board can help with finding a home health agency.

When a home health agency agrees to provide State Plan Home Health Nursing for someone enrolled in the Level One, Individual Options, or Self-Empowered Life Funding waiver, the nursing services must be included in the person’s individual service plan.

It is possible for people to receive Homemaker/Personal Care, or other services, through the waiver as well as  receive State Plan Home Health Nursing, when needed.

State Plan Private Duty Nursing

Private Duty Nursing, or PDN, is available through the Ohio Medicaid State Plan using the Ohio Medicaid card. This service is for people with nursing needs that can be met only in shifts that are longer than four continuous hours.

It can be provided by non-agency (independent) providers, Medicare-certified agencies, or otherwise-accredited home health agencies.

This service requires prior authorization. The prior authorization is submitted by the home health agency. 

For people enrolled in a managed care program, the request is reviewed by the managed care program provider. 

For people not enrolled in a waiver or a managed care program, the request is reviewed by the Ohio Department of Medicaid. 

For people not enrolled in managed care but enrolled in the Level One, Individual Options, or Self-Empowered Life Funding waiver, the requests for PDN services are submitted by the local county board to DODD for review.

County board of developmental disabilities must meet with the person face-to-face to review their physician’s orders, nursing notes, medication records, etc., in order to complete a form called the Nursing Task Inventory, or NTI.

The NTI lists

  • (a) tasks and interventions ordered by the person's physician or primary care providers,
  • (b) how these tasks are provided now,
  • (c) if nursing is being requested,
  • (d) the frequency and duration of each identified tasks,
  • (e) and potential complications of task or medical status of the person related to the identified task.

It is important for the person, parent, or guardian requesting the nursing to review the information completed and gathered by the county board to make sure it is both thorough and accurate.

The county board will submit the NTI, current physician’s orders, nursing documentation, medication administration records for at least the previous three months, along with any other relevant documents to DODD.

DODD will review all submitted documentation to make determination of medical necessity and authorization of services and service hours.

If the identified tasks can be met through non-licensed persons with the proper Medication Certification training, nursing will generally not be considered necessary, except when the person receiving the service has unique or extenuating circumstances that make performing a particular health-related task more difficult or more dangerous to them than for most people.

Should DODD determine that Private Duty Nursing is not medically necessary and, therefore, denies the PDN request, the person, parent, or guardian can schedule a home visit or conference call with the DODD review nurse in order to share additional information. PDN will only be authorized when it is determined that a licensed practical nurse (LPN) working under the direction of an RN or a registered nurse (RN) should perform skilled tasks on an ongoing basis, requiring shifts longer than four hours.

A licensed practical nurse (LPN) or registered nurse (RN) cannot provide Waiver Nursing to more than three people in a group setting during a face-to-face nursing visit.

Waiver Nursing in the Individual Options Waiver

This service is available only through the Individual Options Waiver. Agency and independent providers that have a Medicaid nursing provider agreement and have DODD-Waiver Nursing certification can provide waiver nursing services.

This service is only authorized for people who require a nurse when State Plan Home Health Nursing and/or Private Duty Nursing is unable to meet all of the person’s nursing needs.

Individual Options Waiver Nursing requires prior authorization by DODD using the same process described for Private Duty Nursing.

A licensed practical nurse (LPN) or registered nurse (RN) cannot provide Waiver Nursing to more than three people in a group setting during a face-to-face nursing visit.