New Rules Proposed for PDN Rate Increase, Appeals Process Change in Managed Care 

Situation Report | July 13, 2020  

The state Department of Health (DOH) has posted two proposed rules to implement a rate increase for private duty nursing (PDN) and a change to the appeals process in managed care. 

  • The PDN rule would implement a recent state budget increase in Medicaid fee-for-service reimbursement for PDN services provided to medically fragile children by fee-for-service PDN services providers who enroll in a provider directory. The increased rates will be implemented over a three-year period, starting October 1, 2020, and will be used to address a shortage of nurses who accept the Medicaid fee schedule for an estimated 1,500 medically fragile children.
  • Another proposed rule seeks to align state regulations with current federal regulatory authority that requires enrollees in Medicaid managed care organizations (MMCOs) to exhaust the MMCO’s action (i.e. internal) appeal process for most actions prior to a fair hearing. The federal exhaustion requirement was first promulgated by the U.S. Centers for Medicaid and Medicare Services (CMS) on May 6, 2016 and became effective April 1, 2018. DOH is also seeking to amend and introduce rules regarding procedure and presentation of evidence for Medicaid fair hearings and external appeals. These new rules are intended to clarify and standardize procedures and to promote uniformity in the application of Medicaid rules for the authorization and utilization of services in fair hearing and external appeals processes.