As a rule that does not require a RFA, RAFA or JIS, this rule will be initially reviewed in the calendar year 2025, which is no later than the 5th year after the year in which this rule is being adopted.

The Department of Health (“DOH” or the “Department”) received several comments from St. Mary’s Healthcare Systems for Children regarding the amendment of Social Services Law Sections 363-a(2) and 367-r, Section 505.8 of Title 18 (Social Services) of the Official Compilation of Codes, Rules and Regulations of the State, specifically the proposed rule change to Private Duty Nursing Services to Medically Fragile Children. The comments are summarized below with responses. Comments received were concerning the three-year incremental timeline for fee increases, and the recommendation that private duty nursing (PDN) fees should be the same across fee-for-service Medicaid and Managed Medicaid plans. One comment was not addressed because it did not concern the proposed rule changes.

COMMENT:

“Although St Mary’s values the statute that increases fee for service private duty nursing rates we request future consideration to the three year incremental timeline and the impact it will have on families that have private insurance and are required to remain in fee for service Medicaid. Families in New York State pay high insurance premiums to ensure their medically fragile children receive quality medical care however, due to the managed Medicaid enrollment exclusion they still must rely on fee for service rates to secure private duty nursing. The inequity in the rates will continue to force nursing agencies to compete with managed care rates, minimize their ability to hire nurses and most importantly put families in crisis situations. For these reasons St Mary’s strongly recommends future consideration to an immediate increase to fee for service private duty rates to equal managed care rates rather than an incremental increase over three years.”

RESPONSE:

The responsibility of setting PDN fees will be under the authority of the Commissioner of Health. Current fees for PDN services are set by the county and will transition to regional PDN fees as of 10/1/2020. The regional fees were established to provide equitable reimbursement in two geographical regions, removing the county to county variability. Nurses who provide services to medically fragile children and enroll in the PDN directory will receive an enhanced fee. The enhanced fee will be provided in a three-year incremental timeframe. The enhancement will be calculated based on the new regional fees established. The provider will continue to receive the enhanced fee until the member reaches the age of 23. These increases are in addition to the 30% enhanced fee for nurses who demonstrate that they have the training and experience to treat medically fragile children. The 30% enhancement has also been expanded to nurses servicing members up until the age of 23. Enrollment in the directory, the new regional fees, and enhanced fees will strengthen the network of providers available to Medicaid members and better match medically fragile children with a nurse trained to meet their medical needs.

COMMENT:

“St Mary’s is also concerned about the continuous need to address fee for service private duty nursing rates and strongly recommends the same Medicaid rate for the same service regardless of whether it is fee for service or managed Medicaid.”

RESPONSE:

As stated above, the responsibility of setting PDN fees will be under the authority of the Commissioner of Health. Currently the counties set fees for PDN services and are variable. Regional fees that will go into effect on 10/1/2020 will eliminate the variability between counties. The regional fees were established to provide reasonable and fair reimbursement for PDN services in two geographical areas. The Managed Medicaid Plans are responsible for providing the same coverage for services that fee-for-service Medicaid provides, however, they have the ability to set their own fees. Fee-For-Service Medicaid will set fees based on geographic location and industry standards. As described above, fee enhancements for nurses providing services to medically fragile children are available. With fees being set by the Commissioner of Health as of 10/1/2020 and having only two fees based on region throughout the state, re-evaluation of fees can be performed more consistently and ensure that fee-for-service nursing providers are receiving equitable reimbursement for the services they are providing to Medicaid members.