Private Duty Nursing Services: An Introduction for Texas Health Steps Providers

Texas Medicaid Private Duty Nursing Services

Private duty nursing (PDN) is a benefit of Texas Health Steps for children and adolescents birth through 20 years who meet medical necessity criteria and require individualized, continuous, skilled health care beyond the level provided by a home health skilled nursing or home health aide visit.

PDN services provide skilled nursing care for patients and training and education for their parents and caregivers. The services are intended to:

  • Enhance the patient’s health status and outcomes.
  • Promote family-centered, community-based care by:
    • Preventing prolonged and/or frequent stays in hospitals or institutions.
    • Providing cost-effective and quality health care in the most appropriate, least restrictive environment, which may include a home, school, or child-care facility.

PDN services must:

Be ordered by a physician or a physician-designated advanced practice registered nurse (APRN) or physician assistant (PA).

Document medical necessity as part of the plan of care (POC).

Receive prior authorization before initiation, recertification, or modification of services.

Be provided by an RN or LVN working independently or employed by a home health services agency enrolled with Texas Medicaid.

Qualify as nursing services, as described by the Texas Nursing Practice Act and its implementing regulations.

This course provides an overview of program requirements for making referrals and requesting prior authorization for PDN services. Additional information is available in the Texas Medicaid Provider Procedures Manual (TMPPM) Home Health Nursing and Private Duty Nursing Services and Children’s Services Handbooks. The handbooks can be accessed from the Resources at the end of this course. Home health skilled nursing visits and home health aide services are beyond the scope of this course.

Need to Know

For patients with traditional or fee-for-service (FFS) Medicaid, consult the Texas Medicaid & Healthcare Partnership (TMHP) for information and forms related to PDN services. A link is provided in the Resources at the end of this course.

For patients who are members of a Medicaid managed care organization (MCO), consult the health plan for required processes and forms.

Texas Health Steps — Comprehensive Care Program and PDN

The Texas Health Steps–Comprehensive Care Program (CCP) provides medically necessary services for eligible children and adolescents. Texas Medicaid is not allowed to place a cap or limit on medically necessary services, including PDN. Children and adolescents in Texas Health Steps qualify for CCP services even if the service is not available to the rest of the population eligible for Medicaid.

The Texas Medicaid PDN benefit:

  • Is available to children birth through 20 years who are eligible for Texas Health Steps and require PDN services to promote independence or support them while living at home.
  • May not be denied or reduced based solely on diagnosis, type of illness, or condition.
  • Cannot require parents or other legally responsible adults to provide skilled nursing services. However, parents or other legally responsible adults may choose to receive training and provide care.
  • Gives consideration for all medically necessary skilled nursing services to be provided as they arise over a 24-hour period rather than being based on a designated time for an individual task (“span of time”).