Important Information for Physicians Concerning TennCare
Changes in Coverage of Private Duty Nursing and Home Health
WHO:
• Adult TennCare enrollees age 21 and over will be affected by these changes.
• Children under the age of 21 will NOT be affected
WHAT:
CHANGES TO PRIVATE DUTY NURSING
TennCare will only cover private duty nursing (PDN) for adult patients who:
1. Are ventilator dependent (for at least 12 hours per day), OR
2. Have a functioning tracheostomy requiring suctioning AND need other specified
types of nursing care*.
* Patient must require all of the following: 1) oxygen, 2) nebulizer or cough assist, 3) medication via G-
tube, PICC line or central port and 4) TPN or nutrition via G-tube.
CHANGES TO HOME HEALTH
For all other adult patients, the following home health (HH) coverage limits will apply:
Limits for Most Adult TennCare Enrollees
Home Health Aide Care Home Health Nurse Care
• Up to 35 hours per week • Up to 27 hours per week
o No more than 8 hours/day o Each visit must be < 8 hrs
o No more than 2 visits/day o No more than 1 visit/day
o HH aide and nurse care o HH nurse and aide care
combined cannot exceed combined cannot exceed
35 hours per week 35 hours per week
• For example, 35 hours/week = • For example, 27 hours/week =
o 7 hours, 5 days/week o 5 hours, 5 days/week
o 5 hours, 7 days/week o 3.5 hours, 7 days/week
Limits for TennCare Adults Who Qualify for Level 2 (Skilled) Nursing Facility Care
Home Health Aide Care Home Health Nurse Care
• Up to 40 hours per week • Up to 30 hours per week
o No more than 8 hours/day o Each visit must be < 8 hrs
o No more than 2 visits/day o No more than 1 visit/day
o HH aide and HH nurse o HH nurse and HH aide
care combined cannot care combined cannot
exceed 40 hours per week exceed 40 hours per week
• For example, 40 hours/week = • For example, 30 hours/week =
o 8 hours, 5 days a week o 6 hours, 5 days/week
o 5.5 hours, 7 days a week o 4 hours, 7 days/week
WHEN:
• Effective September 8, 2008 for new orders.
• Effective as early as September 18, 2008 for existing orders.
WHY:
• 24/7 private duty nursing costs on average over $300,000 per person per year
compared to an average annual skilled nursing home cost of less than $60,000.
• TennCare’s private duty nursing and home health costs have grown from $54
million to $243 million in a four year period.
• The annual growth rate of 53% is unsustainable in a taxpayer funded program.
WHAT YOU CAN DO TO ASSIST YOUR PATIENTS:
A notice of the benefit change was mailed to all adult enrollees on August 8th. On
September 8th, MCOs will begin sending an additional letter to any patient who is
currently receiving amounts of care in excess of the new limits providing 10 day advance
notice before TennCare stops payment on services exceeding the limits.
It is critical that you work with your patients currently receiving amounts of care in
excess of the limits to determine the best course of action which may include:
1. A new order for an amount of home health which is covered by TennCare.
2. A continued order for the same amount of home health, with the understanding
that the patient will be financially liable for amounts of care exceeding the limits.
3. An order for nursing home care, if you and the patient/patient’s family believe
this is needed.
OTHER IMPORTANT INFORMATION ABOUT THESE BENEFITS:
• Home health services and private duty nursing orders require prior authorization
by the MCO. The ordering physician must provide specific information
regarding the services the nurse or aide is expected to perform (not just an order
for a number of hours of care).
• A home health nurse visit for an adult will NOT be extended in order to perform
skilled nursing functions at more than one point during the day, unless skilled
nursing services are medically necessary throughout the intervening period.
• Home health nurses/aides and private duty nurses do NOT:
o provide general supervision, safety monitoring or sitter services
o provide non “hands on” care such as housecleaning and meal preparation
o transport patients
• Home health nurses/aides do NOT accompany adult patients outside the home.
• Private duty nurses may accompany an adult patient outside the home only to
school, work or health care appointments.
• Home health and private duty nursing can include services to teach and train the
patient and the patient’s caregivers to manage the patient’s treatment regimen.
• To ensure the health and safety of the patient, in order to receive PDN, the patient
must have a family member or other caregiver trained and willing to meet the
patient’s nursing and non-nursing needs.