Confused about new medicaid rules

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    The mother of the child I care for got a letter from the nursing agency. The letter said that no staff were allowed to take patients to places like parks, movie theaters,libraries,malls etc. The agency said that these types of activities are not covered by medicaid. Medicaid only reimburses services that do not duplicate another provider's service and are medically necessary for the treatment of a specific documented medical disorder, disease or impairment. Therefore, the agency says that the only type of transportation that will be considered for review will be for medically necessary appointments only. So I quess this means no nurse will be provided to go to school with this child who has a trach? Mom said they also told her that she can only get a nurse when she is at work.
    I had thought that the whole purpose of us going into the home was to provide respite for the family so they could take care of their personal business while the nurse took care of their child. Is this just a Florida medicaid rule or all of the states? Thanks for any insight.
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    My employer doesn't even let us go to medical appointments with the patient unless it all occurs during the course of an eight hour shift because they refuse to pay for overtime.
    Blackcat99 likes this.
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    Both agencies I've worked at we aren't allowed to take a patient (meaning drive them ourselves or drive their van or whatever) unless it's a "special circumstance". It's never come up so I don't know what a "special circumstance" might be.

    The only time I accompany the patient is if the transportation is provided by either a family member/friend or a local free or low-cost transportation service such as Access Paratransit which covers the Los Angeles area and provides vans/drivers for a couple of bucks per ride. We only go if it falls within our regular shift hours, but if we know about it in advance, we can jockey the hours a little as nobody wants to pay overtime!!

    In the case of a child going to school it's sort of a no-brainer they will need to pay for a way to get there and back. In my state they have a rule that the School District must find a way to get the child to school regardless of disability even if that means sending a driver out. So maybe that is the sort of duplicate service they (public transit - school transit) are getting at.

    All of us in home health which is supported by medicaid funds can expect to get squeezed tighter and tighter as I know California is not the only state facing a budget crisis. They really fail to realize how much money they actually save by having people stay out of insitutions that make them lack continuity of care and prone to all the infections so prevalent in them. I say that in no way to slam the SNF LTCs they work their butts off, too. It's tough when patient care suffers because there aren't enough dollars in the coffer.
    Blackcat99 likes this.
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    Thanks caliotter3 and nurse156. OK. So it sounds like all the states are doing it. It's a shame that medicaid won't pay for a nurse to go with a child to a non-medical appointment like a school. I guess the school district will have to pay for the nurse's services? No one here seems to know for sure. I called my job a week ago for clarification but no one has returned my call yet.
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    We write Medicaid PA's for nurses to accompany children to school and have about 5 patients that we provide this service for. Several of the PA's were just approved so apparently this isn't true for every state. We have several agencies here who won't write PA's and think they are a hassle, which I don't understand at all. Is your agency actually writing them to include taking the child to school and getting them denied?

    Respite care, however, is totally different. It can only be provided in the home and can't be used if the caregiver is working or in school. Sadly, these kids need socialization and our town has a great resource for handicapped children and adults with sport activities, dances, swimming, horse rides etc. Our staff can't accompany a patient to these events. In one case, we have a family who adopted 2 special needs kids. One parent works and the other cares for the children full time. He can't go to these events and handle both children at the same time, as their activities are different and he can't accompany his daughter into the bathroom. It's sad but we can't provide a nurse to go with them to these events. So Respite care for her means sitting in front of a movie at home. Sad!

    Kyasi

    Kyasi
    Blackcat99 likes this.
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    what about the childs emotional health. so sad that everything comes down to money. it's really not fair to the child who is already struggling with disabilities to be further limited in activities they enjoy.
    Blackcat99 likes this.
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    Thanks kyasi and joprasklpn. I am sorry to hear about the family who has 2 special needs children and is unable to attend any activities. That's interesting that you are able to write medicaid orders for nurses to go to school with the child. I am suspicious about my nursing agency. I wonder if they are just trying to blame medicaid because they (the agency) just doesn't want to be bothered with having to send nurses with the patient to school? I really don't know what my agency is doing. The Mom said that she talked to the nursing agency and that they can't give her a straight answer either. I will update as soon as I know something for sure.
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    Quote from Blackcat99
    The mother of the child I care for got a letter from the nursing agency. The letter said that no staff were allowed to take patients to places like parks, movie theaters,libraries,malls etc. The agency said that these types of activities are not covered by medicaid. Medicaid only reimburses services that do not duplicate another provider's service and are medically necessary for the treatment of a specific documented medical disorder, disease or impairment. Therefore, the agency says that the only type of transportation that will be considered for review will be for medically necessary appointments only. So I quess this means no nurse will be provided to go to school with this child who has a trach? Mom said they also told her that she can only get a nurse when she is at work.
    I had thought that the whole purpose of us going into the home was to provide respite for the family so they could take care of their personal business while the nurse took care of their child. Is this just a Florida medicaid rule or all of the states? Thanks for any insight.
    I'm in Wisconsin and one of my colleagues has another case of a little one who has head start a few half days a week and after school is out, my colleague, the RN, who attends school with her, drives her to her own home for the rest of the day to take care of her there. The Dad lives with his parents and all three adults are not comfortable with having nurses in their home caring for the little one. Kinda weird but to each his own. I haven't heard of any special forms or authorizations having to be filled out for this transportation, just Dad's permission.

    On my own peds case, the two kids are picked up every morning by the school bus and brought home every afternoon on the school bus. Two kids means that two nurses go to school with them. However, only one nurse comes to the home in the morning and the other RN meets them at school so they have supervision on the bus. The one child has a trach but is not on a ventilator.

    I have never heard of any of my co-workers driving my patients to parks, etc tho. I do know that my adult vent patient has one of us PDN RNs go with to his doctor appts during our shift. The way his appts are scheduled and the way are shifts are scheduled, there is no overtime necessary. In Wisconsin, we can work max 12 hours a day with 8 hours of rest in between shifts and no more than 60 hours a week. There is no overtime pay for over 40 hours so from 40-60 hours is still the same hourly wage.

    I hope I answered your questions from the best of my knowledge about Wisconsin
    Blackcat99 likes this.
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    Quote from blackcat99
    thanks kyasi and joprasklpn. i am sorry to hear about the family who has 2 special needs children and is unable to attend any activities. that's interesting that you are able to write medicaid orders for nurses to go to school with the child. i am suspicious about my nursing agency. i wonder if they are just trying to blame medicaid because they (the agency) just doesn't want to be bothered with having to send nurses with the patient to school? i really don't know what my agency is doing. the mom said that she talked to the nursing agency and that they can't give her a straight answer either. i will update as soon as i know something for sure.
    you do pdn thru an agency? in wisconsin, we are all self-employed, independent contractors although we are paid by medicaid. i don't think i would want to work thru an agency with all the problems i read about on these boards. i love my job just fine!!
    Blackcat99 likes this.
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    Thanks KlsqZoo. Thanks for letting me know how things are done in Wisconsin. How nice to be self-employed and not have the nursing agency taking your hard earned money. That was interesting to hear about that nurse that takes the kid to her own house. How strange that the 3 adults don't feel comfortable with nurses in their home. However, it must be nice for that nurse not having the parents watching her like a hawk all of the time.


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