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How do I get nursing services?

Many people with disabilities need nursing care for a medical condition. If you have Medicaid insurance, you may be able to get nursing services in your own home. The Medicaid State Plan covers two types of nursing care:

• With a doctor’s prescription, you can get home health nursing services on a part-time (or intermittent) basis, which generally means no more than 14 hours a week and visits that last no more than four hours at a time. However, under the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) program (known as Healthcheck in Ohio), individuals under age 21 may be able to receive more than 14 hours per week of nursing (https://www.disabilityrightsohio.org/medicaid-epsdt).
• With approval (called “prior authorization”), you can get private duty nursing (PDN) services. These are continuous nursing services that can be more than 14 hours a week and for longer than four hours at a time (https://www.disabilityrightsohio.org/medicaid-prior-authorization).

Nursing services may also be covered through a home and community-based services waiver, like the Ohio Home Care Waiver or Individual Options waiver.

What are some of the reasons why my nursing services would be reduced or denied?

Some of the reasons commonly given for reducing or denying nursing services are:

• a parent or other family member, instead of a nurse, can provide nursing services for you;
• an aide can perform the nursing services instead of a nurse;
• you only need part-time or intermittent nursing services, not “continuous” nursing services; or
• your condition has improved.

Before reducing or eliminating your nursing services, an agency must provide you notice in writing 15 days ahead of time, explaining the reason for the decision and giving you the chance to appeal.

How do I challenge a decision to reduce or deny my nursing services?

The appeal process you should use depends on whether the decision was made by a managed care plan or a different agency. Your denial notice will explain how to appeal and the timeline for asking for an appeal. You may need to act quickly if you want to keep your current level of nursing services during your appeal. See DRO’s FAQs on Prior Authorization and Medicaid Appeals for more information.

What if I need more help challenging the decision?

In addition to asking for an appeal, you should contact Disability Rights Ohio immediately at 800-282-9181, and select option 2 for the intake department. At Disability Rights Ohio, we will help you understand the appeal process and how you can get ready for an appeal.