Since April 2020, pediatric shift nursing in the Medicaid program has not required prior authorization. This means Medicaid health plans have not been able to reduce shift nursing services for children under the age of 21, allowing children to retain their nursing hours without fear of reduction. However, the Department of Human Services (DHS) has announced it intends to lift the freeze and reinstate prior authorization requitements for pediatric shift nursing effective November 1, 2022.
In July, a Medical Assistance Bulletin will go out notifying providers of this upcoming change. Shortly thereafter, an Operations Memorandum will go out to all Medicaid health plans notifying them of the return to prior authorization for shift nursing services starting in November. The Pennsylvania Health Law Project (PHLP) has advocated for a tiered or staggered review of all cases, in order to protect children and advocates alike from an onslaught of shift nursing denials once the freeze lifts on November 1. In response, the Department has agreed to include in the Bulletin and the Operations Memo language directing that the Medicaid health plans stagger their reviews of pediatric shift nursing prior authorizations over a 90-day period beginning November 1.
Anyone whose shift nursing services are denied, reduced, or terminated after November 1 has the right to appeal that decision by asking for a grievance with the health plan. If the grievance is not successful in getting the services approved, there are two more appeal stages available: the external review and the fair hearing. Appealing any service denial within 10 days of the date on the denial notice will allow current services to remain in place while the appeal plays out.
Consumers whose child’s shift nursing services are denied, reduced, or terminated should call PHLP’s Helpline for free legal help at 1-800-274-3258. PHLP will continue to monitor the lifting of the pediatric shift nursing freeze and will distribute copies of both the Bulletin and the Operations Memorandum when they are released by the Department.