Home Care Nursing (HCN) Services (previously known as Private Duty Nursing [PDN])

Effective January 1, 2019, PrimeWest Health is only responsible for payment for HCN services for PrimeWest Senior Health Complete (HMO SNP) and Minnesota Senior Care Plus (MSC+) members. Minnesota Department of Human Services (DHS) fee-for-service (FFS) authorizes and pays for HCN services for Families and Children, MinnesotaCare, and Special Needs BasicCare (SNBC) members. The requirement for Service Authorization from PrimeWest Health is waived for MSC+ and PrimeWest Senior Health Complete (HMO SNP) members if the HCN agency is a contracted provider. If the HCN assessment determines the need for HCN services, the member’s county case manager includes the HCN services on the member’s care plan/service plan. All HCN services by non-contracted HCN agencies require Service Authorization.

Definition

Home care nursing (HCN) services are nursing services that a physician, advanced practice registered nurse, or physician assistant orders for a member whose illness, injury, or physical or mental condition requires more individual and continuous care by a registered nurse (RN) or licensed practical nurse (LPN) than can be provided in a single or twice-daily skilled nurse visit and that requires greater skill than a Home Health Aide (HHA) or Personal Care Assistant (PCA) can provide. HCN services are provided under a plan of care approved by a physician and specify the level of care that a nurse is qualified to provide. HCN services may be used outside of a member’s home during hours when normal life activities takes them outside of their home.

HCN services:

• Are for members who need more individual and continuous skilled nursing care than can provided in an SNV
• Are for care outside the scope of services provided by an HHA/PCA
• Are provided under a plan of care or service plan approved by a physician
• Specify the level of care a nurse is qualified to provide
• Are ordered by a member’s physician
• May be used outside of a member’s home during hours when normal life activities take the member outside of their home
• Must be provided by an RN or LPN
• May be provided by an RN or LPN with a hardship waiver who is one of the following: parent of a minor child, spouse, or non-corporate legal guardian

Professional nursing care is based on an assessment of the member’s medical/health care needs. This service includes ongoing professional nursing observation, monitoring, intervention, and evaluation providing the continuity, intensity, and length of time required maintaining or restoring optimal health. Professional nursing is defined in the Minnesota Nurse Practice Act (MN Stat. sec. 148.171, subd. 1). HCN services have been designated as either “Regular” or “Complex.”

Complex HCN care is provided to members who meet the criteria for regular home care nursing and require life-sustaining interventions to reduce the risk of long-term injury or death

Non-Covered Services

1. HCN visits for the sole purpose of providing household tasks, transportation, companionship, or socialization
2. Services that are not medically necessary
3. Services that are not ordered by a physician
4. Services provided in a hospital, nursing facility (NF), or intermediate care facility (ICF)

HCN Relative Hardship Waiver

The HCN Relative Hardship Waiver allows certain relatives to receive reimbursement for providing services to a PrimeWest Health member. The relative must be currently licensed in the State of Minnesota as an RN or LPN employed by a Comprehensive licensed HCN or Medicare HCN agency enrolled with PrimeWest Health and is:

1. The parent of a member;
2. The spouse of a member;
3. A non-corporate legal guardian of a member; or
4. A family foster parent of a minor child

In order to qualify for a HCN Relative Hardship Waiver, at least one of the following criteria must be met:

1. The relative resigns from a full-time or part-time job to provide HCN for the member
2. The relative goes from a full-time to a part-time job with less compensation to provide HCN for the member
3. The relative takes a leave of absence without pay to provide HCN for the member
4. Because of labor conditions, intermittent hours of care needed, or special language needs, the relative is needed in order to provide an adequate number of qualified HCN services to meet the member’s needs

In the case of a HCN Relative Hardship Waiver, the provider agency is responsible for the following:

1. Receiving the request from the member/responsible party
2. Obtaining the relative’s signature
3. Completing the HCN Hardship Waiver Application (DHS-4109)
4. Ensuring the accuracy of the information
5. Submitting the HCN Hardship Waiver Application (DHS-4109) along with supporting documentation to the Disability Services Division (DSD)
6. Completing a criminal background check

Please note:

1. Provision of paid service does not preclude the parent, spouse, or guardian from their obligations for non-reimbursed family responsibilities of emergency backup caregiver and primary caregiver. The provision of these services is not legally required of the parent, spouse, or legal guardian. Services provided by a parent, spouse, or guardian cannot be used in lieu of nursing services covered and available under liable third party payers including Medicare.
2. Paid hours of service provided by the parent, spouse, or guardian must be included in the member’s care plan. Hours authorized for the parent, spouse, or guardian may not exceed 50 percent of the total approved nursing hours or eight hours per day, whichever is less, up to a maximum of 40 hours per week.
3. A parent, spouse, or guardian may not be paid to provide HCN if they fail to pass a criminal background check or if the home health agency, the waiver case manager, or the physician determines that the care provided by the parent, spouse, or guardian is unsafe.
4. The review process is 30 days. Written notice will be issued upon a decision. The provider must keep this notice in the member’s file. The hardship waiver will be approved from the date received forward. If the hardship waiver is denied an explanation will be provided.

Eligible Members

1. PrimeWest Senior Health Complete (HMO SNP) members
2. Minnesota Senior Care Plus (MSC+) members

Minnesota Department of Human Services (DHS) fee-for-service (FFS) authorizes and pays for HCN services for Families and Children, MinnesotaCare, and Special Needs BasicCare (SNBC) members.

Eligible Providers of HCN Services

• Medicare-certified home health agencies with a comprehensive home care license
• Home care agencies with a comprehensive home care license
• Independent registered nurses (RNs)
• Independent licensed practical nurses (LPNs)

Individual RNs and LPNs must have an active nursing license and must be able to attest to all statements on the Home Care Nurse – Individual LPN or RN Applicant Assurance Statement (DHS-7099).

Requirements

Ongoing HCN and documentation requirements:

1. HCN services require a physician order prior to initiating service.
2. Review/approval of the service plan by the member’s physician is required every 60 days, depending on the member’s individual condition.
3. Signed orders must be on file in the member’s chart at the provider agency’s office.
4. The orders or plan of care must do all of the following:
   1. Specify the disciplines providing care
   2. Specify the frequency and duration of all services
   3. Demonstrate the need for the services and be supported by all pertinent diagnoses
   4. Include member’s functional level, medications, treatments, and clinical summary
   5. Be individualized based on member needs
   6. Have realistic goals
   7. Subsequent plans of care must show member response to services and progress since the previous plan was developed
   8. Changes to the plan of care are expected if the member is not achieving expected care outcomes

Services cannot be provided to two individuals in separate apartments in the same building, to other non-HCN members in the setting, or replace or supplement required staff at licensed facilities.

Shared care must be arranged through the HCN agency.

Shared HCN Services

This option allows two recipients to share HCN services in the same setting at the same time from the same HCN. All regulations pertaining to HCN services also apply to the shared care option.

A setting includes:

1. The home or licensed foster care home of one of the members;
2. Outside the home or foster care home of one of the members when normal life activities take the members outside the home;
3. A child care program licensed under MN Stat. Chap. 245A, or operated by a local school district or private school; or
4. An adult day care service licensed under MN Stat. Chap. 245A.

Requirements

A member, or a member’s legal representative, may select the shared care option at any time by contacting the HCN agency. Together with the member’s physician and the HCN agency staff, the member (or the legal representative) will determine the following:

1. Whether shared care is an appropriate option based upon the needs and preferences of the member; and
2. The number of shared care units that will be part of the overall HCN services. A shared care arrangement does not reduce the total number of service units covered for the member. The use of covered service units should be divided between the shared care option and 1:1 services.

The member (or the member’s legal representative) and the HCN agency determines the following:

1. The other member who is sharing the HCN services. This decision must be based on the ages of the members, their compatibility, and the ability to coordinate their care needs; and
2. The arrangement and the setting for the shared services.

Review the MA Home Care Nursing Assessment (DHS-4071A) following the process described in the updated MA Home Care Nursing Assessment Instructions (DHS-4071B) and the HCN Service Decision Tree (DHS-4071C).

• HCN services require a physician order prior to initiating service.
• The member’s physician must review and approve the service plan every 60 days.

Instructions for completing the Service Agreement (DHS-3070): On a separate line item, enter the procedure code, rate, and total number of units for 1:1 HCN services. On a separate line item, enter the procedure code, rate, and total number of units for shared (1:2) HCN services.

Both 1:1 and 1:2 HCN services use the same procedure codes. For 1:2 services, a modifier and shared care indicator must be used. For the shared HCN line item, enter the following:

1. “TT” in the Modifier 1 (MOD1) field;
2. “Y” in the Shared Care (SHR) indicator; and
3. “5” in the Frequency (FREQ) field on Screen 2 in the ITS.

Waiver program recipients: The county case manager follows the same criteria and process to determine whether the shared care option is an appropriate and safe alternative for a member on a waiver. If the member chooses the shared care option, document the number of shared HCN service units on the member’s waiver care plan and calculate the cost of shared care into the overall cost of service plan. Use Medical Assistance (Medicaid) home care procedure codes for HCN services to the fullest extent possible (for all medically necessary nursing services) before using extended HCN codes on waiver Service Agreements.

Documentation Requirements

Include a copy of each of the following in the member’s chart when service is shared HCN:

1. A signed consent form by each member/legal representative
2. Permission for the agency to schedule shared care up to the maximum hours chosen by the member
3. Any use of services outside the member’s home
4. Permission to place the member’s name in the chart of the other shared member
5. How the needs of both members are appropriately and safely being met
6. Where the shared services will be provided
7. Ongoing monitoring and evaluation of the shared services by the HCN
8. Emergency response backup plans to the member’s illness/absence or HCN’s illness/absence
9. Additional training, if needed, for the HCN to provide care to two members
10. The names of each member receiving shared HCN services
11. The starting and ending times the members received shared HCN
12. Routine nursing documentation such as changes in the member’s condition/any problems due to sharing services

Changing or Discontinuing Shared HCN

The member or legal representative must notify the provider in writing if the member chooses to make a change in their shared care. Changes include the following:

1. The number of allowed units the member wishes to share
2. Discontinuing participation in shared care
3. Changing providers

The written revocation or change must be maintained in the member’s file.

When services are changed or discontinued, the current provider must maintain records of the change or discontinuation in the member’s file.

If an HCN agency is non-contracted, the HCN agency must fax the MA Home Care Technical Change Request (DHS-4074) to PrimeWest Health indicating the change in the number of authorized shared care or the last date of shared HCN services and the total number of units to be designated for shared care.

PrimeWest Health reserves the right to request a copy of the HCN assessment tool from the new provider agency at the time services are transferred or requested.

Billing Requirements

The process for billing shared HCN is the same as billing for 1:1 care with the following modification:

1. Use a separate line item to bill the shared (1:2) HCN units; and
2. Enter “TT" in the Modifier 1 (MOD1) field.

Complex reimbursement rates: A complex care reimbursement rate is available only when the member is receiving 1:1 HCN services. A complex care rate is not available when the member is receiving shared (1:2) HCN services. This means that a member can share HCN services if they need complex care, but the agency will only receive the complex rate during the hours the member is receiving the 1:1 services.

PW_11-19_548
Updated_02/13/2026