Gloves Letter Of Medical Necessity
Date________________________
Child’s Name _________________________
Child’s Medicaid ID # ___________________
Name of Caregiver _______________________
Quantity of gloves per month ______________________
Glove Size Large
Gloves Ref # __________________________
Reason child needs gloves ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Treating physician’s signature _______________________________________
Date: ___________________________________________________________
*protip –
Many medications nurses are required to give to patients like spironolactone are hazardous to both caregivers and LPN/Nurses.
Standard of care in a hospital is for every med, a fresh set of gloves is used.
Ideally, MMA should be provided via DME (durable medical equipment company) the proper quantity of syringes based on size after the med chart is calculated for a 30 day period & 10 ML syringes for a typical flush.
*I will get into the mickey portion in separate letters of medical necessity.
I left the above Red # blank for the gloves as every MMA chooses different DME companies to fill the order.
Calculate how many diapers a day an approx child goes through.
How many times meds and feeds are dispensed.
When a child leaves the room and requires meds, one trick nurses use is to pre draw the meds and keep the predrawn meds and flushes in a glove for safekeeping until it’s time to dispense..
For infection control, I have my son’s room sanitized q 12. Every touch surface in the room is cleaned with an alcohol wipe. I have every nurse clean cell phone/any tablets or laptops they bring since studies prove 90% of cell phones have fecal matter.
1 gram of fecal matter harbors 1 billion bacteria which can mean the difference between life and death.
Hygiene is critical for keeping the child out of the hospital.
The ref # used for 200 boxes
Peer review studies can be added to your letters of medical necessity adding validity as per why the child qualifies for gloves.
Reasons caregivers require gloves
For OT, PT, Speech purposes, items used should be wiped down and requires gloves.
Alcohol wipes delivered via DME a covered benefit under federal law have a cancer warning on the top of the label. 0 nurses or caregivers should ever touch them with the naked hand.
Calculate how many visits a week for OT, PT, Speech Therapy, shifts for LPN/RNs, Diaper changes, Med dispenses, feeds, flushes, to ensure there are enough gloves to meet standard of care for proper plan of care with PDN agency.
The reference # I used for gloves which came in a box of 200
Ref # Halyarrd- 5064 – size large (large fits all nurses)
There are 1000’s of admissions into hospitals which could have been avoided if caregivers knew their rights. Transplant programs across the country could see an increase of survival rates if children had the necessary DME + services required in order to decrease services. Non verbal children are unable to vocalize their needs often leading to a never ending cycle of unfamiliar LPNs/RNs not understanding the significance of hygiene.
It’s one of the dirty little secrets in the PDN sector most of these nurses & LPNs never worked in a hospital and don’t take hygiene as serious as an ICU experienced caregiver.
For Medicaid PDN agencies, only a few provide gloves and when they do it’s often not enough to meet the needs of the case. Depending on the state, here in Fl, PDN agency does not provide gloves, hand sanitizer or paper towels. Maxim does but void of a single patient agreement fail to meet shifts they’re supposed to because of the pay rate.
To give an idea for Florida, RN rate is $30.02 PDN agencies collect.Prior to OCt 2019, the pay rate was $60.04 cents for RN rate. Retention rates were higher.
Go to your state’s regulatory agency, type in the nursing medical coding and billing Medicaid reimbursement rate for RN, PDN, and it will become clear PDN agencies on a 1099 without benefits won’t stay long on any given case due to lack of incentives.
PDN sector is often a side gig.
PDN agencies are not allowed to miss 24 hour in a row of shifts so filing a complaint with your state regulatory agency can lead in fines of the PDN agency who are often FORCED to send LPN(S) for an RN only case. (Highly illegal)
The DOJ due to personal experience FAILS on every level to ensure the office of inspector general has their subordinates forward infractions over to their office.
The end result?
DOJ fines providers while MMA(s) who put providers in a position to commit fraud just to operate in the green by covering shifts with unqualified LPN on an RN only case.
Gloves play a pivotal role in the ability to sustain the child in a home setting.
Medicaid is a federal program and any MMA participating in Medicaid must adhere to Federal legislation and ALL CMS guidelines.
Medicaid services
Mandatory services include:
Physicians Services
Laboratory/x-ray
In-patient, out-patient hospital and nursing facility
EPSDT
Family planning
FQHCs and rural health clinic services
Nursing facility services
Advanced Registered Nurse Practitioner Services
Home Health Care
The Federal laws cited:
42 CFR Subpart B – Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) of Individuals Under Age 21
§ 441.50 Basis and purpose.
§ 441.55 State plan requirements.
§ 441.56 Required activities.
§ 441.57 Discretionary services.
§ 441.58 Periodicity schedule.
§ 441.59 Treatment of requests for EPSDT screening services.
§ 441.60 Continuing care.
§ 441.61 Utilization of providers and coordination with related programs.
§ 441.62 Transportation and scheduling assistance.
-Americans with disabilities act sec 2, 5, and 7
-The Medicaid Act – sections 5&7
-CFR440.70
Laws used
42 CFR 441.15 Section 3
42 CFR Subpart B – Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) of Individuals Under Age 21
Defining the ‘T’ in “EPSDT”
In addition to screening, vision, dental and hearing services, the Medicaid Act defines the EPSDT benefit to include “necessary healthcare, diagnostic services, treatment, and other measures to correct or ameliorate defects, physical, mental illnesses and conditions.
If caregiver lives in the state of Florida, include below information.
For the state of Florida – -Smith Vs Benson (settled in the state of Florida).
In IJanuary 2010 , Smith vs Benson went to the supreme court for incontinence supplies.
This includes diapers, wipes, caths, chuckc. 40% zinc and nystatin ointment/powder heals bed sores with frequent turning q 2
q stands for every, the numbers stand for how many hours in a 24 hour period.
Supreme court ruled in favor of covering incontinence supplies
Smith VS Benson demonstrated the FEDERAL laws every state MMA must adhere to in order to run a medicaid or medicare plan in insert state.
https://casetext.com/case/smith-v-benson (Every caregiver) or administrator looking to ease the burden on discharge coordinators are invited to look over the laws and work them into hospital systems such as epic writing out templates for future letters of medical necessity.
Read carefully, in a fair hearing, a medical director (once an emergency room doctor) not a qualified G.I. will lie under oath and cite an amendment belonging to a case ‘Smith Vs Brown’. which has nothing to do with healthcare. Adjudicators in the state of Florida are clerks working for the dept of children and families. They are NOT trained in anatomy and physiology, from personal experience they cannot interpret basic legislation.
42 C.F.R. § 440.230
§ 440.230 Sufficiency of amount, duration, and scope
(a) The plan must specify the amount, duration, and scope of each service that it provides for –
(1) The categorically needy; and
(2) Each covered group of medically needy.
b) Each service must be sufficient in amount, duration, and scope to reasonably achieve its purpose.
(c) The Medicaid agency may not arbitrarily deny or reduce the amount, duration, or scope of a required service under §§ 440.210 and 440.220 to an otherwise eligible beneficiary solely because of the diagnosis, type of illness, or condition.
42 U.S.C. § 1396a
Section 1396a – State plans for medical assistance
A State plan for medical assistance must-
(1) provide that it shall be in effect in all political subdivisions of the State, and, if administered by them, be mandatory upon them;
State laws:
409.905 (Mandatory Medicaid coverage for disabled children below the age of 21)
Please review Florida state legislation 409.905 Mandatory Medicaid services legislation. Please review section 2 EPSDT and Section 4 of this legislation which is why Florida ruled in favor of Smith under Home Health Services. Scroll down to the section entitled ‘Home Health’.
This includes all mandatory and optional services that the state CAN cover under medicaid, whether or not such services are covered for adults.
For example if the child needs personal care services to ameliorate a behavioral health problem, then ESPDT should cover the services to the extent the child needs them – even if the state places a quantitative limit on personal care services or does not cover them at all for adults.
See, AHCA Model Contract Attachment II, Exhibit II-‐A, at 5 regarding procedures managed care plans should follow and stating “authorization of any medically necessary service to enrollees under the age of twenty-‐one (21) years when the service is not listed in the service-‐specific Florida Medicaid Coverage and Limitations Handbook, Florida Medicaid Coverage Policy, or the associated Florida Medicaid fee schedule, or is not a covered service of the plan; or the amount, frequency, or duration of the service exceeds the limitations specified in the service-‐specific handbook or the corresponding fee schedule. The Managed Care Plan shall also include following language verbatim in its enrollee handbooks: [Insert Managed Care Plan name] must provide all medically necessary services for its members who are under age 21. This is the law. This is true even if [Insert Managed Care Plan name] does not cover a service or the service has a limit. As long as your child’s services are medically necessary, services have:
No dollar limits; or
No time limits, like hourly or daily limits.
https://ahca.myflorida.com/Medicaid/statewide_mc/mma_plans_mc.shtml (Here is the link) For the above information.