The Agency for Health Care Administration (AHCA) has scheduled a rule workshop to review proposed changes to Rule 59G-4.261, updating the Medicaid Private Duty Nursing (PDN) and Family Home Health Aide (FHHA) Services Coverage Policy.

The workshop will be held on Monday, March 2, 2026, at 10:00 AM at AHCA headquarters (2727 Mahan Drive, Building 3, Tallahassee, FL 32308).

The workshop will focus on proposed updates to the coverage policy incorporated by reference in Rule 59G-4.261 and will provide stakeholders an opportunity to offer input prior to final rulemaking.

Summary of Key Proposed Changes

The draft February 2026 coverage policy proposes several substantive clarifications and modifications, including:

Section 1.0 – Introduction

• Removes the age limitation (“under the age of 21 years”) from the introductory description of recipients eligible for services
• The prior reference limiting private duty nursing (PDN) and family home health aide (FHHA) services to recipients under 21 is deleted in this section; eligibility is now clarified in Section 2.0

Section 1.3 – Legal Authority

• Updates federal citation from “42 CFR 440.60 and 440.80” (previous formatting differed in prior draft versions) for technical accuracy and clarity

Section 1.4 – Definitions

• Reorganizes and renumbers defined terms
• Clarifies FHHA definition as a related provider, legal guardian, or caretaker relative employed by a licensed home health agency
• Adds clarification under Medical Necessity:
  • Specifies that the condition prohibiting services “primarily intended for the convenience of the recipient, caregiver, or provider” does not apply when determining medical necessity for PDN and FHHA services
  • All other medical necessity criteria remain applicable

Section 2.2 – Who Can Receive

• Clarifies eligibility language:
  • Specifies that recipients under age 21 may receive PDN
  • Clarifies that recipients receiving medically necessary PDN may also receive medically necessary FHHA services
• Removes prior broader phrasing and tightens eligibility structure

Section 3.2 – Who Can Provide

• Simplifies and consolidates provider eligibility categories
• Clarifies that services must be rendered by:
  • Licensed home health agencies; or
  • Independent registered nurses (RNs) and licensed practical nurses (LPNs) licensed under Chapter 464, F.S.

Section 4.0 – Coverage Information

• Maintains 24-hour per day maximum for PDN
• Clarifies criteria must be met concurrently (extensive care needs, safe home delivery, licensed practitioner oversight)

Section 4.2.1 – PDN Provided by Related Provider, Legal Guardian, or Caretaker Relative

• Clarifies coverage of up to 40 hours per week per related provider
• Requires valid Florida RN or LPN license
• Requires employment by a licensed home health agency
• Removes prior duplicative language and restructures subsection

Section 4.2.2 – Family Home Health Aide Services

• Clarifies coverage up to 12 hours per day and 40 hours per week per recipient (with statutory exception)
• Reinforces prohibition on duplication of PDN hours
• Requires oversight by a non-related RN employed by the home health agency

Section 5.2 – Specific Non-Covered Criteria

• Clarifies and reorganizes exclusions
• Explicitly prohibits:
  • FHHA services provided by independent RNs or LPNs
  • PDN services provided by independent RNs/LPNs when the provider is a related provider
  • Concurrent PDN and FHHA services
  • Both services provided by the same related provider

Section 6.2 – Specific Criteria

• Clarifies documentation requirements:
  • Assessments pursuant to 42 CFR 484.55 and 440.70
  • Written physician orders
  • Plan of Care (POC) requirements
• Requires that initial and recertification assessments be completed by a non-related RN employed by the home health agency
• Clarifies requirement to include all home health services in the POC

Section 7.2 – Specific Criteria

• Requires Quality Improvement Organization (QIO) authorization at least every 180 days
• Requires documentation that:
  • Cumulative PDN and FHHA hours do not exceed 24 hours per day
  • PDN and FHHA services do not occur concurrently
• Clarifies multidisciplinary review and escalation process to physician reviewer when consensus is not reached
• Codifies monthly QIO contact requirement

Section 8.0 – Reimbursement

• Clarifies claim type (837P/CMS-1500)
• Updates billing modifier section formatting
• Maintains multi-recipient rate adjustment structure:
  • 100% first recipient
  • 50% second
  • 25% third and subsequent
• Clarifies exemption for medically complex/technology-dependent children in group homes

Appendix 9.1 – Review Criteria for PDN

• Reorganizes review criteria formatting
• Clarifies required documentation substantiating:
  • Organ system dysfunction
  • Clinical indicators for skilled nursing need
  • Refines language describing first-level and physician review processes

Member Engagement & Comment Submission

The proposed revisions carry significant operational and compliance implications for Medicaid PDN and FHHA providers. We strongly encourage members to carefully review the draft coverage policy and share any operational concerns, recommended clarifications, suggested revisions, fiscal or workforce impacts, and potential implementation challenges.

Providers and stakeholders are also encouraged to submit comments directly to AHCA by Friday, February 27, 2026.

HCAF will submit formal comments as well and welcomes member input to inform our recommendations. Please send your feedback to Kyle Simon, Senior Director of Policy, Advocacy & Communications, at ksimon@homecarefla.org by Thursday, February 26, 2026, to ensure it is incorporated.

If you have questions regarding the workshop or proposed revisions, please call (850) 222-8967. We will continue to monitor developments and provide updates.