Current through Register Vol. 49, No. 9, September, 2024
AMOUNT, DURATION AND SCOPE OF SERVICES
PROVIDED
ATTACHMENT 3.1-A
26. Personal Care
A. Personal care services are provided by a
personal care aide to assist with a client's physical dependency needs. The
personal care aide must have at least 24 hours classroom training and a minimum
of supervised practical training of 16 hours provided by or under the
supervision of a registered nurse for a total of no less than 40
hours.
B. Personal care services
furnished to an individual who is not an inpatient or resident of a hospital,
nursing facility, intermediate care facility for the mentally retarded, or
institution for mental disease that are -
1.
Authorized for the individual by a physician in accordance with a plan of
treatment or (at the option of the State) otherwise authorized for the
individual in accordance with a service plan approved by the State;
2. Provided by an individual who is qualified
to provide such services and who is not a member of the individual's family,
and
3. Furnished in a home,
andatthe State's option, in another location, including licensed residential
care facilities and licensed assisted living facilities.
C. The State defines "a member of
the individual's family" as:
1. A
spouse,
2. A minor's parent,
stepparent, foster parent or anyone acting as a minor's parent,
3. A minor's "guardian of the person" or
anyone acting as a minor's "guardian of the person" or
4. An adult's "guardian of the person" or
anyone acting as an adult's "guardian of the person".
D. Personal care services are covered for
categorically needy individuals only.
E. Personal care services are medically
necessary, prescribed services to assist clients with their physical dependency
needs.
1. Personal care services involve
"hands-on" assistance, by a personal care aide, with a client's physical
dependency needs (as opposed to purely housekeeping services).
2. The tasks the aide performs are similar to
those that a nurse's aide would normally perform if the client were in a
hospital or nursing facility.
F. Prior authorization is required for
personal care for beneficiaries under age 21.
G. Effective for dates of service on or after
April 1, 2002, for services beyond 64 hours per calendar month per beneficiary
aged 21 or older, the provider must request a benefit extension. Extensions of
the personal care benefit will be provided for beneficiaries aged 21 and older
when extended benefits are determined to be medically necessary.
METHODS AND STANDARDS FOR ESTABLISHING PAYMENT RATES
OTHER TYPES OF CARE
ATTACHMENT 4.19-B
5. Personal care furnished in accordance with
the requirements at
42 CFR §
440.167 and with regulations promulgated,
established and published for the Arkansas Medicaid Personal Care Program by
the Division of Medical Services.
(a) Except
as otherwise noted in the plan, state developed fee schedule rates are the same
for both governmental and private providers of personal care services and the
fee schedule and any annual/periodic adjustments to the fee schedule are
published on the Medicaid website at www.medicaid.state.ar.us.
(b) Reimbursement for Personal Care Program
Services is by fee schedule, at the lesser of the billed charge or the Title
XIX (Medicaid) maximum allowable fee per unit of service. Effective for dates
of service on and after July 1, 2004, one unit equals fifteen minutes of
service.
(c) Effective for dates of
service on and after July 1, 2007, reimbursement to enrolled Residential Care
Facilities (RCFs) for personal care services furnished to Medicaid eligible
residents (i.e., clients) is based on a multi-hour rate system not to exceed
one day, based on the individual clients' levels of care. A client's level of
care is determined from the service units required by his or her service plan.
Rates will be recalculated as needed to maintain parity with other Personal
Care providers when revisions of the Title XFX maximum allowable fee occur. The
effective date of any such revised rates shall be the effective date of the
revised fee.
(d)
Reimbursement to enrolled Assisted Living Facilities (ALF) for personal
care services furnished to Medicaid eligible residents (i.e., clients) is based
on a multi-hour rate system not to exceed one day, based on the individual
clients' level of care. A client's level of care is determined from the service
units required by his or her service plan. Rates will be recalculated as needed
to maintain parity with other Personal Care providers when revisions of the
Title XIX maximum allowable fee occur. The effective date of such revised rates
shall be the effective date of the revised fee.
(e) Agencies rates are set as of July 1, 2009
and are effective for services on or after that date.
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Provider Manual Update Transmittal SecV-7-12
Provider Manual Update Transmittal PERSCARE-4-11Section II
Personal Care
215.100
Assessment and Service Plan
Formats 10-1-12
A. The Division of
Medical Services (DMS), in some circumstances and for certain specified
providers, requires exclusive use of form DMS-618
(View or
print form DMS-618.)
to satisfy particular Program
documentation requirements.
1. Whether
Medicaid does or does not require exclusive use of form DMS-618, all
documentation required by the Personal Care Program must meet or exceed DMS
regulations as stated in this manual and other official
communications.
2. When using form
DMS-618, attachments may be necessary to complete assessments and service plans
and/or to comply with other rules.
a. An
assessing Registered Nurse (RN) must sign or initial and date each attachment
he or she adds to a required personal care document.
b. The authorizing physician must sign (or
initial) and date each attachment he or she adds to a service plan or other
required document.
B.
The Division of
Medical Services requires Residential Care Facility (RCF) and Assisted Living
Facility (ALF) Personal Care providers to use exclusively form DMS-618 and to
comply with all rules applicable to RCFs and ALFs regarding the use of form
DMS-618.
216.200
Tasks Associated with Covered Routines 10-1-12
Effective for dates of service on and after March 1, 2008, all
regulations regarding personal care aides' logging beginning and ending times
(i.e., time of day) of individual services, and all references to any such
regulations, do not apply to RCF and ALF Personal Care providers.
217.000
Benefit Limits
10-1-12
Effective for dates of service on and after March 1, 2008,
Arkansas Medicaid does not grant to beneficiaries whose residence is an RCF or
ALF, extension of the personal care benefit for personal care provided at the
RCF or ALF by the RCF or ALF Personal Care provider.
A. Medicaid imposes a 64-hour benefit limit,
per month, per beneficiary, on personal care aide services for beneficiaries
aged 21 and older.
B. The 64-hour
limitation applies to the monthly aggregated hours of personal care aide
services at all authorized locations except RCFs and ALFs.
C. Providers may request extensions of this
benefit for reasons of medical necessity. Submit written requests for benefit
extensions to the Division of Medical Services, Utilization Review Section.
View or print Division of Medical Services. Utilization
Review Section contact information.
220.000
Service Administration
10-1-12
Effective for dates of service on and after March 1, 2008, RCF
and ALF Personal Care providers are exempt from all requirements of Sections
220.000 through 221.000-whether by explicit statement or reference-to record or
log the time of day (clock time) when a service begins or ends.
220.100
Service Supervision
10-1-12
Effective for dates of service on and after March 1, 2008, RNs
supervising RCF and ALF Personal Care providers' personal care aides shall
write, in a designated area on form DMS-873, instructions to aides and comments
regarding the beneficiary and/or the aide.
A. The provider must assure that the delivery
of personal care services by personal care aides is supervised.
1. Supervision must be performed by a
registered nurse (RN).
2.
Alternatively, a Qualified Mental Retardation Professional (QMRP) may fulfill
the RN supervision requirement for personal care services to beneficiaries
residing in alternative living situations or alternative family homes,
authorized or licensed by the Division of Developmental Disabilities
Services.
B. The
supervisor has the following responsibilities.
1. The supervisor must instruct the personal
care aide in
a.Which routines, activities and
tasks to perform in executing a beneficiary's service plan,
b. The minimum frequency of each routine or
activity and
c.The maximum number
of hours per month of personal care service delivery, as authorized in the
service plan.
2. At
least once a month, the supervisor must
a.Review the aide's records,
b. Document the record review and
c.If necessary, further instruct the aide and
document the nature of and the reasons for further instructions.
3. At least three times every 183
days (six months) at intervals no greater than 62 days, the supervisor must
visit the beneficiary at the service delivery location to conduct on-site
evaluation.
a. Medicaid requires that at
least one of these supervisory visits must be when the aide is not
present.
b. At least one visit must
be while the aide is present and furnishing services.
4. When the aide is present during the visit
the supervising RN or QMRP must
a.Observe and
document
(1) The condition of the
beneficiary,
(2) The type and
quality of the personal care aide's service provision and
(3) The interaction and relationship between
the beneficiary and the aide;
b. Modify the service plan, if necessary,
based on the observations and findings from the visit and
c.If necessary, further instruct the aide and
document the nature of and the reasons for further
instructions.
5. When the
aide is not present during the visit, the supervising RN or QMRP must
a.Observe and document the condition of the
beneficiary,
b. Observe and
document, from available evidence, the type and quality of the personal care
aide's service provision, and
c.Query the beneficiary or the beneficiary's
representative and document pertinent information regarding the beneficiary's
opinion of
(1) The type and quality of the
aide's service,
(2) The aide's
conduct and
(3) The adequacy of the
working relationship of the beneficiary and the aide;
d. Modify the service plan, if necessary,
based on observations and findings from the visit, and e. Further instruct the
aide, if necessary, and document the nature of and the reasons for further
instructions.
C. The provider must review the service plan
and the aide's records as necessary, but no less often than every 62 days. The
review will ensure that the daily aggregate time estimate in the service plan
accurately reflects the actual average time the aide spends delivering personal
care aide services to a beneficiary.
220.110
Service Log 10-1-12
Instructions in this section apply to all beneficiaries'
service logs, with one exception. Effective for dates of service on and after
March 1, 2008, RCF and ALF Personal Care providers maintain their service logs
by means of the format and instructions of form DMS-873, "Arkansas
Department of Human Services Division of Medical Services Instructions for
completing the Service Log & Aide Notes For Personal Care Services in a
Residential Care or Assisted Living Facility". Effective for dates of
service on and after March 1, 2008, form DMS-873 is found in Section V of this
manual and DMS requires that RCF and ALF Personal Care providers use it
exclusively for its designated purposes. See Section 220.111 for special
documentation requirements regarding multiple beneficiaries who are attended by
one aide. Those instructions at Section 220.111 do not apply to RCF and ALF
Personal Care providers, effective for dates of service on and after March 1,
2008. See Section 220.112 for special documentation requirements regarding
multiple aides attending one beneficiary. Those instructions at Section 220.112
do not apply to RCF and ALF Personal Care providers, effective for dates of
service on and after March 1, 2008. The examples in these sections and in
Section 220.110 are related to food preparation, but personal care
beneficiaries may receive other services in congregate settings if their
individual assessments support their receiving assistance in that
fashion.
A. Medicaid covers only
service time that is supported by an aide's service log.
B. Service time in excess of the maximum
service time estimates in the authorized service plan is covered only when the
provider complies with the rules in Sections 215.330 and 220.110 through
220.112.
C. The time estimate in
the service plan is not service documentation. It is an estimate of the
anticipated minimum and maximum daily duration of medically necessary personal
care aide service for an individual beneficiary.
D. For each service date, for each
beneficiary, the personal care aide must record the following:
1. The time of day the aide begins the
beneficiary's services.
2. The time
of day the aide ends a beneficiary's services. This is the time of day the aide
concludes the service delivery, not necessarily the time the aide leaves the
beneficiary's service delivery location.
3. Notes regarding the beneficiary's
condition as instructed by the service supervisor.
4. Task performance difficulties.
5. The justification for any emergency
unscheduled tasks and documentation of the prior-approval or post-approval of
the unscheduled tasks.
6. The
justification for not performing any scheduled service plan required
tasks.
7. Any other observations
the aide believes are of note or that should be reported to the
supervisor.
E. If the
aide discontinues performing service-plan-required tasks at any time before
completing all of the required tasks for the day, the aide will record:
1. The beginning time of the
non-service-plan-required activities,
2. The ending time of the
non-service-plan-required activities,
3. The beginning time of the aide's
resumption of service-plan-required activities and
4. The beginning and ending times of any
subsequent breaks in service-plan-required aide activities.
5. If the aide discontinues or interrupts the
beneficiary's service-plan-required activities at one location to begin
service-plan-required activities at another location, the aide must record the
beginning and ending times of service at each location.
220.111
Service Log for
Multiple Beneficiaries 10-1-12
Effective for dates of service on and after March 1,
2008, the rules in this section do not apply to RCF and ALF Personal Care
providers.
An aide delivering services to two or more beneficiaries at the
same service location, during the same period (discontinuing or interrupting a
beneficiary's service plan required tasks to begin or resume service plan
required tasks for another beneficiary, or performing an authorized service
simultaneously for two or more beneficiaries), must comply with the applicable
instructions in parts A or B below:
A.
If providing services for only two beneficiaries, the aide must record in each
beneficiary's service log
1. The name of each
individual for whom they are simultaneously performing personal care service
and
2. The beginning and ending
times of service for each beneficiary and the beginning and ending times of
each interruption and of each resumption of service.
B. If services are performed in a congregate
setting (more than two beneficiaries) the service log must state
1. The actual time of day (clock-time) that
the congregate services begin and end and
2. The number of individuals, and the name of
each individual, both Medicaid-eligible and non-Medicaid eligible, who received
the documented congregate services during that period.
220.112
Service
Log for Multiple Aides with One Beneficiary 10-1-12Effective for dates
of service on and after March 1, 2008, the rules in this section do not apply
to RCF and ALF Personal Care providers.
When two or more aides attend a single beneficiary, each aide
must record the beginning and ending times of each service plan required
routine or activity of daily living that she or he performs for the
beneficiary, regardless of whether another aide is performing a service plan
required routine or activity of daily living at the same
time.
221.000
Documentation 10-1-12 Rule D in this section is effective for dates of
service on and after March 1, 2008.
The personal care provider must keep and make available to
authorized representatives of the Arkansas Division of Medical Services, the
State Medicaid Fraud Control Unit and representatives of the Department of
Health and Human Services and its authorized agents or officials; records
including:
A. If applicable,
certification by the Home Health State Survey Agency as a participant in the
Title XVIII Program. Agencies that provided Medicaid personal care services
before July 1, 1986 are exempt from this requirement.
B. When applicable, copies of pertinent
residential care facility license(s) issued by the Office of Long Term
Care.
C. Medicaid
contract.
D. Effective for dates of
service on and after March 1, 2008, RCF and ALF Personal Care providers will be
required, when requested by DHS, to provide payroll records to validate service
plans and service logs.
E.
Documents signed by the supervising RN or QMRP, including:
1. The initial and all subsequent
assessments.
2. Instructions to the
personal care aide regarding:
a. The tasks the
aide is to perform,
b. The
frequency of each task and c. The maximum number of hours and minutes per month
of aide service authorized by the beneficiary's attending physician.
3. Notes arising from the
supervisor's visits to the service delivery location, regarding:
a. The condition of the
beneficiary,
b. Evaluation of the
aide's service performance,
c. The
beneficiary's evaluation of the aide's service performance and d. Difficulties
the aide encounters performing any tasks.
4. The service plan and service plan
revisions:
a. The justifications for service
plan revisions,
b. Justification
for emergency, unscheduled tasks and c. Documentation of prior or post approval
of unscheduled tasks.
F. Any additional or special documentation
required to satisfy or to resolve questions arising during, from or out of an
investigation or audit. "Additional or special documentation," refers to notes,
correspondence, written or transcribed consultations with or by other
healthcare professionals (i.e., material in the beneficiary's or provider's
records relevant to the beneficiary's personal care services, but not
necessarily specifically mentioned in the foregoing requirements). "Additional
or special documentation," is not a generic designation for inadvertent
omissions from program policy. It does not imply and one should not infer from
it that, the State may arbitrarily demand media, material, records or
documentation irrelevant or unrelated to Medicaid Program policy as stated in
this manual and in official program correspondence.
G. The personal care aide's training records,
including:
1. Examination results,
2. Skills test results and
3. Personal care aide
certification.
H. The
personal care aide's daily service notes for each beneficiary, reflecting:
1. The date of service,
2. The routines performed on that date of
service, noted to affirm completion of each task.
3. The time of day the aide began performing
the first service-plan-required task for the beneficiary;
4. The time of day the aide stopped
performing any service-plan-required task to perform any
non-service-plan-required function;
5. The time of day the aide stopped
performing any non-service-plan-required function to resume
service-plan-required tasks and
6.
The time of day the aide completed the last service-plan-required task for the
day for that beneficiary.
I. Notes, orders and records reflecting the
activities of the physician, the supervising RN or QMRP, the aide and the
beneficiary or the beneficiary's representative; as those activities affect
delivering personal care services.
250.100
Reimbursement Methods
10-1-12
A. Reimbursement for personal
care services is the lesser of the billed amount per unit of service or
Medicaid's maximum allowable fee (herein also referred to as "rate" or "the
rate") per unit.
B. Reimbursement
for Arkansas Medicaid Personal Care services is based on a 15-minute unit of
service.
C. Effective for dates of
service on and after March 1, 2008, RCF Personal Care provider reimbursement is
in accordance with a multi-hour daily service rate system, employing Medicaid
maximum allowable fees (Daily Service Rates) determined by individual
beneficiaries' Levels of Care.
D.
Effective for dates of service on or after October 1, 2012, ALF Personal Care
provider reimbursement is in accordance with a multi-hour daily service rate
system, employing Medicaid maximum allowable fees (Daily Service Rates)
determined by individual beneficiaries' Levels of Care. This excludes the
Living Choices Assisted Living waiver beneficiaries.
250.200
RCF and ALF Personal Care
Reimbursement Methodology 10-1-12
A.
The RCF and ALF Personal Care reimbursement methodology is designed with the
intent that reimbursement under the multi-hour Daily Service Rate system
closely approximates what reimbursement would have been if the providers were
to have billed by units of service furnished.
B. Whenever the unit rate (i.e., the maximum
allowable amount per fifteen minutes service) for personal care services
changes, Daily Service Rates under the RCF and ALF methodology are
correspondingly adjusted in accordance with the initial methodology by which
they were established and which is described in detail in the following
sections.
C. The Daily Service Rate
paid for personal care services is based on a Level of Care determined from the
resident's service plan.
250.210
Level of Care 10-1-12
There are 10 Levels of Care, each based on the average number
of 15-minute units of service per month required to fulfill a beneficiary's
service plan.
A. Level 1 includes RCF
and ALF Personal Care beneficiaries whose service plans comprise 100 units or
less per month of medically necessary personal care.
B. Level 10 includes RCF and ALF Personal
Care beneficiaries whose service plans comprise 256 or more units per month of
medically necessary personal care.
C. Level 2 through Level 9 were established
in equal increments between 101 and 255 units per month.
250.211
Level of Care Determination
10-1-12
A. The average of a service
plan's monthly units of service is used to determine each beneficiary's Level
of Care.
B. Calculate a
beneficiary's average number of monthly units of personal care as follows.
1. Add the minimum and maximum hourly Weekly
Totals from a completed form DMS-618, "Personal Care Assessment and Service
Plan," and divide the sum by 2 to obtain average weekly hours of
service.
2. Convert the average
obtained in step 1 to minutes by multiplying it by 60.
3. Divide the minutes by 15
(15 minutes equals one unit of service) to calculate
weekly average units of service.
4.
Multiply the weekly average units from step 3 by 52 (Weeks
in a year) and divide the product by 12 (Months
in a year) to calculate monthly average units of service.
5. Consult the "RCF and ALF Personal Care
Service Rate Schedule" on the Arkansas Medicaid Personal Care Fee Schedule to
find the applicable Daily Multi-Hour Service Rate for each Level of Care.
Procedure code T1020 is the applicable code for RCF and ALF Personal Care
providers.
262.104
Personal Care in an RCF or ALF
10-1-12
A. To bill for RCF or ALF
Personal Care, use HCPCS procedure code T1020 and the modifier
corresponding to the beneficiary's Level of Care in effect for the date(s) of
service being billed.
B. The Level
of Care that a provider bills must be consistent with the beneficiary's service
plan in effect on the day that the provider furnished the personal care
services billed.
Level of Care Specifications and Modifiers for Procedure
Code T1020
|
Levels of Care |
Minimum Service Units |
Maximum Service Units |
Modifier |
|
Level 1 |
Less than 100 |
100 |
U1 |
|
Level 2 |
101 |
119 |
U2 |
|
Level 3 |
120 |
139 |
U3 |
|
Level 4 |
140 |
158 |
U4 |
|
Level 5 |
159 |
177 |
U5 |
|
Level 6 |
178 |
196 |
U6 |
|
Level 7 |
197 |
216 |
U7 |
|
Level 8 |
217 |
235 |
U8 |
|
Level 9 |
236 |
255 |
U9 |
|
Level 10 |
256 |
256 |
UA |
262.106
Billing RCF and ALF Personal Care Services 10-1-12
A. RCF and ALF Personal Care providers may
not bill for days during which a beneficiary received no personal care services
(for instance, he or she was away for a day or more); therefore, do not include
in the billed dates of service any days the beneficiary was absent.
B. For each unbroken span of days of service,
multiply the days of service by the applicable Daily Service Rate and bill that
amount on the corresponding claim detail.
C. Documentation requirements outlined in the
Medicaid Personal Care Policy Section 216.400 (Personal Care Aide Service and
Documentation Responsibility) must be adhered to when providing Personal Care
services at all ALF facilities.
