Nebraska Administrative Code
Topic - HEALTH AND HUMAN SERVICES SYSTEM
Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES
Chapter 15 - PERSONAL ASSISTANCE SERVICES
Section 471-15-004 - ELIGIBILITY AND AUTHORIZATION

Universal Citation: 471 NE Admin Rules and Regs ch 15 ยง 004

Current through September 17, 2024

004.01 GENERAL SERVICE REQUIREMENTS.

004.01(A) MEDICAL NECESSITY. Medical necessity requirements outlined in 471 NAC 1 apply to the provision of personal assistance services, and are hereby incorporated as if fully rewritten herein.

004.01(B) ELIGIBILITY AND AUTHORIZATION.
004.01(B)(i) ELIGIBILITY CRITERIA. The Department must determine that a client meets all of the following eligibility criteria:
(1) Is a current Medicaid client;

(2) Needs personal assistance services to live in the community;
(a) But does not have needs that require more intensive services than those listed in this chapter due to an acute health care level;

(3) Is not receiving or eligible for personal assistance services or similar staff support based on their residence or place of employment;
(a) EXCEPTION. An individual residing in a licensed residential service program may only be eligible for personal assistance services under this regulation if it is needed to maintain competitive integrated employment if it would duplicate any services already received; and

(4) Lives in a residence that is not a hospital, nursing facility, intermediate care facility, prison, or other institution.

004.01(B)(ii) ASSESSMENT AND SERVICE PLAN. The client must participate in the development of the assessment and service plan by stating his or her service needs and preferences, and jointly determining the units of service needed. If the client is not cooperative in the process, the client is not eligible for services. The Department makes the final determination of units authorized.
004.01(B)(ii)(1) EMPLOYER APPOINTMENT OF AGENT FORM. Before authorization of a personal assistance service provider, the Department must obtain the client's signature on Internal Revenue Service Form FA-65, Employer Appointment of Agent.

004.01(B)(iii) AUTHORIZATION.
004.01(B)(iii)(1) PRIOR AUTHORIZATION. Personal assistance services must be authorized before actual provision of the service, based on the assessment of need and development of the service plan.

004.01(B)(iii)(2) AUTHORIZATION PERIOD. Services must be authorized based on the client's service needs for a period not to exceed a maximum of one year from the service authorization begin date.
004.01(B)(iii)(2)(a) AUTHORIZATION PERIOD OF PROVIDERS. A provider of personal assistance services may only be authorized until the end date of the client's existing authorization for services.

004.01(B)(iii)(2)(b) AUTHORIZATION OF MULTIPLE PROVIDERS. The client must work with the Department to determine the maximum number of units each provider will be authorized to provide. It is the client's responsibility to determine the day-to-day schedule of each provider.

004.01(B)(iii)(3) LIMITATION. Personal assistance services are limited to a maximum of 40 hours per seven-day period. Only the Department, not the approved service provider, may increase the maximum number of units for which the client is eligible per week, within the 40-hour per seven-day maximum. Any services provided in excess of 40 hours per seven-day period must receive prior authorization from the Department.

004.01(B)(iii)(4) RELATIONSHIP TO SERVICE PLAN. Personal assistance services authorized must relate directly to the tasks needed to be performed by someone else and that are essential to remain in the home, as listed on the service plan.

004.01(B)(iv) REVIEW OF SERVICE PLAN AND RE-AUTHORIZATION. Personal assistance services may be re-authorized at the end of an authorization period, which is at least annually, based on continued eligibility and a review of the service plan. The Department will review the service plan together with the client a minimum of once every 12 months, or whenever the client's service needs change.

004.02 SPECIFIC SERVICE REQUIREMENTS.

004.02(A) ESSENTIAL SERVICES. Personal assistance services are based on individual needs and criteria that must be determined through an assessment and development of a service plan that relates directly to the needs identified in the assessment. These services include:
(i) Basic personal hygiene including, but are not limited to, providing or assisting with bathing; shampoo, hair grooming; nail care; oral hygiene; shaving; and dressing;

(ii) Toileting and bowel and bladder care including, but are not limited to, assisting to and from bathroom, on and off toilet or commode, diapering, bedpan; external cleansing of perineal area; maintenance bowel care; and changing or emptying catheter bag;

(iii) Mobility, transfers, and comfort including, but are not limited to, assisting with ambulation with and without aids; repositioning; encouraging active range-of-motion exercises; assisting with passive range-of-motion exercise; and assisting with transfers with or without mechanical devices;

(iv) Nutrition services, including, but are not limited to, preparing meals; planning and preparing special diets; assisting with fluid intake; and feeding; or

(v) Medication services, including, but not limited to, assisting with administration of medications; reminding appropriate persons when prescriptions need to be refilled.

004.02(B) SUPPORTIVE SERVICES. When any of the services listed in 471 NAC 15-004.02(A), items i-v are essential to enable the client to remain in the home and community, the following supportive services can also be provided:
(i) Housekeeping tasks necessary to maintain the client in a healthy and safe environment, including changing the client's bed linens, laundering the client's bed linens and personal clothing, light cleaning in essential areas of the home used by the client; purchasing of food once per week, and cleaning client's dishes; and

(ii) Accompanying and assisting the client with any mobility, transfers, or other needed services for physician office visits, or on other trips to obtain medical diagnosis or treatment when the client is unable to travel alone.

004.02(C) SPECIALIZED PROCEDURES. Specialized procedures that would enable a person to live in their home and community may be performed by a personal assistance service provider at the direction of a competent client or of a caretaker. Such procedures are considered 'health maintenance activities' under the Nebraska Nurse Practice Act, Neb. Rev. Stat. § 38-2219. The client's attending physician or registered nurse must determine that these procedures can safely be performed in the home and community by an approved personal assistance service provider under the client's direction.

004.02(D) SERVICES OUTSIDE A CLIENT'S HOME. When any of the services listed in 471 NAC 15-004.02(A), items i-v are essential to enable the client to remain in the home and community, personal assistance services may be provided outside of a client's home, including at the client's worksite when the client is engaged in competitive integrated employment. Services provided may only include those authorized tasks that might otherwise be needed in the home and community, and if at a worksite, may not be tasks which essentially perform the job the client was hired to do. Accompanying and assisting the client with needed services when the client has work-related travels is also allowable.
004.02(D)(i) LICENSED RESIDENTIAL SERVICE PROGRAMS. An individual residing in a licensed residential service program may only be eligible for personal assistance services under this regulation if it is needed to maintain competitive integrated employment.

004.03 NON-COVERED SERVICES. Personal assistance services do not include the following:

(A) Personal assistance services not documented in the service plan;

(B) Personal assistance services provided by a parent of a minor child or spouse;

(C) Housekeeping services that are not an integral part of a covered personal assistance service;

(D) Services provided without authorization;

(E) Companion services, which provide for a person to be present without specific tasks be completed;

(F) Services provided when a client is not Medicaid eligible;

(G) Services that are defined as personal assistance services in 471 NAC 15-004.02 but are being paid by the Department under some other arrangement or funding source; and

(H) Clients receiving similar personal assistance services under another Medicaid service or program are not eligible for personal assistance services.

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