Current through Register Vol. 35, No. 6, March 26, 2024
MAD pays for medically necessary personal care services
(PCS) furnished to a MAP eligible recipient under 21 years of age as part of
the EPSDT program when the services are part of his or her ISP for the
treatment of correction, amelioration, or prevention of deterioration of a MAD
identified medical or behavioral health condition, see
42 CFR Section
440.167. PCS provides a range of services to
a MAP eligible recipient who is unable to perform some or all activities of
daily living (ADLs) or instrumental activities of daily living (IADLs) because
of a disability or a functional limitation. A prescribed course of regular PCS
services and daily living assistance supports the MAP eligible recipient to
live in his or her home rather than an institution and allows him or her to
achieve the highest possible level of independence. These services include, but
are not limited to, activities such as bathing, dressing, grooming, eating,
toileting, shopping, transporting, caring for assistance animals, cognitive
assistance, and communicating. A MAP eligible recipient may be physically
capable of performing ADLs or IADLs but may have limitations in performing
these activities because of a cognitive impairment. PCS services may be
required because a cognitive impairment prevents a MAP eligible recipient from
knowing when or how to carry out the task. In such cases, PCS services may
include cuing along with supervision to ensure that the MAP eligible recipient
performs the task properly.
A. EPSDT
PCS eligible providers:
(1) agencies that meet
the following conditions are eligible to enroll as providers and be reimbursed
for providing EPSDT PCS services:
(a) a
licensed nursing or home health agency that is a public agency, a private
for-profit agency, or private non-profit agency; and
(b) the PCS attendant to the MAP eligible
recipient must be supervised by a MAD enrolled RN;
(2) certification for participation as a
medicare home health agency is not required; a MAP eligible recipient's family
member may not furnish PCS services to him or her; in this instance, a family
member is defined as a legally responsible relative, such as parents of minor
child or stepparent who is legally responsible for minor child; for a MAP
eligible recipient 18 to 21 years of age, parents or other relatives may
provide PCS services if they are not legally responsible for the MAP eligible
recipient; the parent or another relative must be employed by a MAD approved
PCS agency eligible to bill for PCS services and must meet all MAD required
training and supervision standards.
B. EPSDT PCS attendant training:
(1) The PCS agency is responsible for
ensuring that the PCS attendant has completed a training program and is
competent to provide assigned tasks as a PCS attendant specific to the MAP
eligible recipient's needs.
(2) The
PCS attendant training program must consist of no less than 40 hours of
training to be completed by the PCS attendant in the first year of employment.
Ten hours of training must be completed prior to placing the employee in a MAP
eligible recipient's home. Two of the 10 hours may include agency orientation.
Eight of the 10 hours of training must be specific to the MAP eligible
recipient.
(3) The training
curriculum must include, at a minimum, the following areas:
(a) communication;
(b) MAP eligible recipient's
rights;
(c) recording of
information in MAP eligible recipient's records;
(d) nutrition and meal preparation;
(e) care of ill and disabled children and
adolescents;
(f) emergency response
(first aid, CPR, 911, etc.);
(g)
basic infection control;
(h)
housekeeping skills;
(i) home
safety and fire protection; and
(j)
electronic visit verification (EVV).
C. EPSDT PCS criteria: PCS services are
defined as medically necessary tasks pertaining to a MAP eligible recipient's
physical or cognitive functional ability. The goal of the provision of care is
to avoid institutionalization and maintain the MAP eligible recipient's
functional level. Services are covered under specific criteria.
(1) The MAP eligible recipient must have a
need for assistance with at least two or more ADL's or both such as eating,
bathing, dressing and toileting activities, appropriate to his or her
age.
(2) PCS services must be
medically necessary, prescribed by the MAP eligible recipient's PCP and
included in the MAP eligible recipient's individual treatment plan
(ITP).
(3) The need for PCS
services is evaluated based on the availability of the MAP eligible recipient's
family members or natural supports, such as other community resources or
friends that can aid in providing such care.
(4) PCS services must be provided with the
consent of the MAP eligible recipient's parent or guardian if the MAP eligible
recipient is under the age of 18 years. If a MAP eligible recipient is
emancipated or is at least 18 years old and is able to provide consent, his or
her consent is required.
(5) PCS
services are furnished in the MAP eligible recipient's place of residence and
outside his or her home when medically necessary and when not available through
other existing benefits and programs such as home health, early intervention or
school programs. PCS services are services furnished to a MAP eligible
recipient who is not an inpatient or a resident of a hospital, nursing
facility, intermediate care facility for individuals with intellectual
disabilities (ICF-IID), or an institution for mental illness.
(6) Medically necessary PCS services to
support a MAP eligible recipient attend school are furnished in partnership
with the MAP eligible recipient's school as an alternative to his or her
participation in a homebound program. PCS services should foster the MAP
eligible recipient's independence. PCS services are furnished only to a MAP
eligible recipient based on MAD or its designee's UR contractor's approval. PCS
services may not be furnished to a non-MAP eligible recipient in the school
setting.
(7) Only a trained PCS
attendant who has successfully demonstrated service competency such as bathing,
dressing, eating and toileting may provide PCS services to a MAP eligible
recipient. The PCS attendant must be employed by a MAD approved PCS agency and
work under the direct supervision of a MAD approved RN.
(8) The supervisory RN must be employed or
contracted by the PCS agency and have one year direct patient care experience.
The supervisory RN is responsible for conducting and documenting visits at the
MAP eligible recipient's residence for the purpose of assessing his or her
progress and the PCS attendant's performance. The ITP should be updated as
indicated and in cooperation with the MAP eligible recipient's case manager.
These visits will be conducted and documented every 62 calendar days or more
often if the MAP eligible recipient's condition warrants it.
D. EPSDT PCS covered services: MAD
covers the following personal care services:
(1) basic personal care services consist of
bathing, care of the teeth, hair and nails, assistance with dressing, and
assistance with toileting activities;
(2) assistance with eating and other
nutritional activities, when medically necessary, i.e., due to documented
weight loss or another physical effect; and
(3) cognitive assistance such as prompting or
cuing.
E. EPSDT PCS
noncovered services: PCS services are subject to the limitations and coverage
restrictions which exist for other MAD services. See Section 14 of this rule
for general non-covered MAD EPSDT services or activities. Specifically, PCS
services may not be billed in conjunction with the following services:
(1) any task that must be provided by a
person with professional or technical training, such as but not limited to:
insertion and irrigation of catheters, nebulizer treatments, irrigation of body
cavities, performance of bowel stimulation, application of sterile dressings
involving prescription medications and aseptic techniques, tube feedings, and
administration of medications;
(2)
services that are not in the MAP eligible recipient's approved ITP and for
which prior approval has not been received;
(3) services not considered medically
necessary by MAD or its designee for the condition of the MAP eligible
recipient.
F. EPSDT PCS
treatment plan: The MAP eligible recipient's ITP is approved by MAD or its
designated UR contractor prior to the initiation of PCS services. The PCS ITP
is developed as a result of a face-to-face assessment of the MAP eligible
recipient and must include the following:
(1)
statement of the nature of the specific problem and the specific needs of the
MAP eligible recipient for PCS services;
(2) description of the physical or cognitive
functional level of the recipient as evidenced by the PCP's clinical
evaluation, including social emotional or behavioral health status,
intellectual functioning and the documented medical necessity for PCS
services;
(3) description of
intermediate and long-range service goals that includes the scope and duration
of service, how goals will be attained and the projected timetable for their
attainment;
(4) specification of
the PCS attendant's responsibilities, including tasks to be performed by the
attendant and any special instructions for the health and safety of the MAP
eligible recipient;
(5) a statement
of the least restrictive conditions necessary to achieve the goals identified
in the plan; and
(6) the ITP must
be reviewed and revised in cooperation with the MAP eligible recipient's case
manager according to his or her clinical needs at least every six
months.
G. Use of the
electronic visit verification (EVV) system is required for payment of PCS
services including EPSDT eligible members. The managed care organizations shall
collaborate to offer a single EVV vendor for PCS and monitor compliance with
the federal 21st Century Cures Act. The MCO shall maintain an EVV system
capable of leveraging up-to-date technology as it emerges to improve
functionality in all areas of the state, including rural areas.
