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Appendix IIState Medicaid Manual, Section4480: Personal Care ServicesSection 4480: Personal Care ServicesA. General.—Effective November 11, 1997, HCFA published a final regulation in the Federal Registerthat removed personal care services from regulations at 42 CFR 440.170 and added a new section at 42CFR 440.167, A Personal Care Services in a home or other location. The final rule specifies the revisedrequirements for Medicaid coverage of personal care services furnished in a home or other location asan optional benefit. This rule conforms to the Medicaid regulations and to the provisions of §13601(a)(5)of the Omnibus Budget Reconciliation Act (OBRA) of 1993, which added §1905(a)(24) to the SocialSecurity Act to include payment for personal care services under the definition of medical assistanceUnder §1905(a)(24) of the Act, States may elect, as an optional Medicaid benefit, personal care servicesfurnished to an individual who is not an inpatient or resident of a hospital, nursing facility, intermediatecare facility for persons with mental retardation (ICF/MR), or institution for mental disease. Thestatute specifies that personal care services must be: (1) authorized for an individual by a physician in aplan of treatment or in accordance with a service plan approved by the State; (2) provided by an individualwho is qualified to provide such services and who is not a member of the individual’s family; and(3) furnished in a home or other location.B. Changes Made by Final Regulation.—Personal care services may now be furnished in any settingexcept inpatient hospitals, nursing facilities, intermediate care facilities for the mentally retarded, orinstitutions for mental disease. States choosing to provide personal care services may provide those servicesin the individual’s home, and, if the State so chooses, in settings outside the home.In addition, services are not required by Federal law to be provided under the supervision of a registerednurse nor does Federal law require that a physician prescribe the services in accordance with aplan of treatment. States are now permitted the option of allowing services to be otherwise authorizedfor the beneficiary in accordance with a service plan approved by the State.C. Scope of Services.—Personal care services (also known in States by other names such as personalattendant services, personal assistance services, or attendant care services, etc.) covered under a State’sprogram may include a range of human assistance provided to persons with disabilities and chronicconditions of all ages which enables them to accomplish tasks that they would normally do for themselvesif they did not have a disability. Assistance may be in the form of hands-on assistance (actuallyperforming a personal care task for a person) or cueing so that the person performs the task by him/herself. Such assistance most often relates to performance of ADLs and IADLs. ADLs include eating,bathing, dressing, toileting, transferring, and maintaining continence. IADLs capture more complex life
186 UNDERSTANDING MEDICAID HOME AND COMMUNITY SERVICES: A PRIMERactivities and include personal hygiene, light housework, laundry, meal preparation, transportation,grocery shopping, using the telephone, medication management, and money management. Personalcare services can be provided on a continuing basis or on episodic occasions. Skilled services that maybe performed only by a health professional are not considered personal care services.1. Cognitive Impairments.—An individual may be physically capable of performing ADLs andIADLs but may have limitations in performing these activities because of a cognitive impairment.Personal care services may be required because a cognitive impairment prevents an individual fromknowing when or how to carry out the task. For example, an individual may no longer be able to dresswithout someone to cue him or her on how to do so. In such cases, personal assistance may include cueingalong with supervision to ensure that the individual performs the task properly.2. Consumer-Directed Services.—A State may employ a consumer-directed service deliverymodel to provide personal care services under the personal care optional benefit to individuals in needof personal assistance, including persons with cognitive impairments, who have the ability and desireto manage their own care. In such cases, the Medicaid beneficiary may hire their own provider, train theprovider according to their personal preferences, supervise and direct the provision of the personal careservices and, if necessary, fire the provider. The State Medicaid Agency maintains responsibility forensuring the provider meets State provider qualifications (see E below) and for monitoring service delivery.Where an individual does not have the ability or desire to manage their own care, the State mayeither provide personal care services without consumer direction or may permit family members orother individuals to direct the provider on behalf of the individual receiving the services.D. Definition of Family Member.—Personal care services may not be furnished by a member of the beneficiary’sfamily. Under the new final rule, family members are defined to be “legally responsible relatives.”Thus, spouses of recipients and parents of minor recipients (including stepparents who are legallyresponsible for minor children) are included in the definition of family member. This definition necessarilywill vary based on the responsibilities imposed under State law or under custody or guardianshiparrangements. Thus, a State could restrict the family members who may qualify as providers byextending the scope of legal responsibility to furnish medical support.E. Providers.—States must develop provider qualifications for providers of personal care services andestablish mechanisms for monitoring the quality of the service. Services such as those delegated by nursesor physicians to personal care attendants may be provided so long as the delegation is in keeping withState law or regulation and the services fit within the personal care services benefit covered under aState’s plan. Services such as assistance with taking medications would be allowed if they are permissiblein States’ Nurse Practice Acts, although States need to ensure the personal care assistant is properlytrained to provide medication administration and/or management.States may wish to employ several methods to ensure that recipients are receiving high quality personalcare services. For example, States may opt to a criminal background check or screen personal careattendants before they are employed. States can also establish basic minimal requirements related to age,health status, and/or education and allow the recipient to be the judge of the provider’s competencythrough an initial screening. States can provide training to personal care providers. States also mayrequire agency providers to train their employees. States can also utilize case managers to monitor thecompetency of personal care providers. State level oversight of overall program compliance, standards,case level oversight, attendant training and screening, and recipient complaint and grievance mechanismsare ways in which States can monitor the quality of their personal care programs. In this way,States can best address the needs of their target populations and develop unique provider qualificationsand quality assurance mechanisms.
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Understanding MedicaidHome and Comm
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IntroductionPeople of all ages with
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Introduction 31998—is the group m
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Introduction 5This Primer has been
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CHAPTER 1Medicaid Coverage of Home
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Medicaid Coverage of Home and Commu
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CHAPTER 2Financial Eligibility Rule
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Financial Eligibility Rules and Opt
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Health and Functional Criteria for
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Options for Designing Service Cover
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Guide to Chapter 7Consumer Directio
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