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Options for Designing Service Coverage: General Considerations 61everyday activities both in and outside the individual’shome. 8In January 1999, HCFA released a State MedicaidManual Transmittal that updated the Agency’sguidelines concerning coverage of personal careservices. In it, HCFA made clear (a) that personalcare services include assistance with both ADLsand IADLs, and (b) that personal care for personswith cognitive impairments may include cueingalong with supervision to ensure the individualsperform the task properly. Formerly such supervisiongenerally was considered outside the scopeof personal care. (See Appendix II for the completetext of HCFA’s guidance on this issue.)A state may now extend such services to includesupervision and assistance to persons with cognitiveimpairments, which can include persons withmental illness or mental retardation as well as personswho have Alzheimer’s disease and otherforms of dementia. However, this supervision andassistance must be related directly to performanceof ADLs and IADLs. Simple companionship orcustodial observation of an individual, absenthands-on or cueing assistance that is necessaryand directly related to ADLs or IADLs, is not aMedicaid personal care service. In particular, theManual states:Scope of services—Personal care services coveredunder a state’s program may include a range ofhuman assistance provided to persons with disabilitiesand chronic conditions of all ages, whichenables them to accomplish tasks they would normallydo for themselves if they did not have a disability.Assistance may be in the form of hands-onassistance (actually performing a personal caretask for a person) or cueing so that a person performsthe tasks by him/herself. Such assistancemost often relates to performance of ADLs andIADLs. . . . Personal care services can be providedon a continuing basis or on episodic occasions.Skilled services that may be performed only by ahealth professional are not considered personalcare services.However, skilled services may be provided undera state’s personal care benefit under the state planwhen they are delegated by a nurse and when thepractice is recognized and permitted under statelaw. (Nurse delegation is discussed in detail inChapter 7.)Cognitive impairments—An individual may bephysically capable of performing ADLs and IADLsbut may have limitations in performing theseactivities because [of] a cognitive impairment. . . .Personal care services may be required because acognitive impairment prevents an individual fromknowing when or how to carry out the task. Forexample, an individual may no longer be able todress without someone to cue him or her on how todo so. In such cases, personal assistance may includecueing along with supervision to ensure thatthe individual performs the task properly.In October 1999, HCFA further revised theManual to permit states to offer the option of consumer-directedpersonal care services. TheManual revisions explicitly recognized that provisionof personal assistance services may be directedby the persons receiving such service, includingthose persons’ own supervision and trainingof their personal care attendants. In particular, theManual states:Consumer-directed services—A State may employa consumer-directed service delivery model to providepersonal care services under the personal careoptional benefit to individuals in need of personalassistance, including persons with cognitiveimpairments, who have the ability and desire tomanage their own care. In such cases, the Medicaidbeneficiary may hire their own provider, train theprovider according to their personal preferences,supervise and direct the provision of personal careservices, and, if necessary, fire the provider. TheState Medicaid Agency maintains responsibilityfor ensuring the provider meets State providerqualifications . . . and for monitoring service delivery.Where an individual does not have the abilityor desire to manage their own care, the State mayeither provide personal care services without consumerdirection or may permit family members orother individuals to direct the provider on behalf ofthe individual receiving the services. 9These manual materials describe a robust scope ofpersonal care/personal assistance services a statemay choose to cover under its Medicaid stateplan—in keeping with contemporary views con-
62 UNDERSTANDING MEDICAID HOME AND COMMUNITY SERVICES: A PRIMERcerning the role personal assistance can play insupporting individuals with disabilities in a widerange of everyday activities. As a result of thechanges made in Federal policy, there is now littledifference in the scope of personal care servicesthat may be offered under the Medicaid state planand those that may be offered under an HCBSwaiver program. In many states, consumer directionof personal care services has been a feature ofpersonal assistance programs (both under Medicaidand funded with other dollars) for manyyears. For example, consumer direction was builtinto the Massachusetts Medicaid personal careprogram from its inception. HCFA materialsclearly acknowledge and sanction this model.HCFA has also expressed a strong interest in identifyingand working with the states to eliminateany further barriers to implementation of CD personalassistance service models in Medicaid.(Chapter 7 discusses this topic in greater detail,with respect to both CD personal assistance servicesand self-determination for people with developmentaland other disabilities.)However, neither the provisions of OBRA 93 northe revised Federal regulations and HCFA StateMedicaid Manual guidelines require a state tochange the scope of its pre-1993 coverage. In orderto take advantage of these changes, a state mustfile an amendment to its Medicaid plan.Expenditure RamificationsTwenty-seven states and the District of Columbiacover personal care services under their Medicaidstate plans, but only a few states make it broadlyavailable. 10 The principal reason why many statesdo not cover personal care services at all, orimpose considerable restrictions on the servicesthey offer, is concern about controlling expendituresfor such services. State officials often want toknow: (1) How many Medicaid beneficiaries willqualify to receive the service? (2) How much servicewill they use once eligible?Advocates for personal care/personal assistancepoint out that personal care services are usuallyless costly than institutional services and, consequently,that adding this coverage will result inlower institutional expenditures—by avoiding ordelaying admission of individuals to institutionalSpecial Personal Assistance Issues, Whether under State Plan or an HCBS Waiver ProgramDelegation of Nursing Tasks. Certain personal assistance activities (e.g., medication administration, tubefeeding)fall under the jurisdiction of states’ Nurse Practice Acts. Hence, even though Federal law has “demedicalized”its rules concerning personal care services, state Nurse Practice laws still may dictate closeinvolvement of medical personnel. In such cases, states often restrict delivery of personal care services to homehealth agencies. In these states, changes to the Nurse Practice Acts would be necessary to take full advantageof the flexibility afforded by Federal provisions for personal care services. (Nurse delegation is discussed in detailin Chapter 7.)Provider Qualifications. More and more states are routinely requiring individuals who would provide personalcare services to undergo criminal background checks and checks against abuse/neglect registries. States alsotypically require such individuals to have completed a basic training course. To ensure proper supervision of personalcare workers, some states require that they be employed by agencies that hire the workers and supervisethem. Others permit individuals to furnish personal care in their own right, with the consumer responsible foroversight (including deciding whom to hire). Still others charge case management authorities with oversight andmonitoring responsibilities. (Chapter 7 provides a detailed discussion.)Payment of Family Members. HCFA policy states that:Personal care services may not be furnished by a member of the beneficiary’s family. . . . HCFA defines familymembers as spouses of beneficiaries and parents (or step-parents) of minor beneficiaries. HCFA believesthis to be the preferred definition as this definition is identical to the one that applies to personal care servicesprovided under an HCBS waiver.Based on the foregoing, non-spousal and non-parental relatives not legally responsible for the beneficiary’s caremay provide such services for pay if the state chooses. (Chapter 8 provides a detailed discussion.)
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Understanding MedicaidHome and Comm
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viiiUNDERSTANDING MEDICAID HOME AND
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IntroductionPeople of all ages with
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Introduction 31998—is the group m
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CHAPTER 1Medicaid Coverage of Home
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Medicaid Coverage of Home and Commu
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