Provider Requirements and Service Limitations
From The May 2010 Florida Medicaid Provider Handbook
Personal Care- Requirements To Receive
Personal care assistance is a service that assists a recipient with eating and meal preparation, bathing, dressing, personal hygiene, and other self care activities of daily living. The service also includes activities such as assistance with meal preparation, bed making and vacuuming when these activities are essential to the health, safety and welfare of the recipient and when no one else is available to perform them. This service is provided on a one-on-one basis. Personal care assistance may not be used solely for supervision. Personal care assistance may not be used as a substitute for a meaningful day activity.
This service is not available to individuals enrolled on the DD Waiver – Tier Four.
Personal care assistance is limited to the amount, duration and scope of the services described in the recipient’s support plan and current approved cost plan. A recipient shall receive no more than 180 hours a month, or 720 quarter hour units of this service per month. A recipient having intensive physical, medical, or adaptive needs meeting the requirements for the intense level of personal care assistance, who needs additional hours over 180 to maintain their health and medical status, may request additional hours of personal care assistance services. The requested additional units must be prior authorized by APD.
Personal care assistance services shall be billed at the standard rate level for the service based on the published rate system. The standard rate is paid when a recipient requires minimal support through instructional prompts, cues, and supervision to properly complete the basic personal support areas of eating, bathing, toileting, grooming, and personal hygiene. Standard and moderate level needs for the service cannot exceed 180 hours or 720 quarter hour units of the service per month. A rate other than the standard rate level for this service shall only be authorized when it has been determined through use of the APD-approved assessment and the support planning process that a recipient requires an enhanced level of supports.
The need for an enhanced rate and the approved rate level shall be identified in the recipient’s support and cost plan and on the authorization for service submitted to the provider by the recipient’s support coordinator. Recipients with the following needs may require enhanced services:
- Recipients who have a moderate level of support identified in the current abilities section of the APD-approved assessment may receive the rate level identified as moderate for the service. The moderate rate is paid when a recipient routinely requires prompts, supervision and physical assistance, to include lifting and transferring, to complete the basic personal care areas of eating, bathing, toileting, grooming, and personal hygiene. Moderate needs for the service cannot exceed 180 hours or 720 quarter hour units of the service per month.
- Recipients who have an intense level of support identified in the current abilities section of the APD-approved assessment may receive the rate level identified as intense for the service. The intensive rate is paid when a recipient requires total physical assistance, to include lifting and transferring, in at least three of the basic personal care areas identified above due to physical, medical or adaptive limitations. Additional hours a month over the 180 hour limit may be requested for intensive physical, medical or adaptive needs when the hours are essential to maintain the recipient’s health and medical status. Any recipient who requires PCA services between 10:00 p.m. and 6:00 a.m. shall provide documentation from a physician stating that PCA services are medically necessary during this time. The support plan shall also explain the duties that a PCA provider will perform between the hours of 10:00 p.m. and 6:00 a.m.
This service cannot be provided concurrently (at the same time) with companion services or ADT services. Recipients who receive in-home support services are not eligible to receive personal care assistance.
Note: Refer to the Florida Medicaid Home Health Services Coverage and Limitations Handbook for additional information on Medicaid State Plan coverage. The handbook is available on the Medicaid fiscal agent’s Web site at www.mymedicaid-florida.com. Select Public Information for Providers, then on Provider Support, and then on Provider Handbooks. The handbook is incorporated by reference in 59G-4.130, F.A.C.
Reimbursement* and monitoring documentation to be maintained by the provider:
- *Copy of claim(s) submitted for payment; and
- *Copy of service log.
The provider must submit a copy of service log, monthly, to the waiver support coordinator.
If the provider plans to transport the recipient in his private vehicle, at the time of enrollment, the provider must be able to show proof of valid: 1) driver’s license, 2) car registration, and 3) insurance. Subsequent to enrollment, the provider is responsible for keeping this documentation up-to-date.
*Indicates reimbursement documentation.
Place of Service:
Personal care assistance shall be provided in the recipient’s own home or family home or while the recipient who lives in one of those arrangements is engaged in a community activity. No service may be provided or received in the provider’s home, a hospital, an ICF/DD or other institutional environment.
Personal care assistance for persons under the age of 21 may be provided through Medicaid Home Health State Plan Program services. Recipients who live in their own home or adults that live in a family home may require personal care assistance to assist them with meeting their own personal care needs.
For recipients living in their own home, consider the physical limitations or abilities to meet daily personal care assistance needs. Recipients living in foster or group homes are not eligible to receive this service, except:
- During an overnight visit with family or friends away from the foster or group home to facilitate the visit; or
- When a group home resident recovering from surgery does not require the care of a nurse, and the group home operator is unable to provide the personal attention required to insure the recipient’s personal care needs are being met. Under these circumstances, it would be considered reasonable to provide this service to a group home resident only on a time-limited basis. Once the recipient has recovered, the service must be discontinued.
A relative is defined as someone other than a legally responsible family member, who is required to provide care for the recipient such as a parent of a minor child or a family member who is also a plenary guardian of an adult. With regard to relatives providing this service, controls must be in place to make sure that the payment is made to the relative as a provider only in return for specific services rendered; and there is adequate justification as to why the relative is the provider of care. An example of a viable reason may be lack of providers in a rural area.
Personal care assistance is monitored through the statewide quality assurance program for waiver services and the recipient’s or family’s contact with the waiver support coordinator. The recipient or family member should contact the waiver support coordinator when concerns arise or if needs change. The waiver support coordinator must request changes to the care plan to increase or decrease services based on a significant change in the recipient’s condition or circumstance and must submit the changes to the APD Area Office for approval.
Reimbursement for nursing oversight of services provided by home health agencies and nurse registries is not a separate reimbursable service. The cost must be included in the personal care service.
Personal care assistance providers are not reimbursed separately for transportation and travel cost. These costs are included in the rate.
Personal Care Assistance Provider Requirements
Providers of personal care assistance may be home health or hospice agencies, licensed in accordance with Chapter 400, parts III or IV, F.S. Providers may also be independent vendors. Independent vendors are not required to be licensed, certified, or registered.
Independent vendors and employees of agencies shall be at least 18 years of age and have at least one year of experience working in a medical, psychiatric, nursing or childcare setting or working with recipients who have a developmental disability. College, vocational or technical training equal to 30 semester hours, 45 quarter hours or 720 classroom hours may substitute for the required experience.
Proof of training in the areas of Cardiopulmonary Resuscitation (CPR), HIV/AIDS and infection control is required within 30 days of initially providing personal care assistance. Proof of annual or required updated training shall be maintained on file for review.
The provider is responsible for all training requirements outlined in the Core Assurances.
Note: Refer to the Core Assurances in Appendix A for the provider training requirements.