0810.035.00  PERSONAL CARE SERVICES PROGRAM

The purpose of the Personal Care Services program is to provide eligible Medicaid claimants with personal care in their homes, to prevent or delay institutionalization.  Personal Care Services are a covered Medicaid service.  Refer to the Missouri Medicaid Provider Manual for the scope of services covered by the Personal Care Services program.

The program requires the joint efforts of the Family Support Division, the Division of Medical Services and the Division of Senior Services.

0810.035.05  LEGAL REFERENCE (PERSONAL CARE SERVICES)

The Missouri Personal Care Program was implemented on July 1, 1982, as the result of Senate Bill Number 63.

0810.035.10  BASIC ELIGIBILITY GUIDELINES FOR PERSONAL CARE SERVICES

To be eligible for the Personal Care Services program, a claimant must be:

1. Currently eligible for Title XIX (Medicaid) benefits;
2. Recommended for Personal Care Services by the attending physician;
3. Determined to be in need of Nursing Facility (NF), Acute Care Hospital or ICF/IMR level of care (as if they were entering a nursing care facility); and
4. Evaluated, by the Division of Senior Services, to determine that the available services correspond to the claimant's prescribed needs.

0810.035.15 ELIGIBILITY DETERMINATION (DIVISION OF SENIOR SERVICES)

The Division of Senior Services determines the client's medical need for the Personal Care Services program.  The Division of Senior Services workers are responsible for the following:

1. Making referrals to FSD for applications for Title XIX or verification of current Title XIX status.
2. Evaluating the need for Personal Care Services.  This involves:
   • completing an In-Home Assessment of the client's current situation; and
   • working with the attending physician to obtain the NF level of care information.
3. Developing a Personal Care Service Plan that:
   • obtains the claimant's signature;
   • contains the attending physician's evaluation of the necessary level of care and recommendation of Personal Care Services;
   • obtains the physician's signature;
   • establishes controls to reassess the Care Plan every six months; and
   • notifies the IM Worker, claimant, provider, and the DMS fiscal agent of claimant's eligibility for Personal Care Services.
4. Authorizing the delivery of necessary services.
5. Communicating with the FSD worker regarding:
   • the joint application process; and
   • changes in circumstances affecting the claimant's eligibility, on an ongoing basis.

If the initial request for personal care services is received through the Division of Senior Services, the Division of Senior Services worker will:

1. Inform the claimant of the necessity for Title XIX eligibility.
2. Contact the FSD worker, by using the (IM-54) Referral for Services form, requesting an application for Medical Assistance or one of the cash programs.

   Note:  If the claimant is found to be ineligible for Title XIX services, the Division of Senior Services worker will explore other resources.

If Personal Care Services are not recommended, the Division of Senior Services worker will:

• Assist the claimant with other resources; and/or
• Notify the IM worker (via the IM-54), if institutionalization is requested.  (The SNC or MA vendor process must then be followed.)

0810.035.20 FAMILY SUPPORT DIVISION RESPONSIBILITIES

The FSD Income Maintenance worker is responsible for:

1. Determining the claimant's Medicaid eligibility;
2. Making referrals to the Division of Senior Services workers for the claimant's assessment for the services;
3. Processing referrals from the Division of Senior Services for Title XIX application procedures;
4. Communicating with the Division of Senior Services worker regarding:
   • the joint application process; and
   • any changes in circumstances.

   The request for Personal Care Services may originate through any of the following sources:

   • claimant/family
   • physician
   • hospital
   • long-term care facility
   • Division of Senior Services worker
   • other

   When the IM worker receives a request for Personal Care Services, from any of the above sources, the worker will:

   1. Verify the claimant's current Title XIX status:
      1. If the claimant is currently Title XIX eligible, the worker will notify the Division of Senior Services worker of current Title XIX eligibility dates, by using the (IM-54) Referral for Services form or by verbal confirmation.
      2. If the claimant is not currently Title XIX eligible, the worker will:
         • Take an IM application.
         • If the request was from a source other than the Division of Senior Services worker, notify the Division of Senior Services worker of the request for Personal Care Services, by sending: An IM-54, Referral for Services form indicating Title XIX eligibility determination in process and Personal Care Services requested.
   2. Complete the IM eligibility determination; and
   3. Notify the Division of Senior Services worker of Title XIX eligibility or ineligibility.  (On approvals, beginning and ending Title XIX dates must be reported to the Division of Senior Services worker, for Title XIX billing purposes.)  The IM-54 or a copy of the approval or rejection letter may be used as the vehicle for notifying the Division of Senior Services worker.

      The IM worker will keep the Division of Senior Services worker informed of any changes of circumstances affecting the client's Title XIX eligibility, on an ongoing basis, including the results of reinvestigations and any changes in Title XIX eligibility dates.

0810.035.25  DIVISION OF MEDICAL SERVICES RESPONSIBILITIES

The Division of Medical Services is responsible for:

1. Developing the scope of covered Medicaid services available through the program.
2. Establishing the current Medicaid rate for the available services;
3. Establishing the contract requirements for Medicaid providers;
4. Enrolling eligible Personal Care providers;
5. Authorizing payment for delivered, authorized services; and
6. Assisting providers with questions and concerns regarding the program's operation.

0810.035.30  PERSONAL CARE SERVICE PROVIDER RESPONSIBILITIES

The Personal Care Service provider is responsible for:

1. Delivering the prescribed services to the claimant.
2. Sending a Case Activity Report to the Division of Senior Services.
3. Sending the claim for payment to the Division of Medical Services fiscal agent, on a monthly basis.