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NV Personal Care Services(PCS) TrainingNevada Medicaid and Nevada Check UpHPESDevelopment Company, L.P.The information contained herein is subject to change without notice 2012 Hewlett-Packard
Covered topicsPurpose of PCS Waiver Services Requesting a Functional Assessment Billing for Services 2HP Confidential - PCS Presentation 2012
Handout list/check your handouts PowerPoint Service Plan FA/Service Plan Procedures Medicaid Services Manual Chapter 3500 Emergency Numbers/Contact List Program Brochure Program Criteria Recipient Responsibilities Recipient Bill of Rights Billing Information3HP Confidential - PCS Presentation 2012
Handout list - continuedRecipient Information/Completion: Program Brochure Program Criteria Recipient Responsibilities Recipient Bill of RightsTherapist Completion: PT/OT completes the FunctionalAssessment (pages 1 to 11)HPES Completion: 4HP Confidential - PCS Presentation 2012The Service Plan (pages 1 – 2) usingclinical staff
Program purpose5 To assist, support and maintainrecipients living independently intheir homes and in settingsoutside their homes, includingemployment sites Assistance with Activities of DailyLiving (ADL) and InstrumentalActivities of Daily Living (IADL)(does not cover skilled services) These services are providedwhere appropriate, medicallynecessary and within servicelimitations To prevent institutionalizationHP Confidential - PCS Presentation 2012
Agency types PCS Provider Agency (Medicaid Services Manual 3500) Intermediary Service Organization (Medicaid Services Manual2600)6HP Confidential - PCS Presentation 2012
Program eligibility criteria7 The recipient has ongoing Medicaid or Nevada Check Up (NCU)eligibility for services The recipient is NOT in a facility of any type or group home There is no Legally Responsible Individual (LRI) or other willing caregiveravailable and capable of assisting the recipient The recipient must be cooperative in establishing the service plan andfollow the approved service plan The recipient must be capable of making choices about ADLs (or have aPersonal Care Representative) Service must be medically necessary as defined by DHCFPHP Confidential - PCS Presentation 2012
Personal Care Representative (PCR)An individual who is directlyinvolved in the day-to-day care ofa recipient and is available todirect care in the home.This individual acts on behalf ofthe recipient when the recipient isunable to direct his/her ownpersonal care services.A personal care representativemust be a responsible adult.8HP Confidential - PCS Presentation 2012
Legally Responsible Individual (LRI)Those individuals who arelegally responsible toprovide medical support,including: Spouses of recipients Parents of minor recipientsincluding: stepparents foster parentsLegal guardiansThe LRI must be capableand available.9HP Confidential - PCS Presentation 2012
Criteria for Capable CaregiversCapable CaregiverA capable caregiver is a responsible adult who is physically capable of carrying outnecessary maintenance, health/medical care, education, supervision, support services,and/or the provision of needed ADLs and IADLs. If a LRI is capable and available, PCS cannot be authorized, because PCS are notintended to supplant natural support systems A LRI cannot be paid to provide PCS services to the individual for which he or she islegally responsibleIncapable CaregiverA caregiver who is unable to safely manage required care due to: Cognitive limitations (unable to learn care tasks, memory deficits); infirm Documented physical limitations (unable to render care such as inability to lift recipient) Significant health or emotional issues. Caregiver incapability must be documented by thecaregiver’s treating physician, and must directly prevent or interfere with provision of care10HP Confidential - PCS Presentation 2012
Services to assist with ADLsPersonal care services to assist with the following ADLs may beauthorized when medically necessary and within servicelimitations: Bathing (includes shampooing)/dressing/undressing Toileting Grooming Transfers from one stationary position to another Mobility/ambulation Eating Assistance with medication that are self-administered11HP Confidential - PCS Presentation 2012
IADL covered servicesThese services may be covered when a significant need for ADL isidentified and IADLs are found to be medically necessary.Including: Housekeeping Laundry Essential Shopping Meal PreparationNOTE: Services may be hands on or done by cueing12HP Confidential - PCS Presentation 2012
Escort servicesThe service plan allows: A Personal Care Attendant (PCA) who accompanies a recipientinto the community to provide authorized personal care servicesen route to or while obtaining Medicaid or Nevada Check Upcovered services Are NOT part of the routine service plan A single service authorization request must be submitted to HPESand will be reviewed for medical necessity13HP Confidential - PCS Presentation 2012
Non-Covered services Chore Services Services when the recipient resides in a group home, nursingfacility, ICF/MR, or an institution for the mentally ill Any task that DHCFP determines can be reasonably done by therecipient Services normally provided by a legally responsible individual orable and capable caregiver Any task not approved on the service plan14HP Confidential - PCS Presentation 2012
Non-Covered services – continued Services provided to someone other than the recipient Companion care, baby-sitting, supervision or social visitation Care requiring the technical or professional skill that State statute orregulation mandates must be performed by a health careprofessional licensed or certified by the State15 Specialized feeding techniques of any kind, including but not limited to tubefeedings (including preparing formula), watching the recipient for choking,massaging the throat, etc. Administration of medication - the PCA can remind the recipient to take his/hermedications and remove the cap from the containerHP Confidential - PCS Presentation 2012
Non-Covered services – continued 16Skilled services continued (not limited to) Irrigation of catheters Irrigation of any body cavity Dressing changes Vital signs Rectal digital stimulation Massage Toenail cutting Accompanying a recipient to a medical office for the purpose ofproviding, receiving, or interpreting medical information Finger sticksHP Confidential - PCS Presentation 2012
Non-Covered services – continued Care of pets (except service animals) Respite care Social visits Escort services for social, recreational or leisure activities17HP Confidential - PCS Presentation 2012
Service duplication avoidance Duplication of services (when the services are being provided byanother agency) Duplicative Services18 Full housekeeping hours to each recipient when more than onerecipient lives in the home and utilizes the same area Full meal prep hours when the meal is being prepared for more thanone recipient or eaten as part of a family mealHP Confidential - PCS Presentation 2012
ActionAn action is a termination, suspension, reduction or denial ofMedicaid covered services or disenrollment from NCU.For the purposes of this Chapter, the DHCFP or their designee willnotify the recipient if an adverse action is taken when:19 The recipient does not meet the Personal Care Service (PCS) eligibilitycriteria The recipient’s parent and/or legal guardian is responsible for themaintenance, health care, education and support of their child Services requested exceed service limits Services requested are non-covered benefitsHP Confidential - PCS Presentation 2012
Action – continued The recipient, the PCR, or the recipient’s legal representativerefuses to accept services in accordance with the approvedservice plan All or some services are no longer necessary as demonstrated bythe FA (functional assessment) The recipient’s needs can be met by a Legally ResponsibleIndividual (LRI) Another agency or program provides or could provide theservice20HP Confidential - PCS Presentation 2012
PCS and pregnancy Pregnant women are not considered in need of PCS based solelyupon their pregnancy When it poses imminent danger to the mother or unborn child toperform ADLs, services may be authorized Mothers on bed rest who are allowed up to the bathroom asneeded and to shower once per day do not typically qualify forPCS, because the mother is independent in some ADLs (bathing,dressing, grooming and toileting) Child care of other children in the home because the pregnantmother is on bed rest is not a serviceallowed by the PCS program21HP Confidential - PCS Presentation 2012
PCS for childrenAn able and capable parent and/or legal guardian of a minorchild has an obligation to provide the child necessarymaintenance, health and medical care, education, supervisionand support.PCS are not a substitute for natural and informal supports providedby family, friends or other available community resources.LRIs may NOT be reimbursed by Medicaid for PCS.22HP Confidential - PCS Presentation 2012
PCS for children – continued PCS for disabled children may be appropriate when the parentis unavailable or incapable Some disabled children may never be age appropriate to betoilet trained For children under the age of 21, Early and Periodic Screening,Diagnosis and Treatment (EPSDT) services may provide a vehiclefor receiving medically necessary services beyond PCS servicelimitations A physician’s order is required23HP Confidential - PCS Presentation 2012
Waiver servicesThere are 3 waiver programs whose recipients may receive PCS services: WIN – Home and Community-Based Waiver for Persons with PhysicalDisability CHIP – Home and Community Based Waiver for the Frail Elderly MR/RC – Home and Community Based Waiver for Persons withMentally Retardation (MR)/Related Conditions(RC)24HP Confidential - PCS Presentation 2012
Waiver programs – other optionsOther waiver programs for eligible individuals:1.Home and Community Based 1915(c) Waivers allow the provision oflong term care services in home and community based settings underthe Medicaid program.2.Individuals must meet the appropriate Level of Care for institutionalplacement and other qualifying criteria to receive waiver services.3.All waivers are limited in the number of people served. If you believesomeone might benefit from waiver services, refer them to the localDHCFP District Office for assistance.25HP Confidential - PCS Presentation 2012
Learning check1.The PCS program is a rehabilitation program for recipients byrequest.TRUE or FALSE2.3.Choose the service not covered under the PCS program.a.Bathing and Dressingb.Laundryc.Pet Cared.Task requiring technical skillAn action is a termination, suspension, reduction or denial ofMedicaid covered services or disenrollment from NCU.TRUE or FALSE26HP Confidential - PCS Presentation 2012
Requesting a FunctionalAssessment
Requesting a functional assessment A request for initial (first time) services must be submitted by one of thefollowing individuals: The recipient The recipient’s personal care representative The recipient’s legal representative When requesting that a functional assessment be performed, a FA-24form must be completed first. The form is found on the websitewww.medicaid.nv.gov; from the “Providers” tab, select “Forms,” thenscroll to the form number FA-24 A functional assessment (FA) must be submitted to HPES before theservice can be authorized28HP Confidential - PCS Presentation 2012
Functional assessment (FA) 29The functional assessment prior to initial service must be performedby a physical or occupational therapist who is certified with NevadaMedicaid to provide functional assessmentsHP Confidential - PCS Presentation 2012
At Risk recipientsIf a recipient has been identified to be at risk, aphone call or fax should be placed to the DOnotifying them during the FA, a recipient isdetermined to be At Risk, a phone call or faxshould be placed to the District Office (DO)notifying them that the PT/OT therapist hasidentified an At Risk recipient and the reasonhe/she is At Risk.Personal Care Service agencies do haveresponsibilities to report suspicious situations tothe DHCFP District Office, Child and FamilyServices, or Elder Protective Services.It is MANDATORY that you document why therecipient is At Risk.30HP Confidential - PCS Presentation 2012
Types of assessments31HP Confidential - PCS Presentation 2012 Initial Reassessment Completed prior to the end of the currentauthorized service period (usuallyannually, but timing is based on the lengthof time the previous prior authorizationwas valid) Completed if the recipient has had asignificant change in condition orcircumstance which may indicate the needfor additional time allocated to personalcare services
Single service authorizationsA one-time authorization can be issued directly from HPES withoutan additional assessment when the recipient has an unexpectedneed.32 A one-time authorization for a specific time (one hour in a given day) A one-time authorization not to exceed four weeks (in cases of posthospitalization or a non-available caregiver) Service must be medically necessary and meet all Nevada MedicaidpoliciesHP Confidential - PCS Presentation 2012
FA learning check1.2.The form, FA-24, is completed to PCS servicesbeing provided.a.Initiateb.Discontinuec.Update or continueA recipient At Risk, for purposes of the PCS program, meansthat an agency must place a PCA within 24 hours for initialclients.TRUE or FALSE33HP Confidential - PCS Presentation 2012
Billing for PCS
Billing for PCS services When billing for services, use the PT30 Billing Guidelines located on theProvider Web Portal – www.medicaid.nv.gov From the initial web page click on the Providers tab, then Billing Information,and click on the CMS-1500 Claim Form Instructions Claims may be billed electronically or by the submittal of paper claims The instructions are specific to PCS providers and must be used inconjunction with the complete CMS-1500 Claim Form instructionsprovided on the HP Enterprise Services website If a recipient is eligible for Medicaid and Medicare, know that at thistime, Medicare does not provide coverage for HCPCS codes T1019 andA0160.35 If a recipient is eligible for both Medicare and Medicaid, you may billMedicaid first Include the word Medicare in Field 9d on your claim formHP Confidential - PCS Presentation 2012
Billing for PCS services – continuedBill only for the dates when services were actually provided.If a service was provided on one day only, enter the same date in the Fromand To Date(s) of Service fields. If services were provided on Monday andalso on Wednesday of the same week, but not on Tuesday, bill Mondayand Wednesday individually on separate claim lines.Do not bill as one claim Monday through Wednesday or Sunday throughSaturday, regardless if the authorization period is the full week. If theclaim is billed improperly, the claim will be denied.36HP Confidential - PCS Presentation 2012
Billing a claim on a CMS-1500 paper formField 9d is required to read Medicare ifthe recipient is dual eligible. This is aconditional field based on recipienteligibility.Medicare37HP Confidential - PCS Presentation 2012
Billing a claim on a CMS-1500 paper form2nd halfFields 14-19 are conditionaland not required.38HP Confidential - PCS Presentation 2012
Billing Example for the PT 30Bill HCPCS code T1019.This code is a 15 min. per unit code.2 units 30 minutes, 4 units 1 hr. of service. 8 units 2 hr. of serviceBill A0160 for mileage - 1 mile 1 unit ( bill only if approved)U&CU&CU&CU&CU&C39HP Confidential - PCS Presentation 2012
Billing learning check1.What are the two ways to bill a claim for reimbursement?2.When billing for PCS you may bill one week at a time even ifyou did not provide service on Tuesday and Thursday?TRUE or FALSE3.In field 24b, what should be placed in this field?4.Per Web announcement 436, If you do not know the diagnosiscode supplied by the recipients qualified medical professional,it is acceptable to bill with ICD-9-CM code V604TRUE or FALSE40HP Confidential - PCS Presentation 2012
Contact InformationGlossaryQ&A
Contact informationContact HPES:Customer ServicePhone1-877-638-3472, option 2, then omPCSPhone1-800-525-2395, option 2, then 4Fax (Dental, ADHC, PCS Request, LRIand ISO documentation)1-775-200-1536Fax (PT/OT assessments andcorrespondence)1-775-200-1535Other 03HP Confidential - PCS Presentation 2012
Medicaid District Office contacts43Carson City1-775-684-3651Elko1-775-753-1191Las Vegas1-702-668-4200Reno1-775-687-1900HP Confidential - PCS Presentation 2012
Glossary of common acronyms44AcronymDescriptionADLActivities of Daily LivingCHIPHome and Community Based Waiver for the Frail ElderlyDODistrict OfficeFAFunctional AssessmentIADLIndependent Activities of Daily LivingLRILegally Responsible IndividualNCUNevada Check UpNODNotice of DecisionPCAPersonal Care AttendantPCRPersonal Care RepresentativePCSPersonal Care ServicesHP Confidential - PCS Presentation 2012
Questions and answers45HP Confidential - PCS Presentation 2012
THANK YOU FOR ATTENDING TODAYPlease complete and return the course evaluation.Enjoy your day46HP Confidential - PCS Presentation 2012
Personal Care Representative (PCR) An individual who is directly involved in the day-to-day care of a recipient and is available to direct care in the home. This individual acts on behalf of the recipient when the recipient is unable to direct his/her own personal care services. A personal care representative must be a responsible adult.
