1 8.535 PEDIATRIC PERSONAL CARE SERVICES Definitions Assessment means the systematic and ongoing collection, validation and evaluation of data to monitor client status and response to treatment. Behavioral Intervention means techniques, therapies, and methods used to modify or minimize aggressive (verbal/physical), combative, destructive, disruptive, repetitious, resistive, self-injurious, or other inappropriate behaviors outlined on the CMS-485 Plan of Care (defined below). Behavioral interventions exclude frequent verbal redirection or additional time to transition or complete a task, which are part of the general assessment of the client s needs. Care Coordination means the deliberate organization of client care tasks between two or more participants (including the client) involved in a client s care to facilitate the appropriate delivery of health care and other health care support services. Care Plan means a written specific list of tasks and frequencies to be provided to the client, and which is ordered and signed by the Ordering Provider. Certified Nurse Aide (CNA) means an employee of a Home Health Agency with a CNA certification. CMS-485 Plan of Care (485) means a coordinated plan developed by the Home Health Agency as ordered by the attending physician for provision of services to a client in his or her Residence. Also referred to as the 485 or the HCFA 485. Cuing means proving a prompt or direction to assist a client to perform a task they are physically capable of performing but unable to reliably initiate. Department means the Colorado Department of Health Care Policy and Financing (or any divisions or sub-units within that agency) which is designated as the single State Medicaid agency for Colorado. Designated Review Entity means an entity that has been contracted by the Department to review Prior Authorization Requests (PAR) for medical necessity and appropriateness. Exacerbation means a sudden or progressive worsening of a client s chronic illness, injury, or disability (or its symptoms). Home Care Agency means a Class A or Class B-designated entity that provides Home Health or Personal Care Services. When referred to in this rule without a Class A or Class B designation, the term encompasses both types of agency. Home Health Agency means an agency licensed as a Class A Home Care Agency in Colorado that is certified to provide Skilled Care Services to Medicare and Medicaid eligible clients. A licensed, Class A Home Care Agency may also provide Personal Care Services based on the agency s policies and procedures. Intermittent Basis means Personal Care visits that have a distinct start time and stop time and are taskoriented with the goal of meeting a client s specific needs for that visit.
2 Page 2 of 19 Ordering Provider means a licensed primary care physician, advanced practice nurse, or physician specialist who is responsible for writing orders and overseeing the client s Care Plan. This may include an alternate physician who is authorized by the Ordering Provider to care for the client in the Ordering Provider s absence. Personal Care Agency means an agency licensed as a Class B Home Care Agency certified by the Colorado Department of Public Health and the Environment. Personal Care Services means providing specific unskilled tasks (defined under covered services section) to assist clients with activities of daily living. Personal Care Worker means an employee of a licensed Home Care Agency who has completed the required training to provide Personal Care tasks, or who has verified experience providing Personal Care tasks for clients. Qualified Physician means a licensed primary care physician or other physician specialist. Residence means the client s house, an apartment, a relative's home, temporary accommodation, or other place rented or purchased for the purpose of housing the client for a specified time. A residence does not include nursing facilities or other institutions as defined by CMS and the State of Colorado. Skilled Care Services means services that, due to the inherent complexity of the service, can only be performed safely and correctly by a licensed/certified Registered Nurse (RN) or Licensed Practical Nurse (LPN), Therapist (Physical Therapist, Occupational Therapist, or Speech Language Therapist), or CNA. Skilled Nursing Services means services provided by an actively licensed RN, and who practices under applicable state and federal laws and professional standards. Skilled Nursing Services include services provided by a LPN under the direction of a RN, to the extent allowed under applicable state and federal laws. Unpaid Family Caregiver means a person who provides care to the client without reimbursement by the Department or other entity. This can be the client s parent, legal guardian, foster parent, spouse, relative, or other person who is responsible for the well-being of the client Client Eligibility Personal Care services are a benefit for Colorado Medicaid clients who meet the following criteria: A B C D E. Require assistance with tasks that are medically necessary but that do not require a medically skilled staff; Require a minimum of three Personal Care Tasks; Is 20 years of age and younger; Meet the criteria for EPSDT, at 10 C.C.R , ; and Meet the requirements of the Department defined assessment tool Provider Eligibility
3 Page 3 of A. Home Care Agencies that provide Personal Care services must follow all applicable Colorado Department of Public Health and Environment Home Care Regulations, at 6 C.C.R , and must meet the following requirements: 1. Enrolled as a Medicaid Provider to provide Personal Care Services; and 2. Licensed by the State of Colorado as a Class A or Class B Home Care Agency in good standing and meet all certification and licensure requirements outlined in et seq. of this rule B. Provider Eligibility Records Maintenance 1. Client Files: Home Care Agencies shall maintain records on each client. The specific record for each client shall include, at a minimum, the following information: a. A written order for Personal Care Services; b. A Care Plan completed by the Ordering Provider (updated at least annually, or as required by the client s needs and/or condition); c. All other client file information as required by the Colorado Department of Public Health and Environment, at 6 C.C.R Chapter Personal Care Worker Files: All Personal Care Workers shall have a completed and upto-date personnel file that includes: a. Signed and dated evidence of received training and orientation on the Home Care Agency s written policies and procedures; b. Signed and dated evidence of received training and competency to provide the client s specific Personal Care Tasks; c. A signed and dated job description that clearly states all responsibilities and job duties; d. Proof of current and up-to-date training and education required by the Colorado Department of Public Health and Environment, at 6 C.C.R Chapter ; e. Signed and dated competency information regarding training and skills validation for client-specific Personal Care and homemaking tasks; f. Signed and dated evidence of instruction in basic first aid, and training in infection control techniques, including universal precautions; g. Documentation of consultations with relevant medical staff when clients have complex needs or when there are potentially dangerous situations identified; and h. Information on any complaints received regarding the Personal Care Worker along with documentation on the outcome and follow-up of the complaint investigation.
4 Page 4 of 19 i. Evidence of periodic (at least every 90 days) on-site supervision of the Personal Care Worker by a Registered Nurse, the clinical director, home care manager or other designated supervisory agency employee who is available to the Personal Care Worker at all times for problem resolution client-specific or procedurespecific training of the Personal Care Worker, observation of client's condition and care, and assessment of client's satisfaction with services Covered Services Personal Care Services are considered covered services when they meet the following requirements: A. Services are ordered by a licensed Physician, as regulated by the Department of Regulatory Agencies, at 3 C.C.R. 713; or an Advanced Practice Nurse, as licensed by the Department of Regulatory Agencies, at 3 C.C.R B. Services are medically necessary as defined at 10 C.C.R , C D E F G H. Services are prior authorized and delivered in a manner consistent with professional standards, Colorado licensure standards, and other pertinent regulations. Services are provided on an Intermittent Basis. Services are ordered and provided under a current Care Plan Under the Centers for Medicare and Medicaid Services Conditions of Participation, all Home Health orders and Care Plans must be signed by an MD, Advanced Practice Nurse, or DO. Home Care Agencies may decline to perform any specific task or service if the supervisor or the Personal Care Worker perceives a safety concern to the client or the Personal Care Worker due to the specific task, regardless of whether the task is covered as a Personal Care Service. Covered Personal Care Tasks If a client requires a skilled transfer to complete a task, such as bathing or hygiene, the associated task shall be considered skilled in nature. A Personal Care Worker may provide transfer services when the medically-skilled caregiver or Unpaid Family Caregiver directs and/or assists with the skilled transfer, and only if the client is able to assist with the transfer. When skilled tasks require a Personal Care component, the existing rate for skilled services already includes time spent performing Personal Care Tasks that are linked for the completion of a skilled task. The usual frequency of a task defines the number of times a typical person is likely to need assistance with the task. Some clients will need these tasks performed more or less frequently than is defined in the task. When not noted, usual frequency is as ordered on the Care Plan or 485. Agencies must be prepared to provide additional documentation when clients require a task to be completed more frequently than is typical. 1. Ambulation/Locomotion
5 Page 5 of 19 a. Includes walking/moving from place to place with or without an assistive device (including wheelchair). A Personal Care Worker may provide this task only when: i) The client has the ability to balance and bear weight reliably; i The client is independent with an assistive device; or Assisting a medically-skilled care provider or Unpaid Family Caregiver who is competent in providing the skilled aspect of care. i) The client is unable to assist in the task, direct care, or when hands on assistance is required for safe ambulation; There is a documented decline in condition or an ongoing need c. Special Considerations: i) Ambulation shall not be the standalone reason for a visit. Transferring and positioning into and out of assistive devices is not ambulation, and should be addressed in the transferring and positioning section of this rule, at 10 CCR B Bathing/Showering a. Includes preparing bathing supplies and equipment, assessing water temperature, applying soap (including shampoo), rinsing off, and drying the client. The task also includes cleaning up after the bath, shower, bed bath, or sponge bath as needed. All transfers and ambulation related to the bathing task, and all hair care, pericare, and skin care provided in conjunction with the bathing are included in this task. A Personal Care Worker may provide this task only when: i) The client is able to maintain balance and bear weight reliably, or is able to use safety equipment (such as a shower bench) to safely complete bathing; i The skin is unbroken or the client is independent with assistive devices. Assisting a medically-skilled care provider or Unpaid Family Caregiver who is competent in providing this aspect of care. i) The presence of open wound(s), stoma(s), broken skin and/or active chronic skin disorder(s);
6 Page 6 of 19 i The client is unable to maintain balance or to bear weight reliably due to illness, injury, or disability, history of falls, or a temporary lack of mobility due to surgery or other exacerbation of illness, injury, or disability; There is a documented decline in condition or ongoing need documented in the client s record. c. Usual Frequency: Once daily. d. Special Considerations: A second person may be staffed when required to safely bathe the client, which is supported by documentation that illustrates that the client needs moderate to total assistance to safely complete this task. 3. Dressing a. Includes putting on and taking off ordinary clothing, including pantyhose or socks and shoes. Dressing includes getting clothing out, and may include braces and splints if purchased over the counter or were not ordered by a Qualified Physician. A Personal Care Worker may provide this task only when: i) Providing assistance with ordinary clothing and application of support stockings of the type that can be purchased without a physician s prescription; i Providing transfers and positioning related to dressing and undressing. May include cleaning and maintenance of braces, prosthesis, or other DME; or Assisting a medically-skilled care provider or Unpaid Family Caregiver who is competent in providing the application of anti-embolic or pressure stockings, or placement of braces or splints that can be obtained only with a prescription of a Qualified Physician, or when the client is unable to assist or direct care. i) The client requires assistance with the application of anti-embolic or pressure stockings, placement of braces or splints that can be obtained only with a prescription of a qualified physician; i The client is unable to assist or direct care; The client experiences a temporary lack of mobility due to surgery or other exacerbation of illness, injury, or disability; There is a documented decline in condition or ongoing need documented in the client s record. c. Usual Frequency: Up to two times daily.
7 Page 7 of 19 d. Special Considerations: A second person may be staffed when required to safely dress the client if it is supported by documentation illustrating that the client needs moderate to total assistance to safely complete this task. 4. Meal Preparation a. Includes preparing, cooking, and serving food to client. Includes formula preparation and ensuring food is a proper consistency based on client s ability to swallow safely. A Personal Care Worker may provide all meal preparation, except as defined in part b. of this section. i) Diet requires nurse oversight to administer correctly; i Meals must have a modified consistency; There must be a documented decline in condition and/or ongoing need c. Usual frequency: Up to three times daily. 5. Feeding a. Includes ensuring food is at the proper temperature, cutting food into bite-size pieces, or ensuring the food is the proper consistency for the client, up to and including placing food in client's mouth. A Personal Care Worker may provide this task when: i) The client can independently chew and swallow without difficulty and be positioned upright; The client is able to safely eat or be fed with adaptive utensils. i) Syringe feeding and tube feeding; Oral feeding when: 1) The client is unable to communicate verbally, non-verbally or through other means; 2) The client is unable to be positioned upright; 3) The client is on a modified texture diet; 4) When the client has a physiological or neurogenic chewing and/or swallowing problem; 5) When a structural issue (such as cleft palate) is present; or
8 Page 8 of 19 6) Other documented swallowing issues. i The client has a history of aspirating food or is on mechanical ventilations. Oral suctioning is required. v) There is a documented decline in condition, or ongoing need c. Usual Frequency: Up to three times daily (snacks are not included) 6. Hygiene Hair Care/Grooming a. Includes shampooing, conditioning, drying, styling and combing. Does not include perming, hair coloring, or other or extensive styling such as, but not limited to, updos, placement of box braids or other elaborate braiding or placing hair extensions. A Personal Care Worker may provide this task only when: i) Assisting client with the maintenance and appearance of his/her hair; i Shampooing with non-medicated shampoo or medicated shampoo that does not require a physician s prescription; Drying, combing and styling of hair; Active and chronic skin issues such as dandruff and cradle cap do not make this task skilled. i) The client is unable to complete task independently; i The client requires shampoo/conditioner that is prescribed by a qualified physician and dispensed by a pharmacy; The client has open wound(s) or stoma(s) on the head; There is a documented decline in condition, or ongoing need c. Usual Frequency: Up to twice daily. 7. Hygiene Mouth Care a. Includes brushing teeth, flossing, use of mouthwash, denture care, or swabbing (toothette). A Personal Care Worker may provide this task only when: i) Assisting with basic oral hygiene; Denture care;
9 Page 9 of 19 i The presence of gingivitis, receding gums, cavities and other general dental problems do not make mouth care skilled. i) The client is unconscious; i The client has difficulty swallowing or is at risk for choking and/or aspiration; The client has decreased oral sensitivity or hypersensitivity; The client is on medications that increase the risk of dental problems or bleeding, injury or medical disease of the mouth; v) The client requires oral suctioning; vi) There is a documented decline in condition, or ongoing need c. Usual Frequency: Up to three times daily 8. Hygiene Nail Care a. Includes soaking, filing and cuticle care. A Personal Care Worker may provide this task only when: i) Assisting with nail care, soaking of nails, pushing back cuticles without utensils, and filing of nails; Assistance by the Personal Care Worker shall not include nail trimming. i) The client has a medical condition that involves peripheral circulatory problems or loss of sensation; i The client is at risk for bleeding and/or is at high risk for injury secondary to the nail care; The client requires nail trimming; There is a documented decline in condition, or ongoing need c. Usual Frequency: Up to one time weekly. 9. Hygiene Shaving a. Includes assisting with shaving of face, legs and underarms with a safety or electric razor. A Personal Care Worker may provide this task only when assisting a client with shaving with an electric or a safety razor.
10 Page 10 of 19 i) The Client has a medical condition that involves peripheral circulatory problems or loss of sensation; i The client has an illness or takes medications that are associated with a high risk for bleeding; The client has broken skin at/near shaving site, or has a chronic active skin condition; The client is unable to shave themselves; v) There is a documented decline in condition, or ongoing need c. Usual Frequency: Up to one time daily 10. Hygiene Skin Care a. Includes applying lotion or other skin care product, only when not completed in conjunction with bathing or toileting (bladder and bowel). May be included with positioning. A Personal Care Worker may provide this task only when: i) General skin care assistance, only when a client s skin is unbroken, and when any chronic skin problems are not active; Skin care is preventative rather than therapeutic in nature and may include the application of non-medicated lotions and solutions, or of lotions and solutions not requiring a physician s prescription. i) The client requires additional skin care lotions or solutions that must prescribed by a qualified physician; i The client has broken skin, wound(s) or an active skin disorder, and is unable to apply product independently due to illness, injury or disability; There is a documented decline in condition, or ongoing need c. Special Considerations: Skin care completed in conjunction with bathing and toileting as ordered on the 485 is not included in this task. 11. Mobility Positioning a. Includes moving the client from a starting position to a new position while maintaining proper body alignment and support to a client s extremities, and avoiding skin breakdown. A Personal Care Worker may provide this task only when:
11 Page 11 of 19 i) Assisting a client with positioning when the client is able to identify to the provider, verbally, non-verbally, or through other means, when their position needs to be changed and only when skilled skin care is not required in conjunction with positioning; i Alignment in a bed, wheelchair, or other furniture; Placing any padding required to maintain proper alignment; Receiving direction from or assisting a medically-skilled care provider or Unpaid Family Caregiver who is competent in providing this aspect of care. i) The client is unable to communicate verbally, non-verbally or through other means; i The client is not able to perform this task independently due to fragility of illness, injury or disability, temporary lack of mobility due to surgery or other exacerbation of illness, injury or disability; Adjusting the client s alignment or posture in a bed, wheelchair, other furniture, assistive devices, or Durable Medical Equipment that has been ordered by a qualified physician; There is a documented decline in condition, or ongoing need c. Special Considerations: i) Positioning and padding shall not be the sole purpose for the Personal Care visit; i A second person may be staffed when required to safely position the client, which is supported by documentation that illustrates that the client needs moderate to total assistance to safely complete this task; Visits must be coordinated to ensure that effective positioning scheduling is utilized for Skilled Care and Personal Care Services. Positioning shall be done in conjunction with other skilled tasks; Positioning is not considered a separate task when a transfer is performed in conjunction with bathing, bladder care, bowel care, or other Personal Care Tasks requiring positioning. 12. Mobility Transfer a. Includes moving the client from a starting location to a different location in a safe manner. It is not considered a separate task when a transfer is performed in conjunction with bathing, bladder care, bowel care or other Personal Care Task. A Personal Care Worker may provide this task only when:
12 Page 12 of 19 i) Assisting with a transfer when the client has sufficient balance and strength to reliably stand, pivot and assist with the transfer to some extent; Transferring clients with adaptive and safety equipment (including lifts) if: 1) The client and the Personal Care Worker are fully trained in the use of the equipment; and 2) The client or client s Unpaid Family Caregiver can direct the transfer step by step; or 3) The Personal Care Worker is deemed competent in the specific transfer technique for the client. i Gait belts may be used in a transfer as a safety device, if the Personal Care Worker has been properly trained in their use. b. Factors that make task Skilled: i) The client is unable to communicate verbally, non-verbally or through other means; i The Client is not able to perform this task independently due to illness, injury or disability, temporary lack of mobility due to surgery and/or other exacerbation of illness, injury or disability; The client lacks the strength and stability to stand or bear weight reliably; The client is not deemed independent in the use of assistive devices or Durable Medical Equipment that has been ordered by a qualified physician; v) The client requires a mechanical lift for safe transfers; vi) There is a documented decline in condition, or ongoing need c. Special Considerations: i) Transferring shall not be the sole purpose for the visit. i A second person may be used when required to safely transfer the client. A Personal Care Worker may never assist with a transfer if the client is unable to assist with the transfer. 13. Protective Oversight a. Includes monitoring a client to reduce or minimize the likelihood of injury or harm due to the nature of the client s injury, illness or disability. A Personal Care Worker may provide this task only when:
13 Page 13 of 19 i) Providing protective oversight as stand-by assistance with any other Personal Care Task; Trained in appropriate intervention and redirection techniques if the client requires protective oversight to prevent wandering or dangerous or destructive behaviors. b. Special Considerations: i) Protective Oversight may only be provided during the completion of other Personal Care Tasks listed in this rule. The need for Protective Oversight is indicated by significant impairment in behavior, memory, or cognition. 14. Toileting Bladder Care a. Includes assistance with toilet, commode, bedpan, urinal, or diaper use, as well as emptying and rinsing the commode or bedpan after each use. This includes transfers, skin care, ambulation and positioning related to bladder care. This task concludes when the client is returned to his/her pre-urination state. A Personal Care Worker may provide this task only when: i) Assisting a client to and from the bathroom, and with bedpans, urinals and commodes; i Pericare, and changing of clothing and pads of any kind used for the care of incontinence; Assisting a medically-skilled care provider or Unpaid Family Caregiver who is competent in providing this aspect of care. i) The client is unable to assist or direct care; i The client has broken skin or a recently healed skin breakdown (less than 60 days); The client requires skilled skin care associated with bladder care; The client has been assessed as having a high and ongoing risk for skin breakdown; v) There is a documented decline in condition, or ongoing need c. Special Considerations: A second person may be staffed when required to safely complete bladder care with the client, which is supported by documentation that illustrates that the client needs moderate to total assistance to safely complete this task.
14 Page 14 of Toileting Bowel Care a. Includes changing and cleaning incontinent client or hands-on assistance with toileting. This includes returning client to pre-bowel movement status, transfers, skin care, ambulation and positioning related to the bowel program. A Personal Care Worker may provide this task only when: i) Assisting the client to and from the bathroom, and with bedpans and commodes; i Pericare, and changing of clothing and pads of any kind used for the care of incontinence; Assisting a medically-skilled care provider or Unpaid Family Caregiver who is competent in providing this aspect of care. i) The client is unable to assist or direct care; i The client has broken skin or a recently healed skin breakdown (less than 60 days); The client requires skilled skin care associated with bowel care; The client has been assessed as having a high and ongoing risk for skin breakdown; v) There is a documented decline in condition, or ongoing need c. Special Considerations: A second person may be staffed when required to safely complete bowel care with the client, which is supported by documentation that illustrates that the client needs moderate to total assistance to safely complete this task. 16. Toileting Bowel Program a. Includes emptying and changing the ostomy bag, as ordered by the client s qualified physician. This includes skin care at the site of the ostomy and returning the client to pre-bowel program status. A Personal Care Worker may provide this task only when: i) Emptying ostomy bags; Providing client-directed assistance with other ostomy care only when there is no need for skilled skin care, or for observation or reporting to a nurse; b. Factors that make task Skilled:
15 i) The client requires the use of digital stimulation, suppositories, or enemas; Page 15 of 19 There is a documented decline in condition, or ongoing need c. Special Considerations: The Personal Care Worker shall not perform digital stimulation, insert suppositories, or give an enema. 17. Toileting Catheter Care a. Includes perineal care and emptying catheter bag. This includes transfers, skin care, ambulation and positioning related to the catheter care. A Personal Care Worker may provide this task only when: i) Emptying urinary collection devices, such as catheter bags, when there is no need for observation or reporting to a nurse; Providing pericare if the client has an indwelling catheter. i) Emptying catheter collection bags (indwelling or external) when there is a need to record and report the client s urinary output to the client s nurse; i All insertion and removal of catheters, and all care of catheters; Changing from a leg to a bed bag and cleaning of tubing and bags; If the indwelling catheter tubing needs to be opened for any reason and the client is unable to do so independently; or v) There must be a documented decline in condition and/or ongoing need c. Usual Frequency: Up to two times a day. d. Special Considerations: Catheter care shall not be the sole purpose of the visit. 18. Medication Reminders a. Include verbally communicating to a client that it is time for medication, opening and handing pre-filled medication reminder container to a client. A Personal Care Worker may provide this task only when: i) Inquiring as to whether medications were taken; i Verbal prompting to take medications; Handing the appropriately marked medication reminder container to the client; and
16 Page 16 of 19 Opening the appropriately marked medication reminder container for the client if the client is physically unable to open the container. v) All medication (prescription medications and all over-the-counter medications) must be: b. Special Considerations: 1) Pre-selected by the client, the client s Unpaid Family Caregiver, a nurse, or a pharmacist; 2) Stored in pre-filled medication reminder boxes that are marked as to day and time of dosage. i) Medication reminders are Skilled Care tasks when the client requires services within the scope of a CNA-MED certified CNA. Skilled Care Services which can be provided by a CNA-MED certified CNA can be found in this rule at Section E.8.o and 3 C.C.R Chapter 19 Section 6. CNAs may not administer medications without obtaining the CNA-MED certification from the DORA approved course Non-Covered Services Medicaid does not reimburse for the following services under the Medicaid State Plan Personal Care Services benefit: A B C. Transportation of a client; Services provided by a person under 18 years of age, or services provided by a person not employed by the Home Care Agency; Services provided at: 1. Hospitals; 2. Nursing facilities; 3. Intermediate Care Facilities for Persons with Intellectually Disabled (ICF/ID); 4. Public school grounds; 5. Individual Residential Services & Supports IRSS; 6. Group Residential Services & Supports (GRSS); 7. Alternative care facilities; 8. Medical offices; or 9. Other Medicaid reimbursed settings.
17 Page 17 of D. Tasks that are defined as Skilled Care Services, as defined in 10 CCR , et seq; E F G H I J K L M N. Services provided for the purpose of companionship, respite, financial management, child care, education or home schooling, for the benefit of someone other than the Medicaid client, or are not justified by the documentation provided are not eligible. Homemaker services, or tasks that are performed to maintain a household. These tasks are considered to be non-medical tasks and include grocery shopping, laundry, and housekeeping. Exercise and range of motion services. Time or mileage required to travel to the client s place of service. Any services that are reimbursed by another insurance agency or other state, federal or private agency. Services provided by agency staff that are excluded from participation in federally funded health care programs by the US Department of Health and Human Services (HHS)/Office of the Inspector General (OIG). Visits that occur for the sole purpose of supervising or training the Personal Care Worker. Personal Care Services provided or billed during a Skilled Care Services visit. When the client or the client s Unpaid Family Caregiver is willing and able to perform the services or tasks independently. Any service or task for a single client performed by two staff (any combination of Registered Nurse, Licensed Practical Nurse, CNA, Physical Therapist, Occupational Therapist, Speech Language Therapist, or Personal Care Workers) during the same visit, from the same or a different agency, except when two staff are required to safely complete the service or task and there is no other person available to assist. 1. If services are provided by two staff, the highest level of required care will subsume the other service. For example: A CNA and a Personal Care Worker perform a Skilled Care and a Personal Care Service respectively. Only the CNA visit will be paid, because the Personal care service should have been performed during the CNA visit. 2. In instances where the two staff are of the same type, but from different agencies, the Home Care Agency which usually provides services to the client will be paid for the service O P. Assistance with services that are being provided as a reasonable accommodation as part of the Americans with Disabilities Act (ADA), the Rehabilitation Act of 1973, and/or Part B of the Individuals with Disabilities Education Act (IDEA). CNA visits shall not be approved for, nor shall CNA extended units be billed for the sole purpose of completing Personal Care Services that are billable under this benefit.
18 Page 18 of Q R S. In accordance with Section 1905 (a)(24) of the Social Security Act, Personal Care Services provided by the client s parent, spouse, or other legally responsible adult cannot be reimbursed by Medicaid. If a client s situation meets any of the factors that make a task Skilled Care Services, the client must receive all services related to that task through the Home Health Services benefit, at 10 CCR The Pediatric Personal Care benefit does not cover Skilled Care Services. Physical behavioral interventions, such as restraints, shall not be used, per the Colorado Department of Health and the Environment rights of the consumer, at 6 CCR , Chapter 26, Section Prior Authorization Requirements (PAR) A B C D E F. Personal care services that are not prior authorized (PAR) by the Department or its Designated Review Entity will not be reimbursed. Approval of the PAR does not guarantee payment by Medicaid. The client and the Personal Care Worker shall meet all applicable eligibility requirements at the time services are rendered and services shall be delivered in accordance with all applicable service limitations. Medicaid is always the payer of last resort and the presence of an approved or partially approved PAR does not release the agency from the requirement to bill Medicare or other third party insurance prior to billing Medicaid. All Personal Care Services must be prior authorized by the Department or its Designated Review Entity utilizing the Department s specific utilization management tools before services are provided. Personal Care PARs may be submitted for up to a full year of anticipated services unless: The client is not expected to need a full year of services, the client s eligibility is not expected to span the entire year, or as otherwise specified by the Department or its Designated Review Entity. A PAR will be pended by the Department or its Designated Review Entity if all of the required information is not provided in the PAR request, or additional information is required by the Designated Review Entity to complete the review. PARs shall be submitted to the Department or its Designated Review Entity in the manner required by the Department or its designee, and with the required documentation. 1. PAR requests shall include the State assessment form to determine the client s need for Personal Care Services. 2. It is the Home Care Agency s responsibility to provide sufficient documentation to support the necessity for the requested services G. When a PAR includes a request for reimbursement for two staff members at the same time (excluding supervisory visits) to perform two-person transfers and/or two persons are needed for a task, documentation supporting the need for two people and the reason adaptive equipment cannot be used must be included.
19 Page 19 of H I J. All other information determined necessary by the Department or its Designated Review Entity to make a decision on the medial necessity and appropriateness of the proposed treatment plan must be included. The Home Care Agency is required to request a revision to the Care Plan as necessary when the client experiences a change in condition necessitating a change in the amount, duration or frequency of Personal Care Services being delivered to the client. All Personal Care Services must have an approved PAR in place before services commence Reimbursement A B C. All Personal Care Services will be reimbursed at the Medicaid Personal Care rate even if the person providing Personal Care holds credentials for CNA, RN or other skilled profession. Medicaid is the payer of last resort, except under certain circumstances as defined in Medicaid provider billing manuals, Personal Care rules and regulations, provider bulletins, and Early Intervention services. Clients eligible for both Colorado Medicaid and the Colorado Department of Human Services Home Care Allowance program, at 9 C.C.R Section 3.570, may choose to have their Personal Care needs met either through the State Plan Medicaid Personal Care benefit or receive assistance through the Home Care Allowance program, but cannot receive both.
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