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day or night. The assessment process should also evaluate the availability of informalsupports who may be willing and available to provide assistance with needed tasks andwhether the member’s day or nighttime needs can totally or partially be met throughthe use of efficiencies and specialized medical equipment including, but not limited to,commode, urinal, walker, wheelchair, etc. A care plan must be developed that meetsthe member’s scheduled and unscheduled day and nighttime personal needs.b. Safety Monitoring. Managed Care Organizations should authorize some or total assistancewith the recognized medically necessary personal care services tasks. Allotment of timeseparate and apart from the personal care tasks authorized is not required for safetymonitoring. However, there is a clear and legitimate distinction between safety monitoringas a non-required stand alone function while no PCS is being provided and the appropriatelevel of safety monitoring while the enrollee is receiving assistance with PCS tasks such astransferring, toileting, or walking. As an example, if a member requires assistance withgetting in and out of the tub and also has a condition that limits the ability to discerntemperature the PCS worker would monitor the water temperature for the member as a safetymeasure. As another example, if a member requires assistance with walking, the PCSworker takes appropriate measures to guard the member’s safety while assisting the memberwith the task of walking. These are but two examples of the appropriate safety monitoringthat must be provided to assure that the particular Level I or Level II task is safely completed.Safety monitoring under PCS does not, however, include monitoring an individual withdementia, for example, when no other Level I or Level II personal care services task is beingprovided, to assure that the individual a does not wander away from home or engage inunsafe behavior. This type of safety monitoring is covered as a discrete service in the NursingHome Transition and Diversion Waiver.c. The Consumer Directed Personal Assistance Program (CDPAP) will be included in theBenefit Package effective November 1, 2012. Consumer Directed Personal Assistance meansthe provision of some or total assistance with personal care services, home health aideservices and skilled nursing tasks by a consumer directed personal assistant under theinstruction, supervision and direction of a consumer or the consumer’s designatedrepresentative. If a member requests information about the program prior to it becoming anin-plan benefit on November 1, 2012, the plan must refer the member to the local socialservices district. Under the CDPAP a member may arrange for an aide to perform not onlypersonal care services tasks but also home health aide and nursing tasks. Information aboutthe CDPAP will be covered under separate guidelines.II.Accessing the benefita. Request for Service: A member, their designee, including a provider or a case manager onbehalf of a member, may request PCS. The MCO must provide the member with the medicalrequest form (M11Q in NYC, DOH-4359 or a form approved by the State, for use bymanaged long term care plans (MLTC), and the timeframe for completion of the form andreceipt of request.Note: When a request for PCS is made, the MCO must provide the member with informationabout the Consumer Directed Personal Assistance Program (“CDPAP”) using the brochureprovided by SDOH. There is a further discussion about CDPAP below.b. Nursing and Social Assessment:May 31, 20134

i. Initial assessmentOnce the request is received the MCO is responsible for arranging an assessment ofthe member by one of its contracted providers. This may be a certified home healthagency, CASA, licensed home health agency (LHCSA), registered nurses from withinthe plan or some other arrangement. The initial assessment must be performed by aregistered nurse and repeated at least twice per year.ii. Social AssessmentIn response to recent requirements by the Centers for Medicare and Medicaid Services(CMS) MCOs must also have a social assessment performed. The social assessmentincludes social and environmental criteria that affect the need for personal careservices. The social assessment evaluates the potential contribution of informalcaregivers, such as family and friends, to the member’s care, the ability andmotivation of informal caregivers to assist in the care, the extent of informalcaregivers’ involvement in the member’s care and, when live-in 24 hour personal careservices are indicated , whether the member’s home has adequate sleepingaccommodations for a personal care aide.This nursing assessment and the social assessment can be completed at the same time.The forms in New York City are the M27-r Nursing Assessment Visit Report andHome Care Assessment form. For the rest of the state, the forms are the DMS-1 andDSS 3139. MCOs may use assessment forms approved under the MLTC program.NOTE: All assessments will be conducted using the Uniform Assessment Tool when itbecomes available.iii. The MCO will provide to the LHCSA a copy of the medical request form, thenursing/social assessment and the authorization for services.iv. Other considerations when conducting an assessment1. Certified Home Health Agency: When an MCO is contracting with a CHHAfor the purpose of requesting an assessment of personal care services need theCHHA is not required to open a case pursuant to the rules and regulationsspecified under 10 NYCRR § 763.5 (“opening a case”). The CHHA is subjectto the terms of the contractual arrangement.v. MCOs must assure, through quality monitoring and utilization monitoring, that when aLHCSA performs the assessment and is also providing the PCS to the member that thelevel of services are appropriate and not in excess of the level and scope of servicesneeded by the member.c. Authorization of services: The MCO will review the request for services and the assessmentto determine whether the enrollee meets the requirements for PCS and the service is medicallynecessary. An authorization for PCS must include the amount, duration and scope of servicesrequired by the member. The duration of the authorization period shall be based on themember’s needs as reflected in the required assessments. In determining the duration of theauthorization period the MCO shall consider the member’s prognosis and/or potential forrecovery; and the expected length of any informal caregivers’ participation in caregiving. Noauthorization should exceed six (6) months. There is a more detailed discussion aboutauthorization of services and timeframes for authorization, notices and rights when there is adenial of a request for PCS below.d. Arranging for Services: The MCO is responsible for notifying and providing the memberwith the amount, duration and scope of authorized services. The MCO must also arrange forMay 31, 20135

the LHCSA to care for the member. The MCO will provide the LHCSA with a copy of themedical request, the assessment and the authorization for services. The LHCSA will arrangefor the supervising RN, the personal care services worker, the member or the member’sdesignated representative to develop the plan of care based on the MCO’s authorization.III.Authorization and Notice Requirements for Personal Care Servicesa. Standards for review. Requests for PCS must be reviewed for benefit coverage and medicalnecessity of the service in accordance with PHL Article 49, 18 NYCRR §505.14 (a), theMMC Model Contract and these guidelines. As such, denial or reduction in services mustclearly indicate a clinical rationale that shows review of the enrollee’s specific clinical dataand medical condition; the basis on which request was not medically necessary or does notmeet specific benefit coverage criteria; and be sufficient to enable judgment for possibleappeal. If the determination results in a termination or reduction, the reason for denial mustclearly state what circumstances or condition has changed to warrant reduction or terminationof previously approved services.b. Timing of authorization review.i. An MCO assessment of services during an active authorization period, whether toassess the continued appropriateness of care provided within the authorization period,or to assess the need for more of or continued services for a new authorization period,meets the definition of concurrent review under PHL § 4903(3) and must bedetermined and noticed within the timeframes provided for in the MMC ModelContract Appendix F.1(3)(b).ii. A “first time” assessment by the MCO for personal care service (the enrollee wasnever in receipt of PCS under either FFS or MMC coverage, or had a significant gapin Medicaid authorization of PCS unrelated to an inpatient stay) meets the definitionof preauthorized review under PHL §4903(2) and must be determined and noticedwithin the timeframes provided for in Appendix F.1(3)(a).c. Determination Notice. Notice of the determination is required whether adverse or not. If theMCO determines to deny or authorize less services than requested, a Notice of Action is to beissued as required by Appendix F.1(2)(a)(iv) and (v), and must contain all requiredinformation as per Appendix F.1(5)(a)(iii).d. Level and Hours of Service. The authorization determination notice, whether adverse or not,must include the number of hours per day, the number of hours per week, and the personalcare services function (Level I/Level II):i. that were previously authorized, if any;ii. that were requested by the Enrollee or his/her designee, if so specified in the request;iii. that are authorized for the new authorization period; andiv. the original authorization period and the new authorization period, as applicable.e. Terminations and Reductions. Authorizations reduced by the MCO during the authorizationperiod require a fair hearing and aid-to-continue language and must meet advance noticerequirements of Appendix F.1(4)(a). Fair hearing and aid-to-continue rights are included inthe “Managed Care Action Taken Termination or Reduction in Benefits” notice, which mustbe attached to the Notice of Action. Eligibility for aid-to-continue is determined by the Officeof Administrative Hearings.May 31, 20136

i. If the authorization being amended was an LDSS authorization for PCS made pursuantto 18 NYCRR §505.14, an enrollee requesting a fair hearing has the right for aid-tocontinue unchanged until the fair hearing decision is issued. (See 18 NYCRR § 3583.6).ii. If the authorization being amended was issued by an MCO (either current or previousMCO), an enrollee requesting a fair hearing has the right for aid-to-continueunchanged until the expiration of the current authorization period (see 42 CFR438.420(c)(4) and 18 NYCRR §360-10.8). The Action takes effect on the start date ofa new authorization period, if any, even if the fair hearing has not yet taken place.iii. All notices must reflect the reasons for reduction, discontinuation or denial of areauthorization for PCS. Appropriate reasons for reducing, discontinuing or denying areauthorization of personal care services include but are not limited to:1. the client’s medical, mental, economic or social circumstances have changedand the MCO determines that the personal care services provided under thelast authorization or reauthorization are no longer appropriate or can beprovided in fewer hours than they were previously;2. a mistake occurred in the previous personal care services authorization;3. the member refused to cooperate with the required assessment of services;4. a technological development renders certain services unnecessary or less timeconsuming;5. the member can be more appropriately and cost-effectively served throughother Medicaid programs and services;6. the member’s health and safety cannot be reasonably assured with theprovision of personal care services;7. the member’s medical condition is not stable;8. the member is not self-directing and has no one to assume thoseresponsibilities;9. the services the member needs exceed the personal care aide’s scope ofpractice.f. Reauthorization. Notice by the MCO for new authorization period beyond the expiration ofthe current authorization period requires notice of fair hearing rights if services are authorizedat a level that is less than what was requested by the enrollee or the amount previouslyauthorized. If the re-authorization request was generated by the MCO to ensure timelyassessment and continuity of care, the MCO should issue notice of fair hearing rights for anyreduction in service for the new period (unless such reduction was requested by the enrollee).i. If the authorization period that is expiring was an LDSS authorization for PCS madepursuant to 18 NYCRR §505.14, and the MCO did not conduct a new assessment orissue an authorization determination for such period, and the MCO determines toreduce the services authorized in the new period, the notice of fair hearing mustinclude aid continuing rights (“Managed Care Action Taken Termination or Reductionin Benefits” notice). An enrollee requesting a fair hearing has the right for aid-tocontinue unchanged until the fair hearing decision is issued.ii. If the authorization period that is expiring was issued by an MCO (either current orprevious MCO), and the effective date of the Action is after the expiration of thecurrent authorization period, the notice of fair hearing does not require aid-to-continuelanguage (“Managed Care Action Taken Denial of Benefits Under Managed Care”May 31, 20137

notice). The enrollee does not have a right for aid-to-continue unchanged past theexpiration of the current authorization period.iii. Appropriate reasons and notice language to be used when reducing, discontinuing ordenying a reauthorization of personal care services include those listed in Section III(e)(iii) above.g. Benefit Denials. If the MCO determines that the enrollee does not meet the criteria for theprovision of the personal care services benefit, a Notice of Action is issued with fair hearingrights, using the “Managed Care Action Taken Denial of Benefits Under Managed Care” or“Managed Care Action Taken Termination or Reduction in Benefits” notice, as applicable.i. If the Action terminates, suspends, or denies a new authorization period following anLDSS authorization for PCS made pursuant to 18 NYCRR §505.14, an enrolleerequesting a fair hearing has the right for aid-to-continue unchanged until the fairhearing decision is issued.ii. If the Action terminates or suspends an authorization issued by an MCO (eithercurrent or previous MCO), an enrollee requesting a fair hearing has the right for aidto-continue unchanged until the expiration of the current authorization period.iii. If the effective date of the Action is beyond the expiration of the current authorizationperiod, the notice of fair hearing does not require aid-to-continue language (“ManagedCare Action Taken Denial of Benefits Under Managed Care” notice). The enrolleedoes not have a right for aid-to-continue unchanged past the expiration of the currentauthorization period.iv. Appropriate reasons and notice language to be used when reducing, discontinuing ordenying a reauthorization of personal care services include those listed in Section III(e)(iii) above.v. For a member who is hospitalized or admitted to a facility for short-term rehabilitationand who was receiving personal care services immediately prior to entering thehospital or rehabilitation facility, the member’s personal care services authorization istemporarily suspended during the hospital or rehabilitation stay, and the MCO mustreinstate such services under the authorization immediately upon the member’sdischarge from the hospital or rehabilitation facility, unless the medical discharge planindicates otherwise.h. Enrollee Safety.i. The plan must ensure that any change to the level of personal care services does notpresent a safety issue for the member. If it is determined that personal care servicescannot maintain an individual safely in the home, then an assessment for theappropriate level of care must be arranged by the MCO.ii. As determined by the Office of Administrative Hearings, in the case of an MCOAction affecting a home bound enrollee, aid-to-continue at the same or higher level ofcare may be required until the time the fair hearing decision is issued.iii. If the MCO is unable to arrange for personal care services for the member due toconditions in the member’s home or the member rejects all available personal careservices workers there is a constructive refusal of the benefit by the member. TheMCO will issue a benefit denial notice to the member providing that the plan is unableto provide the benefit to the member. The MCO must contact appropriate resources atthe LDSS (such as APS), if applicable.IV.SupervisionMay 31, 20138

a. In-home supervision of the personal care services worker occurs when on-the-job instructionis needed to implement the plan of care and is covered by the MCO as part of PCS, subject tothe terms of the agreement between the MCO and its contracted provider;b. Supervision is provided by a registered nurse;c. The number of nurse supervision visits occurs no less than twice per year. More frequent inhome visits may be warranted and authorization should not be unreasonably withheld by theMCO when:i. The personal care services worker is not providing care in accordance with the careplan;ii. The member complains about the care received by the PCS worker;iii. A change in the member’s condition warrants a change to the plan of care.V.Transitional Carea. Existing enrollee in Receipt of PCS Authorized by an LDSS. Enrollees who are in receipt ofPCS as of August 1, 2011 continue their course of treatment as authorized by the LDSS,regardless of whether the PCS provider participates in the MCO’s network, until the MCO hasassessed the Enrollee’s needs and an approved treatment plan is put into place. MCOrequirements for prior authorization or notification may not be applied to Non-ParticipatingProviders until an approved treatment plan is put into place by the MCO even if the approvedtreatment plan is delayed beyond 60 days from enrollment. After August 1, 2011 LDSSshould verify whether an individual is enrolled in an MCO prior to acting upon a request forpersonal care services.b. New Enrollee in Receipt of Personal Care Services Authorized by the LDSS or another MCO.Transitional care services consistent with Section 15.6(a)(i) of the MMC Model Contract andthe SDOH transitional care policy entitled, “Medicaid Managed Care and Family Health PlusCoverage Policy: New Managed Care Enrollees in Receipt of an On-going Course ofTreatment,” apply to newly enrolled individuals with an authorization for PCS at the time ofenrollment in the MCO.VI.Contractinga. Personal Care Services Providersi. NYC Provider Networks. NYC area MCOs must include in their networks and utilizeonly home attendant vendor agencies having a contract with the HRA Home CareServices Program during the period August 1, 2011 through February 28, 2014. TheMCO is not required to contract with home attendant vendor agencies unwilling toaccept the applicable HRA rate or the Medicaid fee-for-service rate as long as theMCO maintains an adequate network of Participating Providers to treat members.ii. Continuity of the worker. The MCO must assure continuity of the personal careservices worker for the members who were enrolled in the MCO as of August 1, 2011and were previously in receipt of PCS authorized by the LDSS, unless:1. the home attendant vendor agency is unwilling to contract with the MCO;2. the personal care services worker is no longer working for the home attendantvendor agency; or3. the member requests a different personal care services worker.iii. Sole Source Arrangements. MCOs must continue Sole Source Arrangements withagencies caring for less than 10 members until there are no longer any membersMay 31, 20139

receiving personal care services from that vendor. This is to assure there is continuityof the worker for members enrolled in the MCO as of August 1, 2011. The MCO mayassign a member to a participating provider at the member’s request or if the vendorends the arrangement.b. Personal Care Services Worker Parity Rulesi.

c. Grooming, including care of hair, shaving and ordinary care of nails, teeth and mouth; d. Toileting, this may include assisting the patient on and off the bedpan, commode or toilet; e. Walking, beyond that provided by durable medical equipment, within the home and outside t