Par.1.   Material Transmitted and Purpose -- Transmitted with this Manual Letter are revisions to Service Chapter 535-05, Medicaid State Plan Personal Care Service Policies and Procedures.  New language is in red and underlined; deleted language is in red and struck through.

Par. 2.   Effective Date – January 1, 2010

1.	Definitions 535-05-10
 
1.	”Activities of Daily Living (ADLs)” means physical activities routinely performed on a daily basis by an individual and generally includes bathing, dressing, eating, toileting, transferring, maintaining continence, and mobility.
2.	“Authorizing agent” means a home and community based service case manager employed by a county social service board or a developmental disabilities employed by a regional human service center.
3.	“Basic care assistance provider” means an entity that is licensed as a basic care facility; is not owned or administered by state government; does not specifically provide services for individuals with traumatic brain injury or Alzheimer’s disease or related dementia; and is enrolled with the Department as such.
4.	“Instrumental Activities of Daily Living (IADLs)” means complex life activities routinely performed by an individual such as housework, laundry, meal preparation, taking medications, shopping, outside mobility, management of money, personal hygiene, and use of telephone.
5.	“Level A personal care services” means the level of care for an individual meeting the minimum eligibility criteria for personal care services.
6.	“Level B personal care services” means the level of care for an individual meeting the nursing facility or ICF/MR level of care criteria in addition to the minimum eligibility criteria for personal care services.
7.	“Level C personal care services” means  the level of care for an individual meeting the nursing facility or ICF/MR level of care criteria in addition to having an impairment in 5 ADLS. 
8.	"Long term care need" means the need for the services available under the SPED Program, ExSPED Program, Medicaid Waiver Program, or the Medicaid State Plan Personal Care Option that is anticipated to exceed 30 days.
9.	“Personal care service provider” means a qualified service provider or a basic care assistance provider.
10.	”Personal care services” means services consisting of a range of human assistance, provided to an individual with disabilities or conditions, that will allow the individual to live as independently as possible while delaying or preventing the need for institutionalization. Assistance may be in the form of hands on assistance or cuing so that the individual can perform a task without direct assistance.
11.	Qualified service provider” means a county social service board, agency, or independent contractor that agrees to meet standards for service and operations established by the North Dakota Department of Human Services pursuant to NDCC 50-06.2-02(6) and NDAC 75-03-23.
12.	“Unit” means either a 15-minute increment or a day.
 
2.	Personal Care Eligibility Requirements 535-05-15
To qualify for coverage of personal care services an individual must meet at least ONE of the following criteria:
1.	Must have applied for and been found eligible for Medicaid benefits
2.	Be Impaired in at least one of the following ADLs:
a.	Bathing
b.	Dressing
c.	Eating
d.	Toileting
e.	Continence
f.	         Transferring
g.	Mobility
3.	Or be impaired in at least THREE of the following IADLs:
a.	Meal Preparation
b.	Housework
c.	Laundry
d.	Taking medications

An individual meeting the above criteria, qualifies for Level A personal care services. An individual who meets the above criteria may qualify for Level B personal care services if the individual also meets the nursing facility level of care criteria set forth at NDAC 75-02-02-09 or meets ICF/MR level of care criteria.
To qualify for coverage of personal care services, an individual must have applied for and been found eligible for Medicaid benefits 
And
1.	Eligibility criteria for  Level A (up to 480 units per month), Daily Rate care, or Basic Care includes:
a.	 Be impaired in at least one of the following ADLS of:
i.	Bathing
ii.	Dressing
iii.	Eating
iv.	Toileting
v.	Continence 
vi.	Transferring
vii.	Inside Mobility
Or 
b.	Be impaired in at least THREE of the following IADLs:
i.	Meal Preparation
ii.	Housework
iii.	Laundry
iv.	Taking medications
2.	Eligibility for Level B (up to 960 units per month) includes:
c.	Be impaired in at least one of the following ADLS of:
i.	Bathing
ii.	Dressing
iii.	Eating
iv.	Toileting
v.	Continence 
vi.	Transferring
vii.	Inside Mobility
Or 
d.	Be impaired in at least THREE of the following IADLs:
i.	Meal Preparation
ii.	Housework
iii.	Laundry
iv.	Taking medications
 AND
e.	Meet the nursing facility level of care criteria set forth at NDAC 75-02-02-09 or meets ICF/MR level of care criteria.

3.	Eligibility for Level C (up to 1200 units per month) includes:
f.	Be impaired in at least five of the following ADLS of:
i.	Bathing
ii.	Dressing
iii.	Eating
iv.	Toileting
v.	Continence 
vi.	Transferring
vii.	Inside Mobility
AND
g.	Meet the nursing facility level of care criteria set forth at NDAC 75-02-02-09 or meets ICF/MR level of care criteria.
AND
h.	None of the 300 hours (1200 units) approved for personal care services can be allocated to the tasks of laundry, shopping, or housekeeping.
AND
i.	Have written prior approval for this service from a HCBS Program Administrator, Medical Services Division, Department of Human Services. The approval must be updated every three months. 

3.	Limitations and Non-covered Services 535-05-25
8.	Authorized personal care services may not exceed 120 hours (480 units) per month for Level A Personal Care Services, or 240 hours (960 units) per month for Level B Personal Care Services., and 300 hours (1200 units) per month for Level C Personal Care Services.

4.	Payment for Services 535-05-40
Case management activities must be documented in the case file before payment for case management can be requested. The authorizing agent may be paid for targeted case management (TCM) for a Medicaid eligible individual in need of long term care services only if the individual is not receiving case management under any HCBS waiver or other targeted case management provisions. No claim may be made for TCM when a change in funding source for case management occurs or if an individual is not eligible for Medicaid. When accessing Targeted Case Management payment, documentation must support that the individual is at risk of requiring long-term care services this can be narrated on the SFN 1047, Application for Services, or in the assessment narrative.

5.	Provider Billing Procedures 535-05-45 
A personal care service provider who is enrolled as a QSP must use the Turnaround Document for Home and Community Based Care for the Elderly/Disabled (TAD), SFN 925, or the QSP online billing option to bill for services. A personal care service provider enrolled as a basic care assistance provider must bill using the Basic Care Assistance Turnaround Document. Only one (1) procedure code per individual may be entered in any one section on the TAD. Procedure code T1019 must be used be used to bill on a 15-minute increment basis.  Billing is limited to the time in performance of the authorized tasks provided. The provider must bill in 15-minute increments on a daily basis.  Each 15-minute increment is one (1) unit and the number of units of service provided on each day of care must be shown on the billing document. Procedure code T1020 must be used to bill a daily rate for a provider authorized to bill a daily rate. Only 1 unit per client may be billed per day for procedure code T1020. The provider may be paid the daily rate only for days on which personal care services were provided. The daily rate may not be paid for any days on which the individual was in the hospital or a health-care facility or on leave from the residence, except payment is allowed for the day the individual returns to the provider’s care. Payment may be claimed when personal care services are provided on the day of death.

6.	Appeals Reductions, Denials, and Terminations 535-05-50
If the service is reduced the client must be informed in writing of the reason(s) for the reduction in service on the SFN 662, the reduction in service becomes effective no less than 10 days effective date of the reduction must be no sooner then 11 days after the client signs the SFN 662 and the client must be given a copy of the appeal rights printed on back of the SFN 662.

Termination of a Personal Care Service Plan if Personal Care Service has not been used in 60 days:  
The authorization for personal care service may be terminated if the service is not used within 60 days, or if services lapse for at least 60 days,  after the issuance of the authorization to provide personal  care services.

Health Welfare and Safety:
The department may deny or terminate personal care services when service to the client presents an immediate threat to the health or safety of the client, the provider of the service, or others, or when the services that are available are not adequate to prevent a threat to the health or safety of the client, the provider of services, or others.

The client is no longer eligible for Medicaid:
The Case Manager must send a letter informing the client that eligibility for MSP-PC is dependent on eligibility for Medicaid (the right to appeal the closure of the Medicaid benefit is sent to the client by Economic Assistance).
 
7.	Provider Qualifications 535-05-55
To provide personal care services, an individual or agency must be enrolled with the Medical Services Division as a qualified service provider. A residential care provider must be licensed and enrolled as a basic care provider. Agency and residential care providers must ensure that each employee meets the required standards for a QSP before an employee can provide personal care services. Residential providers must ensure that each employee meets the required standards in the Basic Care Licensing Standard outlined by the North Dakota Department of Health.
 
8.	Instructions for Completing Personal Care Services Plan, SFN 662 535-05-70-01

The individual's case manager must complete the PCSP in conjunction with the individual or his/her legal representative. The signature of the individual or the legal representative on the PCSP is required before services can be authorized for payment. If the individual or legal representative refuses to sign the PCSP, the reason for the refusal must be noted in the case file. Any changes or revisions to a PCSP require the signature of the client with the exception of a change in provider. When a change in service provider occurs between case management contacts -- the client or legal representative may contact the case manager requesting the change in provider. The contact and approval for the change in provider must be verified in the case manager's documentation and noted on the ICP PCSP which is sent to the Department. A copy of the updated care plan must be sent to the client or legal representative. However, changes in services or the amount of service must be signed by the client or legal representative and approved.
 
Section II – Eligibility for Personal Care Service
Score the individual’s needs in accordance with the instructions for scoring ADLs and IADLs to determine if the individual qualifies for personal care services. If the individual has an impairment (a score of at least 2) in any one of the ADLs or a impairment (a score of at least 1) in 3 of the 4 IADLs the individual qualifies for personal care services. Narratives in the individual’s file must verify the rationale for each score, and the determination for eligibility.

Choose the level of personal care needed based on the eligibility criteria outlined in Personal Care Eligibility Requirements 535-05-15.
 
Determine the type of provider that will be providing services based on the individual’s choice. 
Check/complete the appropriate box:
PCS-A 
PCS-B
PCS-C
LOC Determination Date
Daily
PCS Basic Care
None

If the individual chooses to receive services from a QSP(s) refer to  and the individual needs 120 hours or less per month of personal care services check PCS – A.

If the individual requires more than 120 hours (480 units) per month of personal care services, a nursing facility or ICF/MR level of care determination must be completed to determine if the individual qualifies for Level B Personal Care Services. Enter the date the LOC determination was approved and check PCS – B  if the individual meets NF or ICF/MR level of care. A LOC determination approval must be obtained whenever an individual has not had any LOC determination approved within 12 months of the start of a care plan period. If the individual does not meet NF or ICF/MR level of care then check PCS-A. The date of the next LOC determination is the responsibility of the case manager and needs to be scheduled to allow sufficient time in which to give the client a ten working day notice should personal care services be reduced because the individual no longer meets the criteria for Level B services LOC.
 
If the individual chooses to receive services on a daily rate (T1020), the "Daily" check box must be checked. To determine the Daily rate send a completed SFN 662 and 663 to Medical Services and the rate will be calculated by Medical Services. The provider and case manager will receive a copy of a profile that documents the rate. The  daily rate needs to be recalculated whenever there is a increase or decrease in units of service approved for a client. 
 
If the individual chooses to receive services from a Basic Care Assistance provider, check PCS – Basic Care.
 
If the individual does not qualify for personal care services, check NONE (provide the client with a formal Denial and completed SFN 1647) and skip to Section V Signatures.  

Instructions For Obtaining ICF/MR Level Of Care (LOC) Determination (for use by DD case managers)
An individual in need of Level B or C personal care services must have an ICF/MR LOC determination done whenever a comprehensive needs assessment is completed. The date of the next ICF/MR LOC determination is the responsibility of the case manager and needs to be scheduled to allow sufficient time in which to give the client a ten working day notice should personal care services be reduced because the individual no longer meets the criteria for Level B or C services.

Instructions For Obtaining Nursing Facility (NF) Level Of Care Determination
An individual in need of Level B or C personal care services who does not meet ICF/MR level of care criteria must have a NF level of care determination approved within 12 months of the start of any personal care service plan. The date of the next NF level of care determination is the responsibility of the case manager and needs to be scheduled to allow sufficient time in which to give the client a ten working day notice should personal care services be reduced or terminated.
 
Section III – Approved Services
For QSPs who will be paid based on 15 minute unit rate basis, enter the personal care service provider name, provider number, the units authorized on SFN 663, the 15-minute (T1019) procedure code, and the billable units (units will be the same as the authorized units) to be provided on a monthly basis. If multiple providers are listed on SFN 663 list all providers and provider numbers but complete only 1 line for authorized units, procedure code, and billable units. The procedure code for services must be T1019. The total number of units of service to be provided per month by all providers based on 15-minute increments must be entered. The total number of units per month for procedure code T1019 may not exceed 480 units if PCS – A is checked or 960 units if PCS – B is checked or 1200 units if PCS-C is checked.

Section V – Signatures
The instructions for the completion of a reduction is outlined in Denials, Terminations, and Reductions 535-05-50
 
If the care plan for personal care services expires and a new care plan is not going to be issued, you must follow the policy for Termination. If a care plan for personal care services is being canceled (terminated) prior to the end of the effective date of the plan send a copy of the canceled care plan SFN 662 to the client and Department and a copy of the canceled authorization SFN 663 to the client, provider, and Department. The instructions for the completion of a Termination is outlined in Denials, Terminations, and Reductions 535-05-50.

If the individual was determined not to qualify for personal care services in Section II, then the individual must be informed of their rights. The instructions for the completion of a Denial is outlined in Denials, Terminations, and Reductions 535-05-50

If the client is not in agreement with the PCSP, they should enter their initials indicating they are not in agreement with the plan of care. The Case Manager must provide the client with a completed SFN 1647, (Reduction, Denial, or Termination Form).
 
The individual (or the individual’s legal representative) and the case manager both must sign to signify agreement with the PCSP. If the individual refuses to sign the PCSP, the case manager must provide the client with a completed SFN 1647 and a copy of the unsigned plan must be forwarded to the state office. 

If a care plan changed due to a change such as; a change in provider, or change in units approved, or other change prior to the end of an existing care plan period, check the reason for the change and describe if appropriate. Then send a copy of the canceled and updated care plan SFN 662 to the client and Department and send copy of the canceled and updated SFN 663 to client, provider, and Department.
 
If the care plan expires and a new care plan is not issued, you do not need to send a copy of the expired care plan SFN 662 or the expired authorization SFN 663 to the client, provider, or Department.   

The case manager should check the appropriate identification of the program case management, DDCM for Developmental Disabilities Case Manager or HCBS-CM for Home and Community Based Waiver Case Manager.
 
The individual (or the individual’s legal representative) and the case manager both must sign to signify agreement with the PCSP. If the individual refuses to sign the PCSP, then the case manager should deny the personal care services and inform the individual of the right to appeal the decision(s) that precipitated the individual’s refusal to sign the PCSP. If the individual was determined not to qualify for personal care services in Section II, then the individual must be informed of the right to appeal per NDAC 75-01-03. Check the box indicating the individual’s agreement or disagreement with the plan and have the individual sign the form or note the individual’s refusal to sign. If the individual refuses to sign the plan, a copy of the plan must be forwarded to the respective state office.  

If the client is not in agreement with the PCSP, they should enter their initial indicating they are not in agreement with the plan of care. Then the Case Manager must provide the client with a completed SFN 1647, HCBS Notice of Reduction, Denial or Termination Form.