Par. 1.  Material Transmitted and Purpose --Transmitted with this Manual Letter is revised Service Chapter 535-05, Medicaid State Plan – Personal Care Services.  IM 5097 is superseded.  New language is underlined and deleted information is struck through.

Par. 2.   Effective Date -- December 1, 2010 for all new clients and must be implemented within 6 months for all current clients.  

Reductions, Denials, and Terminations 535-05-50 (IM 5097)
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 effective date of the reduction must be no sooner than 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.

Instructions for Completing Personal Care Services Plan, SFN 662 535-05-70-01

Instructions For Obtaining Nursing Facility (NF) Level Of Care Determination
You are encouraged to submit by web based method; however you may fax the information or do a telephone determination.  Before conducting the telephone determination with DDM you must have completed DDM’s ND LEVEL OF CARE/Continued Stay Review Determination Form.  Personal Care must be checked In the “Requested Screen Type” section. An individual qualifying for personal care services may also be eligible for waivered services and if so, the appropriate waivered service must also be checked on the form. This includes having the client's Medicaid ID number. DDM will not process the determination without having the client's Medicaid ID number.  When conducting a telephone determination, you must have the written materials on file in the client's case record for verification of the basis of the information transmitted in the telephone determination. Check the appropriate screen type.

Following are the screen types listed on the LOC Determination Form.
•	MSP-PC
•	HCBS Waiver/MSP-PC (Check only if eligible for both)
•	MSP-PC/SPED under age 18, (Check only if eligible for both)

Instructions for Completing the Authorization to Provide Personal Care Services, SFN 663 535-05-70-05

“Total Authorized Units” – enter the total units authorized to be provided, this includes the total of the units approved in the Authorized Units per Task Category behind the correct procedure code. If the procedure code is T1020 (Daily Rate) complete the per day rate/cost.
	
Authorized Units per Task Category” - enter the total authorized units of service based on 15-minute increments for each personal care services tasks authorized under ADL - activities of daily living, Meal Prep -meal preparation, Med Assist – medication assistance, Ldry/Shp/Hskp - laundry, shopping, housekeeping, and Other. Total of the five subgroups must equal total authorized units. NOTE: Total authorized housekeeping, laundry, and shopping units of service may not exceed 30% of the total units of all personal care services authorized for the client. Authorized units must be supported by documentation in the individual’s case file. 
•	Some flexibility is anticipated in the provision of tasks amongst the categories of ADL, Other, Meal Prep, and Med Assist and the provider is allowed to bill up to the total units approved in these 4 categories; however, the provider may not bill for units in excess of the units authorized in the category of Ldry/Shp/Hskp.
•	A written, signed recommendation for the task of vital signs provided by a nurse or higher credentialed medical provider must be on file that outlines the requirements for monitoring, the reason the task is required and frequency. When the tasks of Temp/Pulse/Respiration/Blood Pressure are authorized, the individual to be contacted for readings must be listed on the SFN 633.
•	For the task/activity of exercise a written recommendation and outlined plan by a therapist for exercise must be on file. Exercise is limited to maintain or improve physical functioning that was lost or decreased due to a injury or a chronic disabling condition (i.e., multiple sclerosis, parkinson’s, stroke etc). Exercise does not include physical activity that generally should be an aspect of a wellness program for any individual (i.e., walking for weight control, general wellness, etc). 

This is the link for this chapter – go into Financial Help.

http://www.state.nd.us/humanservices/policymanuals/home/financialhelp.htm