Medicaid Personal Care Services
Personal care services (PCS) is a Medicaid benefit for the elderly, people with disabilities, and people with chronic or temporary conditions. It assists them with activities of daily living and helps them remain in their homes and communities. Examples of PCS include bathing, dressing, light housework, money management, meal preparation, and transportation. Prior OIG reviews identified significant problems with States’ compliance with PCS requirements. Some reviews also showed that program safeguards intended to ensure medical necessity, patient safety, and quality, and prevent improper payments were often ineffective. The OIG will determine whether improvements have been made to the oversight and monitoring of PCS and whether those improvements have reduced the number of PCS claims not in compliance with Federal and State requirements.
Examples of past non-compliance include home health agencies bill Medicaid for personal care services performed by individuals who did not meet state qualification requirements and not having the proper documentation (i.e. plan of care, medical supervision, etc.). Home health agencies should ensure all services billed to Medicaid are provided by individuals meeting both federal and state qualifications as well as ensuring proper documentation.
Home health agencies and hospices both provide care to Medicaid PCS recipients who are receiving PCS services from a non-hospice/non-home health agency provider. These providers could also be impacted by this particular OIG Work Plan item even though they are not providing PCS services to the recipient. No Medicaid plan should pay for services that should be provided under Medicare. Medicare Home Health and Medicare Hospice benefits provide for aide services and there may be times when the home health agency or hospice should be providing these services under the Medicare benefit, but instead the PCS provider delivers this care and bills Medicaid. It is possible that in such cases, the State would recoup these payments from the PCS provider. This could impact the relationship between the PCS provider and the home health agency/hospice.
What should providers do?
- Home health agencies providing Medicaid PCS services should ensure all state qualification and documentation requirements are met in addition to Federal requirements.
- Home health agencies providing Medicare services to beneficiaries who are also receiving Medicaid PCS services (either by the same home health agency or another agency), should ensure that all services required under Medicare are being provided. Specifically, if aide services are required and the home health agency provides aide services, the agency should provide the aide services necessary to meet the requirements at Section 50.7 of Chapter 7 of the Medicare Benefit Policy Manual and ensure care coordination with the Medicaid PCS provider.
- Hospices providing Medicare services to beneficiaries who are also receiving Medicaid PCS services, should ensure that all services required under Medicare are being provided. Specifically, if aide services are required, the hospice should provide the aide services necessary to meet the requirements at Sections 40.1.7 and 40.5 of Chapter 9 of the Medicare Benefit Policy Manual and ensure care coordination with the Medicaid PCS provider.
- Medicaid Managed Care Organization Denials
This particular issue is of interest to home health agencies and hospices for any services they provide requiring prior authorization.
The State Medicaid agency and the Federal Government are responsible for financial risk for the costs of Medicaid services. Managed care organizations (MCOs) contract with State Medicaid agencies to ensure that beneficiaries receive covered Medicaid services. The contractual arrangement shifts financial risk for the costs of Medicaid services from the State Medicaid agency and the Federal Government to the MCO, which can create an incentive to deny beneficiaries’ access to covered services. The OIG states that their review will determine whether Medicaid MCOs complied with Federal requirements when denying access to requested medical and dental services and drug prescriptions that required prior authorization.