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Personal Care Services (PCS) FAQs

Frequently Asked Questions

What is PCS?

The PCS program is designed to provide personal care services to qualifying individuals that need assistance in their effort to perform their activities of daily living that include bathing, dressing, mobility, toileting and eating.

What are the PCS qualification requirements?

Requirement for Qualifying Activities of Daily Living (ADLs)

PCS are provided to a Medicaid beneficiary who qualifies for coverage and has documented unmet needs for hands-on assistance with:

  • Bathing;
  • Dressing;
  • Mobility;
  • Toileting; or
  • Eating

Medicaid beneficiaries are required to have active Medicaid at the time of service and have a medical condition, cognitive impairment or disability while demonstrating unmet needs for at minimum:

  • Three of the five ADLs with limited hands on assistance;
  • Two ADLs, one of which requires extensive assistance; OR
  • Two ADLs, one of which requires assistance at the full dependence level.
  • Be considered medically stable
  • Remain under the care of their primary care physician or specialist for the condition causing limitations and seen them in the last 90 days
  • Reside in a private living arrangement, or in a residential facility licensed by the State of North Carolina as an adult care home, a combination home, or a group home as a supervised living facility
  • Not have a family member or caregiver who is willing and able to provide care

 

Define the term medically stable in relation to the PCS policy.

Medically Stable when the beneficiary has reached a point in his or her medical treatment where a life-threatening or serious injury, disease, medical condition, or cognitive impairment has been brought under control and the beneficiary no longer requires medical care, services, supervision, or monitoring from a licensed health care professional and can live safely at home under his or her current living conditions.

How many days a week may a beneficiary receive PCS?

If needed, PCS may be approved up to 7 days a week.

How many hours a month may the beneficiary receive PCS?

For adults, the max allowable hours is 80 hours, 130 for individuals who have a degenerative disease that is characterized by irreversible memory dysfunction; see Clinical Coverage Policy 3L, section 5.3.1 (b) for full description.

For kids (up to 21), the max allowable hours is 60 unless approved for a higher amount based on care needs.

How do I apply for the PCS program?

The individual’s primary care or attending physician, physician assistant, or nurse practitioner must make the referral for the individual to be assessed for PCS using the Request for Independent Assessment for Personal Care Services Attestation of Medical Need Form (Form 3051) Request for Services and Instructions (DHB 3051)

Once completely filled out, the physician should fax the referral form to Acentra Health at 833-521-2626.

Who can make a referral for PCS?

In most cases, the beneficiary's primary care physician (PCP) should make the referral. If the beneficiary is being discharged from an inpatient facility (hospital, nursing home, rehab facility), the attending physician, hospitalist, nurse practitioner, or physician's assistant may make the referral. In these cases, the case manager or discharge planner should be listed as the contact person on the referral form. If the beneficiary does not have a PCP, he/she should get the referral from the doctor who is treating the health problem that is causing disability.

Frequently Asked Questions

Expedited Process for PCS

Q. What is an expedited assessment?

A. An expedited assessment is an immediate review of an individual who meets the eligibility requirements below. Because of this time frame, the process is done by fax and telephone.

Q. Who can request an expedited assessment?

A. A hospital discharge planner, skilled nursing facility discharge planner, LME/MCO Transition Coordinator, or Adult Protective Services (APS) Worker

Q. Who's eligible for an expedited assessment?

A. A qualified beneficiary if that individual is currently hospitalized, in a medical facility, in a Skilled Nursing Facility (SNF), part of the Transition to Community Living Initiative, or in cases of an active Adult Protective Services (APS) case

Eligibility Requirements

  • There is an active Adult Protective Services (APS) case.
  • The beneficiary is currently hospitalized, in a medical facility or in a Skilled Nursing Facility (SNF).
  • Is in individual in the transition to living community initiative.
  • For an Adult Care Home (excluding 5600 facilities), the beneficiary must have a Pre-Admission Screening and Resident Review (PASRR) number. To learn more about this form and process, please go to www.ncmust.com/pasarr/pasarrsummary.jsp.
  • The beneficiary is medically stable.
  • The beneficiary has active or pending Medicaid.

Q. What is the expedited assessment process?

A.

  • If eligibility requirements are met, a hospital discharge planner, skilled nursing facility discharge planner, LME/MCO Transition Coordinator, or Adult Protective Services (APS) Worker may request an Expedited Assessment by faxing the Request for Services form to 1-833-551-2602 followed by a call to Acentra Health at 833-522-5429.A hospital discharge planner, skilled nursing facility discharge planner, LME/MCO Transition Coordinator, or APS worker will need to have the beneficiary select a provider of services before PAs can be issued.
  • Expedited Assessments for beneficiaries seeking placement in ACHs (not 5600s) will need a PASRR number.
  • Once connected with Acentra Health, the request will be reviewed and immediately approved or denied by a Customer Service Team Member. If approved, the caller will be transferred to an Acentra Health nurse who will conduct a brief telephone assessment. If approved, the beneficiary will be immediately awarded temporary hours for PCS services.
  • Acentra Health will then contact the beneficiary within 14 business days to schedule a complete assessment in person.

For any questions concerning the expedited assessment process, please contact Acentra Health at 833-522-5429.