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.
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:
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:
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.
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.
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.
Expedited Process for PCS
A. A hospital discharge planner, skilled nursing facility discharge planner, LME/MCO Transition Coordinator, or Adult Protective Services (APS) Worker
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
For any questions concerning the expedited assessment process, please contact Acentra Health at 833-522-5429.