Case Studies of Six State Personal Assistance Service Programs Funded by the Medicaid Personal Care Option. III. Gatekeeping and Supervision Functions: Eligibility, Needs Assessment, Case-Management, Medical Supervision


A. Eligibility Determination

Eligibility may be determined by either the AAAs or Disability Service offices. SDSD administrators say there is a general policy of assessing the total needs of the person, and then piecing together an individual package of services which addresses those needs. A single instrument is used, the Client Assessment and Planning System (CAPS). Income, assets, living situation, medical history, current support system, and functional limitations are all assessed. Special financial workers are responsible for determining financial eligibility and fee scales for benefits. If the applicant meets income eligibility requirements (<100% of SSI), needs assistance with at least one ADL, lives at home, and is determined to need low or intermittent amounts of skilled PAS, PCS will be offered.

The CSD caseworkers offering PCS reimbursement to foster parents do not use this system, but rather complete a special rate/personal care service authorization to add to the foster care agreement. An RN does a detailed assessment of medical and functional needs.

B. Needs Assessment

Based on the CAPS assessment SDSD clients are ranked in terms of severity of need, and services are allocated based on this ranking. People at the bottom of the list currently receiving services may be bumped if higher need cases are added. For CSD clients, the RN assessment results in a detailed plan of care which specifies the child's needs and the hours allocated to deal with those needs.

C. Case Management

Case management is offered through the SDSD and CSD offices. Case managers are civil servants, and must have a Bachelor's degree in the behavioral sciences. SDSD caseworkers have average caseloads of roughly 120 people, and are required to do in home visits every 6 months. Agency RNs may assume some case-management functions for PCS recipients. Some private agency administrators and advocates expressed concern that there is an over reliance on state workers in the current system, that some caseworkers are poorly trained, and that caseworkers are underpaid and overworked.

D. Medical Supervision

RN supervision is required every 60 to 180 days for PCS provided through SDSD, and at least every 180 days for CSD clients. The consumer's physician must reauthorize services annually.

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