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

Income eligibility is determined by the DPW. People with disabilities may become eligible for PCA services through meeting regular income eligibility requirements, 102% of poverty level. A spend down option for income eligibility is also available; the difference in the recipient's monthly income and financial eligibility guidelines can be deducted from the monthly PCA reimbursement, and the consumer can pay the difference to the PCA out of pocket. People eligible for 1619B do not pay a contribution in order to access Medicaid, but receive Medicaid services at no cost.

Two state-funded programs also offer PCA services to people who don't meet regular Medicaid income eligibility. Some working MRC clients are also receiving PCA services through the ILCs, but intake to this program has been closed. Massachusetts also offers a Medicaid buy-in (Commonhealth Extra) for people of all incomes with disabilities as part of the state's Medicaid services. There is no asset cap for Cornmonhealth Extra, and an individual may purchase a full or supplemental premium.

PCA agencies do an initial intake for PCA, then refer to a nurse and occupational therapist who are either PCA agency employees or independent contractors. The RN and OT conduct an in- home assessment of functional limitations. Eligible recipients must need a minimum of 10 hours of assistance with ADLs per week, or 14 hours of ADLS and IADLs per week. The consumer must also have a condition which is "permanent or chronic in nature."

The PCA prior approval coordinator at the ILC mails a copy of the functional evaluation to the consumer's physician for signing. The physician's authorization must be returned before the ELC forwards the evaluation to the prior authorization unit of DPW. Services may begin immediately after the PCA agency requests prior approval (although the DPW usually takes about three weeks to give formal approval).

B. Needs Assessment

The OT and RN allocate hours based on functional limitations using a standardized formula. Deviations from this allocation formula must be documented. Questionable hour allocations may lead to a denial of prior authorization. When the consumer is living with family, the family is responsible for provision IADLs when possible. When a consumer is living with other program recipients, PCA time for homemaking tasks must be split among all consumers in the household.

C. Case Management

Fundamentally, the PCA program trains consumers to be their own case managers. Medicaid pays for extensive consumer training by the ILCs, but there is no mandated contact between the ILCs and the consumer after training has occurred. The ILCs have resource coordinators or service coordinators paid by the MRC. The qualifications of such staff are based upon knowledge, skills, and ability not education.

In 1989, PCA services began to be used for as part of the service package for people who were hospitalized (e.g. people with AIDS). A special case management unit was developed for these high cost cases.

D. Medical Supervision

Services must be prescribed by a physician. An RN must do a home assessment at least once a year. The low level of medical supervision was singled out by HCFA as a flaw of the program, but consumers and advocates think that the present system is non-intrusive and cost-effective. Because of this criticism, the state is considering increasing RN supervision to at least twice yearly.

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