Case Studies of Six State Personal Assistance Service Programs Funded by the Medicaid Personal Care Option. Questionnaire for Administrators, Advisors and Advocates


I. Program History - Timeline

  1. When was this program created?
  2. What has been the evolution of services since that time? (probe for changes in regulations and requirements over time)
  3. What groups and individuals pushed for the creation of this program and how did they impact the structure of this program (i.e. consumer groups, parent groups, providers, legislators, state/local government staff)?

II. Program Objectives and Population Served - Why was this program created?

  1. What are the program objectives? (probe for: employment, community integration, deinstitutionalization) Are these objectives being met?
  2. What population does this program target? (probe for: age, income, disability level, amount of informal support available) Is this population being adequately served)
  3. Are there any plans to change the program's mission?

III. The Relationship of the PC-Option to Other State Services

  1. How does this program compare to other PAS programs in the state? (probe for differences in populations served, i.e. age, income, severity of disability)
  2. What is the relationship of this program to other PAS programs in the state? (probe for: referral relationship, fall back options, gap filling)
  3. Who in the state still isn't being served in the home and community (probe for: those needing services 24 hours per day, cognitively disabled)?
  4. What is the spectrum of Long Term Care Services in the state? (probe for: Who is targeted for each of these services?, What percentage of the total population served gets each of these services?, What percentage of total LTC expenditures go for each of these services?)

IV. Federal Oversight: To what degree has federal oversight impacted the design of this state's PC-Option program?

  1. What are the current requirements of this program r.e. the following issues?:
    1. medical supervision (probe for: by whom, how often, what does it entail - e.g. file review, home visit?)
    2. location of service provision (probe for: limited to individual homes, board & care homes, medically related travel)
    3. family providers (probe for: definition of family, circumstances under which family provider is used)
    4. Have any other Medicaid requirements shaped this program?
  2. How would the following proposed HCFA regulation affect the program? (show summary card; probe for the impact on the population served and on the type and amount of services provided):
    1. Personal Care services are defined as "those tasks directed at the recipient and or his or her immediate environment that are medically related ... but would not include skilled services that may be performed only by a health professional."
    2. Household and chore services can only be provided as directly related to personal care needs, and are not to constitute more than one third of the total time expended per visit.
    3. Services can only be provided in the home or in connection with brief services outside the home for medical exam or treatment or shopping to meet health care or nutritional needs.
    4. Exclusion of services for institutions serving more than four clients (e.g. board and care homes).
    5. Exclusion of family providers, defined as: husband, wife, parent, child, sibling, adoptive child, adoptive parent, stepparent, stepchild, stepbrother, stepsister, father in law, mother in law, son in law, daughter in law, sister in law, brother in law, grandparents, grandchild.
    6. Physician must review and reauthorize plan of treatment at least every six months. PC services must be specified in the plan of treatment to ensure that services are adequate and provided only to those who need them.
    7. A registered nurse or "licensed practitioner of the healing arts" visit the consumer every three months to assess health status, need for PC services, quality of services, and to review plan of treatment.

V. Attendant Liability Issues - Who is the Employer?

  1. Who is the attendant employer for purposes of tax liability (i.e. FICA, Income tax)?
  2. Who is the employer for purposes of tort liability?
  3. Who is the employer for purposes of worker's compensation and other labor related issues?
  4. Is there program insurance for negligence?
  5. How has concern about these liability issues impacted program design?

VI. Gatekeeping Functions: Eligibility Determination, Needs Assessment, Case-Management

  1. Eligibility Determination
    1. Who determines eligibility?
    2. What does the process of eligibility determination entail and how much individual discretion is involved? (probe for formulas, guidelines)
  2. Needs Assessment
    1. Who provides needs assessment?
    2. What does the process of needs assessment entail and how individualized is the service allocation? (probe for formulas, budget limits, individual discretion) Is there a per person cap on services or an average cap?
  3. Case Management
    1. Who provides case-management?
    2. What are the minimum qualifications for case-managers?
    3. What is the relationship of the case-manager to the program? (probe for: individual contractor, employee of provider agency, civil service employee)
    4. What are the average caseloads?
    5. Is there a mandated minimum level of case-management? (probe for flexibility based on need and capacity for self-management)
    6. What is the scope of case management, i.e. do they assist in all the recipients needs or just Medicaid PAS?

VII. Support Services: Who Provides and Pays for the Following Services (i.e. State Government, County, City, AAA, ILC, Other Non-Profit, Consumer, Family, Friends, Other)?

  1. Attendant Recruitment
  2. Attendant Screening
  3. Attendant Interviewing
  4. Attendant Certification
  5. Attendant Hiring
  6. Attendant Training
  7. Attendant Supervision
  8. Attendant Payment
  9. Attendant Termination
  10. Consumer Advocacy
  11. Consumer Training
  12. Consumer Outreach
  13. Conflict Resolution
  14. Quality Monitoring

VIII. Relative Service Costs

  1. What percentage of the overall program budget goes toward direct services (provider wages and benefits)?
  2. What percentage of the overall program budget goes toward support services?
  3. What percentage goes to case management?
  4. What percentage goes to administration? (probe for definition of administration)

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