Personal Care Services Authorization Form

ARTC.UM.19 Personal Care Services

Page 1 of 9 POLICY AND PROCEDURE POLICY NAME: Personal Care Services Authorization POLICY ID: ARTC.UM.19 BUSINESS UNIT: Arkansas Total Care FUNCTIONAL AREA: Utilization Management EFFECTIVE DATE: 01/2024 PRODUCT(S): Medicaid REVIEWED/REVISED DATE: 01/29/2024; 4/29/2024; 01/03/2025; 07/17/2025 REGULATOR MOST RECENT APPROVAL DATE(S): Refer to system of record – Archer

POLICY STATEMENT: All Areas and Departments within Centene Corporation and its subsidiaries must have written Policies and Procedures that address core business processes related to, among other things, compliance with laws and regulations, accreditation standards and/or contractual requirements. PURPOSE:
The purpose of this policy and procedure is to outline the procedure for authorization of personal care services (PCS) for the Plan’s members. SCOPE:
This policy applies to employees of the Utilization Management (UM) Department of Arkansas Total Care (ARTC). This includes officers, directors, consultants, and temporary workers (collectively, the “Plan”).
DEFINITIONS: Age-appropriate ADL Deficit: In children under the age of 18, a deficit in ability to perform associated activity of daily living without supervision or assistance of a responsible adult (parent, legal guardian, or custodian) that would be present in a child of that age level. For example, a 3-year-old would require assistance with meal preparation, cutting meals, laundry, etc. regardless of physical or mental disease, illness, or condition.
Medical Necessity: Medically necessary services are those that: • Are appropriate and consistent with the diagnosis of the treating practitioner and the omission of which could adversely affect the member’s medical or behavioral health (BH) condition. • Are compatible with the standards of acceptable medical practice in the community. • Are provided in a safe, appropriate, and cost-effective setting given the nature of the diagnosis and the severity of the symptoms. • Are not provided solely for the convenience of the member, the practitioner, or the facility providing the care. • Are not primarily custodial care unless custodial care is a covered service or benefit under the member's evidence of coverage and appropriate; and
• There must be no other effective and more conservative or substantially less costly treatment, service and setting available.
• Treat the prevention, diagnosis, and treatment of the member’s disease, condition, and/or disorder that results in health impairments and/or disability. • Allow for the ability for the member to achieve age-appropriate growth and development. • Allow for the ability for the member to attain, maintain, or regain functional capacity; and • Allow the opportunity for the member receiving LTSS to have access to the benefits of community living, achieve person-centered goals, and live and work in the setting of their choice.

ARTC.UM.19 Personal Care Services

Page 2 of 9 Personal Care Services: Are tasks that are:
• Reasonable and medically necessary,
• When a member has physical limitations due to illness, injury, or developmental delays.
• Associated with an activity of daily living or instrumental activity of daily living only.
POLICY: The Plan authorizes PCS for members. Such services are intended to supplement, not supplant, other resources available to the member. Personal care services are primarily based on the assessed physical dependency need for "hands-on” services with the following activities of daily living (ADL): eating, bathing, dressing, personal hygiene, toileting, and ambulating.
Hands-on assistance in at least one (1) of these areas, based on the Arkansas Independent Assessment (ARIA) and/or other relevant assessment results is required, and such services require a prior authorization. An individualized plan of care (person-centered care plan “PCSP”) is developed based on the ARIA assessment results and information in the form designated by the Plan that is submitted by the provider and is based on a member’s assessed dependency in at least one of the above-listed activities of daily living. This type of assistance is provided by a personal care aide based on a member's physical dependency needs (as opposed to purely housekeeping services). IADLs (instrumental activities of daily living) include meal preparation, incidental housekeeping, laundry, medication assistance, etc. While not a part of the eligibility criteria, the need for assistance with other tasks and IADLs are considered in the assessment. Both types of assistance are considered when determining the amount of overall personal care assistance authorized. The Time and Hour Standard (THS) grid used by the Arkansas Medicaid program is used to determine eligible hours for personal care services for each member based on the ARIA and/or other relevant assessments.
Although the tasks the aide performs are similar to those that a nurse’s aide would normally perform if the member were in a hospital or in a nursing facility, these services prevent institutionalization and enable the recipient to be treated in their own home and community on a more cost-effective basis.
The policy of the Plan is to authorize reasonable and medically necessary PCS in the home, or community, for members within the following parameters: A. Must be included in an approved plan of care/treatment plan completed by the provider:
• Have a physician’s prescription or referral for the service initially or have the request signed by the members primary care physician (PCP) (MD, APRN, PA or DO, no RN signature allowed).
• If the request is for an increase in units, the request form must be signed by the PCP. • Request must include ARTC Personal Care Services Request form. • Must meet medical necessity criteria supported by clinical records and the assessment narrative submitted with the request • Service plan of the provider must indicate tasks to be performed, frequency, and quantity of time allotted to task. The service plan must reflect only those ADL’s or IADL’s a member requires assistance with. Inability of the primary caregiver to perform needed tasks is considered in the determination of medical necessity and must be documented on the ARTC Personal Care Services Request Form under resource availability.
• Provider must certify that the service plan does not duplicate any other in-home services of which the provider is aware. This includes waiver supportive living services.
• Service must be requested for CPT code T1019 • Provider must have a signed freedom of choice form available upon request from the Plan. B. The services must include the performance of direct care, and cannot consist solely of oversight, cuing, or supervision, unless documentation provided indicates the oversight, cuing, or supervision is to prevent harm to the member,

ARTC.UM.19 Personal Care Services

Page 3 of 9 • PCS are not to be provided to meet childcare needs nor as a substitute for the parent in the absence of the parent for age-appropriate ADL deficits. • PCS are not allowable for the purpose of providing respite care for the primary care giver. • Supervision is related to safety in performance of an ADL or IADL only . General supervision not related to an ADL or IADL is not covered.
C. The services must be provided by a qualified individual who does not meet the definition of family as defined by the Arkansas Department of Human Services Medicaid Personal Care Provider Manual and meets the standards for personal care as set by the Arkansas Department of Human Services Medicaid Personal Services Provider manual.

D. The services cannot be met by other resources. • Authorization requests must contain information on available resources (ability and availability for completion of needed assistance). • For members under the age of 18, documentation should clearly indicate the circumstances that impede care by the responsible adult (parent, legal guardian, custodial guardian) that a prudent layperson would assume to be given to a child of the same age without a health condition. E. All services must be prior authorized for periods that will be required to meet to provide for duration of condition, not to exceed 12 months and be services outlined on the member’s PSCP.

F. Assistance with IADL’s is only approved if the member has at least one qualifying ADL for which personal care services are required.

G. Services requested must meet the qualifications for the task or routine as outlined. Requests are approved for only the tasks or routines that meet medical necessity.

H. Personal care services are services furnished to an individual who is not an inpatient or a resident of: • A hospital, • A nursing facility, • A Level II assisted living facility, • An intermediate care facility for individuals with intellectual disabilities (ICF/IID) or • An institution for mental diseases (IMD). ADLs and IADLs Meal Preparation A. Meal preparation is a covered personal care service if the aide's logged service time meets certain conditions: • The aide must make reasonable efforts to prepare servings of a size or an amount commensurate with the member's nutritional needs and normal appetite. • The Plan does not cover an aide's time at meal preparation tasks or assisting at meal preparation tasks for members of the member’s household, or whose personal care service plans do not include meal preparation tasks or assistance with meal preparation tasks. B. This routine includes the tasks involved in: • Preparing and serving a meal and

ARTC.UM.19 Personal Care Services

Page 4 of 9 • Cleaning articles and utensils used in the preparation of the meal. C. To be eligible to receive personal care assistance with meal preparation, a member's physical dependency needs must prevent or substantially impair his or her ability to perform meal-preparation tasks or to clean up the utensils and preparation area. Dependency or need must meet medical necessity criteria and not be attributable to normal age-appropriate ADL deficits.

D. The aide's service in the member's meal preparation routine is hands-on assistance with meal preparation tasks the member cannot physically perform, according to the detailed physical dependency needs described in the assessment.

E. The service plan must correlate each required task with its corresponding physical dependency need.
Consuming Meals
A. The service related to this routine includes the tasks involved in giving the member hands-on assistance to consume a meal and fluids.

B. To receive personal care assistance with this routine, a member's physical dependency needs must prevent or substantially impair his or her ability to execute tasks such as cutting food in bite-size pieces or negotiating food from plate to mouth. • Dependency or need must meet medical necessity criteria and not be attributable to normal age-appropriate ADL deficits. C. The related service is hands-on assistance with the member's physical dependency needs to accomplish eating. The aide may only assist with or perform functional tasks the member cannot physically perform, in accordance with the member's physical dependency needs described in the assessment.

D. The service plan must correlate each required task with its corresponding physical dependency need.

E. Observing a member eat is not a covered service unless documented in the service plan that failure to observe the member's eating places the member at risk of injury or harm.

Personal Hygiene A. The tasks constituting this service are those involved in hands-on assistance with the member's personal hygiene.
“Personal hygiene” means grooming, shampooing, shaving, skin care, oral care, brushing or combing of hair, and menstrual hygiene. • An aide's time spent reminding a member to perform personal hygiene tasks is not a covered service unless the member's service plan includes hands-on assistance with personal hygiene. • An aide's time spent observing a member perform personal hygiene tasks is not a covered service unless documentation is present in the service plan that failure to observe the activity places the member at risk of injury or harm. B. Beneficiaries eligible for this service must have a physical dependency preventing or substantially impairing their ability to perform hair and skin care and grooming, oral hygiene, shaving and nail care. • Dependency or need must meet medical necessity criteria and not be attributable to normal age-appropriate ADL deficits. C. The aide's service in regard to this routine is hands-on assistance with personal hygiene tasks the member cannot physically perform, according to the detailed physical dependency needs described in the assessment.

D. The service plan must correlate each required task with its corresponding physical dependency need.

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Bowel and Bladder Requirements A. The tasks constituting this service are those involved in hands-on assistance with the member's elimination routines.

B. Beneficiaries eligible for this service must have a physical dependency need preventing or substantially impairing their ability to: • Safely enter and exit the bathroom, or • Properly complete elimination routines without assistance. C. The aide's service in this routine is hands-on assistance with bladder-and-bowel-voiding tasks the member cannot physically perform alone, according to the detailed physical dependency needs described in the assessment. • Dependency or need must meet medical necessity criteria and not be attributable to normal age-appropriate ADL deficits. D. The service plan must correlate each required task with its corresponding physical dependency need. Medication A. Personal care aide services regarding medication routines are covered only to the extent that they are permitted by the Arkansas Nurse Practice Act and implementing rules and regulations.

B. Tasks constituting this service are those involved in hands-on assistance with the member's medications.

C. Beneficiaries eligible for this service must have a physical dependency need preventing or substantially impairing their ability to dispense and ingest orally administered prescription medications safely and correctly.

D. The aide's service in regard to the member's medication routines is hands-on assistance with tasks the member cannot physically perform, according to the detailed physical dependency needs described in the assessment,
• Dependency or need must meet medical necessity criteria and not be attributable to normal age-appropriate ADL deficits. E. Observing or supervising a member take medications is not a covered service unless documented in the service plan that failure to observe the member's taking of medication places the member at risk of injury or harm

F. The service plan must correlate each required task with its corresponding physical dependency need. Mobility and Ambulation A. The tasks constituting this service are those involved in hands-on assistance with the member's mobility and ambulation. “Mobility and ambulation” mean functional mobility (moving from seated to standing, getting in and out of bed) and mastering the use of adaptive equipment.

B. Beneficiaries eligible for this service must have a physical dependency need preventing or substantially impairing their ability to:
• Turn themselves in bed, • Move from bed to chair (including wheelchair or motorized chair), • Walk (alone or with a device) or • Operate a push wheelchair or a motorized chair.

ARTC.UM.19 Personal Care Services

Page 6 of 9 C. The aide's service in this routine is hands-on assistance with ambulation and mobility tasks the member cannot physically perform alone, according to the detailed physical dependency needs described in the assessment. • Dependency or need must meet medical necessity criteria and not be attributable to age-appropriate ADL deficits. D. The service plan must correlate each required task with its corresponding physical dependency need.
Incidental Housekeeping A. "Incidental housekeeping" means cleaning of the floor, furniture, and areas that are directly used by the member.

B. The aide's service in regard to incidental housekeeping is hands-on assistance with covered tasks the member cannot physically perform, according to the detailed physical dependency needs described in the assessment. • Dependency or need must meet medical necessity criteria and not be attributable to normal age-appropriate ADL deficits. C. The assessment must describe the impairments that prevent or impede the member's ability to move freely and safely about their living area and clean the floor and furniture in the area they occupy.

D. The service plan must correlate each required task with its corresponding physical dependency need.
Laundry A. "Laundry" means laundering only items incidental to the care of the member. Laundry is not a covered service if it includes laundry services for the convenience of individuals residing in the same service delivery location.

B. The aide's service in regard to laundry is hands-on assistance with covered laundry tasks the member cannot physically perform, according to the member's physical dependency needs detailed in the assessment. • Dependency or need must meet medical necessity criteria and not be attributable to normal age-appropriate ADL deficits. C. The assessment must also describe the impairment(s) that prevent or impede the member's ability to move freely and safely about his or her living area and to perform some or all of the laundry tasks involved in maintaining his or her own clothing and bed and bath linens.

D. The service plan must correlate each required task with its corresponding physical dependency need. Shopping
"Shopping" means services to address the member's physical dependency need by assisting the member with shopping or by shopping for the member. A. Assisting a member with shopping is a covered service only when the member is purchasing items that are necessary for the member's health and maintenance in the home (such as food, clothing, and other essential items) and that are used primarily by the member. • The aide's service in regard to shopping is hands-on assistance with covered shopping tasks the member cannot physically perform, according to the member's physical dependency needs detailed in the assessment. • The assessment must describe the impairment(s) that prevent or impede the member's ability to move freely and safely in stores and perform some or all of the shopping tasks necessary to maintain his or her health and comfort. • The service plan must correlate each required task with the member's corresponding physical dependency need.

ARTC.UM.19 Personal Care Services

Page 7 of 9 B. If the service plan requires the aide to shop for the member: • The member, or the member's representative, has freedom of choice to describe the items to be purchased (within the constraints stated herein) for the member's maintenance in the home. • The member has freedom of choice to designate the individual stores at which to purchase the items. C. If there are other members of the member's household, the service plan must not include shopping, or assistance with shopping, unless the assessment fully documents all reasons each household member can neither: • Assist with or do the member's shopping, nor • Arrange for someone else to assist with or to do the member's shopping.

D. The Plan provides no additional coverage for an aide's mileage incurred performing shopping tasks. Excluded Services The following services are not appropriate for personal care and are not reimbursable as PCS. Other exclusions may be cited above under specific ADL/IADL sections: • Medical, skilled nursing, pharmacy, skilled therapy services, medical social services, or medical technician services of any kind, including, but not limited to, aseptic or sterile procedures, application of dressings, medications administration, injections, observation and assessment of health conditions, insertion, removal, or irrigation of catheters, tube or other enteral feedings, tracheostomy care, oxygen administration, ventilator care, drawing blood, application of a device that monitors blood sugars or administers medications, and care and maintenance of any medical equipment; • Services within the scopes of practice of licensed cosmetologists, manicurists, electrologists, or aestheticians, except for necessary assistance with personal hygiene and basic grooming. • Services provided for a person other than the member, including but limited to a provider, family member, household resident, or neighbor. • Companion, socialization, entertainment, or recreational services or activities of any kind (including, but not limited to, game playing, television watching, arts and crafts, hobbies, and other activities pursued for pleasure, relaxation, or fellowship).
• Habilitation services, including assistance in acquiring, retaining, or improving self-help, socialization, and/or adaptive skills; and • Mental health counseling or services. • Babysitting, respite services, or after school services. PROCEDURE: Authorization Protocols (Initial and Reauthorization) PCS authorizations are approved for a maximum of 180 days at a time. A unit of personal care service is 15 minutes of direct service to the member. Time spent for travel, lunch, breaks, or administrative activities such as completing reports or paperwork are not to be included.
A. The following documentation is required prior to authorization or reauthorization of personal care services: • Physician’s referral for PCS. Physician referral shall be valid as a signed prescription from the PCP or a signed requested service plan in the request form.
o Initiation of services requires an order/referral from the member’s treating provider. A valid prescription or signed service plan for the first request after the effective date of this policy meets this requirement.

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o Services are authorized forthe period of time to meet the needs for the duration of the condition, not to exceed 12 months. .

o Physician signatures on requests after initial approval are only required for an increase in units.

o Referral can be by the primary care physician or consulting physician, which can be a physician, physician’s assistant, or a nurse practitioner. Referral cannot be from a registered nurse.

• Individual Service Plan prepared by the PCS agency as designated on ARTC Personal Care Authorization Request form. NO SERVICES may be initiated or changed prior to approval by the Plan. o Plan of Care must be completed in its entirety and include the tasks to be provided. Frequency and duration of these tasks, and total number of hours per day and week are needed to perform the tasks.

o Request form must be signed by the ordering provider as described above.

o An Individual Service Plan signed by the member’s ordering provider may be used as the order/referral.

• Medical records from the ordering provider supporting the medical need for the amount and duration of requested personal care services are required for approval. o The member’s Arkansas Independent Assessment (ARIA) cannot be used alone to support medical necessity.

• Providers are encouraged to utilize the ARTC Personal Care Authorization Request Form. All requests for services shall include specific information applicable to the individual member, including: o Member and provider information.

o A detailed narrative of the member’s needs. Assessment narrative should describe in detail the type and level of assistance required in the ARTC Personal Care Services Request form. For example, a member can manage his own laundry, but he cannot extract wet items from the washer while leaning over the machine, or member is unable to pick up slender items, such as spoons and toothbrushes, and sometimes loses his grip on those objects. When the request is reviewed, a personal care provider's records must read so that the service plan logically follows the assessment, which is possible only if the provider assesses the member at the individual task performance level. A generic assessment that member needs assistance with ADL’s may result in a request for more information and delay determination.

o Certification that the member’s service plan does not duplicate any other in-home services of which the provider is aware.

o The total number of hours per month the service provider seeks to offer the member.

o Detailed information on all personal assistance available to the member through other sources, including informal caregivers (e.g., family, friends), community organizations (e.g., Meals on Wheels), Medicare (e.g., Medicare home health aide services), or the member’s Medicare Advantage health plan.

o The frequency of in-person supervisory visits to be made by an agency supervisor based on the specific needs of the member and the recommendations of an agency-designated registered nurse.

B. Requests to increase personal care units must include the same information as detailed in section A.
Authorizations are not transferable between agencies. Recipients have the right to change providers at any time; however, the current agency must notify the Plan of recipient’s discharge and new agency must obtain their own authorization through the usual authorization process. Service disruption is avoided with transfer between PASSE’s, and authorization for previously authorized services.

ARTC.UM.19 Personal Care Services

Page 9 of 9 Hours approved cannot be ‘saved’ for another week or ‘banked’ for future use. Personal care services for members under the age of 21 are not subject to service limits. Members over the age of 21 are limited to 64 hours a month in personal care services. The units of service approved shall be based on the physical requirements of the member and medical necessity for the covered services in the program, using the THS Grid and the ARIA and/or other relevant assessments to determine the allowable units of service.
The rules governing PCS and determinations are outlined in the State Provider Manual. Care cannot be provided by family as defined by the state of Arkansas. The State defines “a member of the individual’s family” as: • A spouse, • A minor's parent, stepparent, foster parent, or anyone acting as a minor's parent, • A legal "guardian of the person" or anyone acting as a minor's "guardian of the person" or • An adult's "guardian of the person" or anyone acting as an adult's "guardian of the person The clinical decision process begins when a request for authorization of services is received at the Plan. Upon verification of receipt of required documentation, the standard authorization process is followed.
REFERENCES:
Arkansas Department of Human Services, Medicaid Billing and Provider Manuals, Personal Care Services, Section II 42 CFR 440.167 Personal Care Services

ATTACHMENTS: Arkansas Total Care Task and Hour Standards (THS) Form

ROLES & RESPONSIBILITIES: UM Staff

REGULATORY REPORTING REQUIREMENTS: N/A

REVISION LOG REVISION TYPE REVISION SUMMARY DATE APPROVED & PUBLISHED New Policy Document N/A 10/2023 Ad Hoc Review
Reformatted, Updated policy references; changed age from 19 to 21 for personal care services; updated the definition of “a member of the individual’s family”; removed staff names from the policy
01/29/2024 Ad hoc Review Clarified details on assessment narrative. Clarified supervision is for supervision related to performance of ADL’s or IADL’s. Clarified resource availability documentation. Clarified IADL’s are covered only if an ADL meets medical necessity. Clarified needs an initial RX for PCS, added THS grid use in policy. References updated to include 42 CFR 440.167 Personal Care Services. Clarified PCS can not be performed by aid that meets the state definition of family.
4/29/2024 Annual Review Clarified authorization process must include medical records and not rely on ARIA alone. Clarified requests to increase units must include same information. Removed references to internal policies. Minor grammatical edits. 01/03/2025 Ad hoc Review Changed authorization duration from 6 months to “period of time to meet the needs for the duration of the condition not to exceed 12 months as per AR legislative change.” 7/14/2025

POLICY AND PROCEDURE APPROVAL

The electronic approval retained in RSA Archer, the Company’s P&P management software,
is considered equivalent to a signature.