Understanding Medicaid Personal Care Services

By Ronald A. Fatoullah, Esq. and Stacey Meshnick, Esq.

{4:01 minutes to read} The New York State Medicaid program provides coverage for a category of home care services called Personal Care Services (PCS). Under the Medicaid rules and regulations, personal care services are defined as the assistance of a personal care aide/home attendant with nutritional, environmental support, and personal care functions. According to the regulations, such services must be essential to the maintenance of the patient's health and safety in his or her own home, ordered by the attending physician, and based on an assessment of the patient's needs and based upon the appropriateness and cost-effectiveness of services.^[1]

The two "levels" of PCS in New York State are Housekeeping, which is considered "Level 1" and Personal Care, which is "Level 2." Housekeeping services are limited to eight hours per week and entail housekeeping, cleaning, meal preparation, grocery shopping, and laundry.

Level 2 personal care consists of housekeeping tasks as well as assistance with personal needs such as bathing, dressing, toileting, walking, turning and positioning, feeding, and routine skin care. PCS must be medically necessary and is intended for individuals who can be safely maintained at home.

In order to receive PCS, the individual must be able to direct care or have someone with a daily contact who is able to direct care. In addition, if the patient has a condition that is unstable, i.e., expected to show sudden deterioration or improvement, and requires some type of skilled professional or nursing judgment, he or she will not be eligible for PCS care.

Personal Care Aides/Home Attendants may not perform tasks that are deemed "skilled." They differ slightly from "home health aides" who can provide skilled care in Certified Home Health Agencies (CHHA) because they are supervised by nurses.

However, aides in the Medicaid Consumer Directed Personal Assistance Program (CDPAP) are not bound by these restrictions and may perform tasks that would otherwise be considered "skilled."

In order to receive PCS, one must first apply for and become eligible for community Medicaid. Once found eligible, the individual can be evaluated by a Managed Long Term Care Agency (MLTC) to determine the number of hours the agency will provide.

New York State has two types of 24-hour care available when medically necessary. (1) Live-in 24-hour personal care services means "the provision of care by one personal care aide for a patient who, because of the patient's medical condition, needs assistance during a calendar day with toileting, walking, transferring, turning and positioning, or feeding and whose need for assistance is sufficiently infrequent that a live-in, 24-hour personal care aide would be likely to obtain, on a regular basis, five hours daily of uninterrupted sleep during the aide's eight-hour period of sleep." The patient's home must have sleeping accommodations for a personal care aide. If this is not the case, split-shift (two 12- hour aides) must be authorized.^[2]

(2) Split-shift or "continuous personal care services" means "the provision of uninterrupted care, by more than one personal care aide, for more than 16 hours in a calendar day for a patient who, because of the patient's medical condition, needs assistance during such calendar day with toileting, walking, transferring, turning or positioning, and needs assistance with such frequency that a live-in, 24-hour personal care aide would be unlikely to obtain, on a regular basis, five hours daily of uninterrupted sleep during the aide's eight-hour period of sleep." Before December 2015, split-shift continuous care was only for people with "unscheduled" needs, while live-in was for predictable needs. Now regulations require that agencies look at the frequency of the need.^[3]

Given the different rules and the difficulty of navigating the system, it is advisable to seek assistance from a qualified elder care attorney.