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D.C. Municipal Regulations (Last Updated: September 13, 2017) |
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Title 29. PUBLIC WELFARE |
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Chapter 29-50. MEDICAID REIMBURSEMENTS FOR PERSONAL CARE AIDE SERVICES |
Section 29-5003. PCA SERVICE AUTHORIZATION REQUEST AND SUBMISSION
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5003.1 Except as provided in Subsection 5003.8, in order to be reimbursed by Medicaid, PCA services shall not be initiated or provided on a continuing basis by a Provider without a PCA Service Authorization from DHCF or its designated agent that, for each beneficiary, identifies the amount, duration and scope of PCA services authorized and the number of hours authorized.
5003.2A Medicaid beneficiary who is seeking PCA services for the first time shall submit a request for a PCA Service Authorization to DHCF or its designated agent in writing, accompanied by a copy of the physician’s or Advanced Practice Registered Nurse’s (APRN) written order for PCA services that complies with the requirements set forth under this chapter.
5003.3DHCF or its designated agent shall be responsible for conducting a face-to-face assessment of each beneficiary using a standardized assessment tool to determine each beneficiary’s need for assistance with activities of daily living that the beneficiary is unable to perform. The assessment shall:
(a) Confirm and document the beneficiary’s functional limitations and personal goals with respect to long-term care services and supports;
(b) Be conducted in consultation with the beneficiary or the beneficiary’s representative;
(c) Document the beneficiary’s unmet need for services, taking into account the contribution of informal supports and other resources in meeting the beneficiary’s needs for assistance; and
(d) Document the amount, frequency, duration, and scope of PCA services needed.
5003.4Based upon the results of the face-to-face assessment conducted in accordance with Subsection 5003.3, DHCF or its authorized agent shall issue to the beneficiary a PCA Service Authorization that specifies the amount, frequency, duration, and scope of PCA services authorized to be provided to the beneficiary.
5003.5Payment shall not exceed the maximum authorized units specified in the PCA Service Authorization and must be consistent with the plan of care in accordance with Section 5015.
5003.6If authorized, PCA services may be provided up to eight (8) hours per day seven (7) days per week. Additional hours may be authorized if a person is deemed eligible under the Elderly or Persons with Physical Disabilities (EPD Waiver) or Individuals with Intellectual and Developmental and Disabilities Waiver (ID/DD Waiver).
5003.7A Registered Nurse (R.N.) employed by DHCF or its designated agent shall conduct the initial face-to-face assessment following the receipt of a request for service authorization and shall conduct a face-to-face reassessment at least every twelve (12) months, or upon significant change in the beneficiary’s condition. A request for service authorization may be made by a Medicaid beneficiary, family member, the beneficiary’s representative or a health care professional.
5003.8DHCF may authorize the face-to-face reassessment for a period not to exceed eighteen (18) months, if necessary, to align the assessment date with the Medicaid renewal date.
5003.9If, based upon the assessment conducted pursuant to this section, a beneficiary is found to be ineligible for PCA services, or the amount, duration or scope of PCA services is reduced, DHCF or its agent shall issue a Beneficiary Denial, Termination or Reduction of Services Letter informing the beneficiary of the reasons for the intended action, the specific law and regulations supporting the action, his or her right to appeal the denial, termination, or reduction of services in accordance with federal and District law and regulations, and the circumstances under which PCA services will be continued if a hearing is requested (See 42 C.F.R. §§ 431.200 et seq., D.C. Official Code § 4-205.55).