Personal Care Services – Policy Changes – Effective October 2020
Release by Texas Medicaid and Healthcare Partnership (TMHP)
PCS are support services provided to clients who meet the definition of medical necessity and require assistance with the performance of ADLs, instrumental activities of daily living (IADLs), and health maintenance activities (HMAs) due to a physical, cognitive, or behavioral limitation related to a client’s disability or chronic health condition. PCS are provided by someone other than the responsible adult of the client who is a minor child or the legal spouse of the client.
A responsible adult is an individual, 18 years of age or older, who has agreed to accept the responsibility for providing food, shelter, clothing, education, nurturing, and supervision for the client. Responsible adults include, but are not limited to, biological parents, adoptive parents, step parents, foster parents, legal guardians, court-appointed managing conservators, and the primary adult who is acting in the role of parent.
PCS are those services that assist eligible clients in performing ADLs, IADLs, and HMAs. The scope of ADLs, IADLs, and HMAs includes a range of activities that healthy, nondisabled adults can perform for themselves. Typically, developing children gradually and sequentially acquire the ability to perform these ADLs, IADLs, and HMAs for themselves. If a typically developing child of the same chronological age could not safely and independently perform an ADL, IADL, or HMAs without adult supervision, then the client’s responsible adult ensures that the client’s needs for the ADLs, IADLs, and HMAs are met.
PCS include direct intervention (assisting the client in performing a task) or indirect intervention (cueing or redirecting the client to perform a task).
ADLs, IADLs, and HMAs include, but are not limited to, the following:
|Bathing||Escort or Assistance with Transportation Services|
|Dressing||Grocery or Household Shopping|
|Locomotion or Mobility||Light housework|
|Personal Hygiene||Meal preparation|
|Transferring||Telephone Use or Other Communication|
|* Escort or Assistance with Transportation Services includes the coordination of transportation to medical appointments and accompaniment to appointments to assist with needed ADLs. PCS does not include the payment for transportation or transportation vehicles since these services are available through MTP.|
Note: Health maintenance activities (HMAs) and nurse-delegated tasks that fall within the scope of the task listed above are allowable in PCS.
Note: Exercise and range of motion are not available through PCS, but are services that could be provided through PT, PDN, or home health SN.
PCS does NOT include the following:
- ADLs, IADLs, or HMAs that a typically developing child of the same chronological age could not safely and independently perform without adult supervision
- Services that provide direct intervention when the client has the physical, behavioral, and cognitive abilities to perform an ADL, IADL, or health-related function without adult supervision
- Services used for or intended to provide respite care, child care, or restraint of a client
- Stand-by supervision related to safety
- Potty training
- Grocery shopping for members of the client’s family or household
- Cleaning for members of the client’s family or household (exception: light housework is approved if the client shares a room with a person)
- Cleaning the entire house (exception: a need for clean environment is approved if related to the client’s diagnosis or condition [e.g., asthma, allergies, or autoimmune deficiencies])
Note: Cleaning an area or equipment that is used to complete a task may be included in the light housework IADL, as appropriate.
- Laundry services for members of the client’s family or household (exception: laundry is approved when related to the client’s diagnosis or condition that results in soiled bedding or clothing for the client beyond the norm [e.g., incontinence, feeding tube, trachea, an ostomy, diapers, or skin condition])
- Waiting time for the laundry machine to complete a cycle in the home setting (exception: the time an attendant is at a laundromat completing the laundry task for the client is covered for PCS)
- Meal preparation for members of the client’s family or household
- Time of a PCS attendant while acting as the responsible adult for the receipt of medical care or providing medical transportation
An escort is approved if it is related to the client’s diagnosis or condition, such as using the toilet at the appointment or assistance carrying equipment (e.g., feeding pump, oxygen tank).
An escort is approved if it is related to the client’s diagnosis or condition and the responsible adult is occupied during the transport. For example, a child’s condition might include behaviors that create an unsafe situation for the child during transport, such as removing a seatbelt, attempting to open the car door while the car is in motion, or elopement.
PCS does cover the entire time that an attendant is away from the home performing this task.
For more information or to visit the TMHP website, please use the link provided below.