10 Colo. Code Regs. § 2505-10-8.500-A
Capitalized terms within this Benefit Coverage Standard that do not refer to the title of a benefit, program, or organization, have the meaning specified in the Definitions section.
A. BRIEF COVERAGE STATEMENT
This Benefit Coverage Standard describes Pediatric Personal Care (PC) Services benefits for Colorado Medicaid clients under 21 years of age. PC Services are Medically Necessary services provided to assist the client with PC Tasks in order to meet the client's physical, maintenance, and supportive needs. This assistance may take the form of Hands-On Assistance, Supervision, or Cuing the client to complete the PC Task.
B. RELATED SERVICES ADDRESSED IN OTHER BENEFIT COVERAGE STANDARDS
1. Home Health
2. Private Duty Nursing
C. ELIGIBLE PROVIDERS
1. Ordering, Prescribing, Referring (OPR) Providers
In accordance with the Centers for Medicare and Medicaid Services (CMS) Conditions of Participation, all 485 Plans of Care-or other form with identical content-must be signed by one of the following:
a. Physician
i) Doctor of Medicine (MD), or
ii) Doctor of Osteopathic Medicine (DO)
b. Advanced Practice Nurse
2. Personal Care Workers
As a condition of reimbursement, Personal Care Workers (PCW) must meet all of the following requirements:
a. Not excluded from participation in any federally funded health care programs,
b. Employed by or providing services under a contract with a licensed Class A or Class B Home Care Agency (HCA) that is enrolled as a Colorado Medicaid provider;
c. Completion of the Department's PC Services provider training; and has verified experience in the provision of PC Services for clients, as regulated by the Colorado Department of Public Health and Environment (CDPHE) at 6 CCR 1011-1, Chapter 26, Section 8.5.
D. AGENCY REQUIREMENTS
As a condition of reimbursement, Home Care Agencies (HCAs) must meet all of the following requirements:
1. Licensed by the State of Colorado as either a Class A or Class B Agency in good standing;
2. Maintain up-to-date personnel files for each PCW, containing proof of current training, education, and PCW competency, as appropriate to the client's needs and as required by CDPHE; and
3. Comply with the requirements outlined in the Personal Care Worker Supervision section of this Benefit Coverage Standard.
E. ELIGIBLE PLACES OF SERVICE
Pediatric PC Services are covered under this benefit when provided in a client's Residence or outside a client's Residence, subject to the limitations listed in the Non-Covered Services section of this Benefit Coverage Standard.
F. ELIGIBLE CLIENTS
Pediatric PC Services are a benefit for Colorado Medicaid clients who:
1. Are 20 years of age or younger; and
2. Qualify for moderate to total assistance with at least one Personal Care Task
G. GENERAL REQUIREMENTS
For Medicaid clients ages 20 and younger, Pediatric PC Services are covered in accordance with the provisions of the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) program found at 10 CCR 2505-10 Section 8.280.
1. Requirements of Covered Services
Pediatric PC Services are covered only when:
a. Medically Necessary, as defined in Colorado Medicaid's EPSDT rule at 10 C.C.R. 2505-10, Section 8.280;
b. Provided to assist the client with PC Tasks, in order to meet the client's physical, maintenance, and supportive needs;
c. Provided on an intermittent basis;
d. Provided for the sole benefit of the client;
e. Prior authorized and delivered in a manner consistent with professional standards, Colorado licensure requirements, and all other applicable state and federal regulations;
f. Ordered by a licensed physician, as regulated by the Department of Regulatory Agencies (DORA), or an advanced practice nurse, as licensed by DORA; and
g. Provided under a current, written 485 Plan of Care, signed by the Ordering Provider.
2. Documentation Requirements
The HCA is required to maintain a record for each client. The record for each client must include all of the following:
a. A 485 Plan of Care completed by the Ordering Provider. This constitutes a written order for PC services. The 485 Plan of Care must be updated at least annually, or more frequently if required by the needs or condition of the individual client, and must include:
i) The frequency of each PC Task required by the client.
ii) A range of the frequency for each PC Task required by the client on an as-needed basis. An order for a PC Task "PRN" or "as needed" must be accompanied by a range of the frequency with which the client may require that PC Task to be provided.
iii) Documentation or explanation for each PC Task that is required more frequently than the defined Usual Frequency for that task.
b. Evidence of Care Coordination between the HCAs, when the client is receiving other services from another agency, including but not limited to Medicaid Home Health services, Medicaid HCBS waiver programs, and services from other payers.
c. Documentation of consultations with relevant medical staff when clients have complex needs or when there are potentially dangerous situations identified.
d. A written explanation of how the requested PC Services do not overlap with any other services the client is receiving from another agency.
e. All other client file information, as required by Colorado Medicaid, and by CDPHE, as outlined in rule at 6 C.C.R. 1011-1, Chapter 26, Section 6.20.
H. COVERED SERVICES
Under the description of each task below, Usual Frequency of Task refers to the number of times a typical client is likely to need a task performed. A PC Task will be performed at the usual frequency, unless otherwise specified on the 485 Plan of Care. If a client needs a PC Task performed more frequently than the usual frequency for that PC Task, it must be specified on the 485 Plan of Care.
Covered Pediatric PC Services include assistance with the following PC Tasks:
1. Bathing/Showering
a. Included in Task:
Bathing/shower includes: Preparing bathing supplies and equipment, assessing the water temperature, applying soap (including shampoo), rinsing off, and drying the client; cleaning up after the bath, shower, bed bath, or sponge bath as needed; all transfers and ambulation related to the bathing/showering task; and all hair care, pericare, and skin care provided in conjunction with the bathing/showering task.
b. Usual Frequency of Task: Once daily.
c. Factors that Make Task Personal Care:
Client is able to maintain balance and bear weight reliably, or able to use safety equipment (such as a shower bench) to safely complete the bathing/showering; client's skin is unbroken; client is independent with assistive devices; or when a PCW is assisting a medically-skilled care provider, caregiver, or Unpaid Family Caregiver who is competent in providing this aspect of care.
d. Factors that Make Task Skilled:
There is the presence of open wound(s), stoma(s), broken skin and/or active chronic skin disorder(s); or client is unable to maintain balance or to bear weight reliably due to illness, injury, or disability, history of falls, or a temporary lack of mobility due to surgery or other exacerbation of illness, injury, or disability.
e. Special Considerations:
A second person may be staffed when required to safely bathe the client, when supported by documentation that illustrates that the client requires moderate to total assistance to safely complete this task.
2. Dressing a. Included in Task:
Dressing includes putting on and taking off clothing, including pantyhose or socks and shoes. Dressing includes getting clothing out and may include braces and splints if purchased over the counter and/or or not ordered by a Qualified Physician.
b. Usual Frequency of Task: Up to two times daily.
c. Factors that Make Task Personal Care:
Client only needs assistance with ordinary clothing and application of support stockings of the type that can be purchased without a physician's prescription; when assistance is needed with transfers and positioning related to dressing and undressing, which may include the cleaning and maintenance of braces, prosthesis, or other DME; or when a PCW is assisting a skilled care provider, caregiver, or Unpaid Family Caregiver who is competent in providing the application of an ace bandage and anti-embolic or pressure stockings or placement of braces or splints that can be obtained only with a prescription of a Qualified Physician, or when the client is unable to assist or direct care.
d. Factors that Make Task Skilled:
Client requires assistance with the application of anti-embolic or pressure stockings, placement of braces or splints that can be obtained only with a prescription of a Qualified Physician, or when the client is unable to assist or direct care. Services may also be skilled when the client experiences a temporary lack of mobility due to surgery or other exacerbation of illness, injury, or disability.
e. Special Considerations:
A PCW may be staffed with a skilled care provider or Unpaid Family Caregiver when required to safely dress the client, and when supported by documentation that illustrates that the client requires moderate to total assistance to safely complete this task.
3. Feeding
a. Included in Task:
Feeding includes ensuring food is the proper temperature, cutting food into bite-size pieces, or ensuring the food is at the proper consistency for the client, up to and including placing food in client's mouth.
b. Usual Frequency of Task: Up to three times daily.
c. Factors that Make Task Personal Care:
The client can independently chew and swallow without difficulty and be positioned upright; the client is able to eat or be fed with adaptive utensils.
d. Factors that Make Task Skilled:
The client requires syringe feeding and tube feeding, which may be performed by a CNA who has been deemed competent to administer feedings via tube or syringe;
Oral feeding when: The client is unable to communicate verbally, non-verbally, or through other means; the client is unable to be positioned upright; the client is on a modified texture diet; the client has a physiological or neurogenic chewing and/or swallowing problem; or when a structural issue (such as cleft palate), or other documented swallowing issue exists.
The client has a history of aspirating food or is on mechanical ventilations that may create a skilled need for feeding assistance, or; when oral suctioning is required.
e. Special Considerations:
Documentation must illustrate that the client needs moderate to total assistance to safely complete this task. If a client requires snacks in addition to three meals per day, this need must be specified in the 485 Plan of Care.
4. Medication Reminders
a. Included in Task:
Medication Reminders include verbally communicating to a client that it is time for medication, and/or opening and handing a pre-filled medication reminder container to a client.
b. Factors that Make Task Personal Care:
PCWs may assist clients with medication reminders by: inquiring whether medications were taken; verbally prompting the client to take medications; handing the appropriately marked medication reminder container to the client; and opening the appropriately marked medication reminder container for the client if the client is physically unable to open the container.
All medication (prescription medications and all over-the-counter medications) must be pre-selected by the client, the client's Unpaid Family Caregiver, a nurse, CNA, or a pharmacist, and stored in pre-filled medication reminder boxes which are marked with day and time of dosage.
c. Factors that Make Task Skilled:
Medication reminders are PCW tasks unless the client requires services within the scope of a certified CNA.
5. Ambulation/Locomotion
a. Included in Task:
Walking or moving from place to place with or without an assistive device (including wheelchair).
b. Factors that Make Task Personal Care:
A PCW may assist clients with ambulation only if the client has the ability to balance and bear weight reliably, when the client is independent with an assistive device, or when the PCW is assisting a skilled care provider or Unpaid Family Caregiver who is competent in providing the skilled aspect of care.
c. Factors that Make Task Skilled:
Ambulation is considered a skilled task when the client: is unable to assist in the task, direct care, or when hands-on assistance is required for safe ambulation.
The task is also considered skilled when a client is unable to maintain balance, unable to bear weight reliably, or has not been deemed independent with assistive devices ordered by a Qualified Physician.
d. Special Considerations:
Ambulation may not be the standalone reason for a visit. Transferring and positioning into and out of assistive devices is not ambulation, and is addressed in the transferring and positioning section of this standard. Documentation must illustrate the need for moderate to total assistance to safely complete this task.
6. Meal Preparation
a. Included in Task:
Meal preparation includes preparing, cooking, and serving food to a client. Includes formula preparation and ensuring food is a proper consistency based on the client's ability to swallow safely.
b. Usual Frequency of Task: Up to three times daily.
c. Factors that Make Task Personal Care:
All meal preparation is a PC task, except as defined in the Factors that Make Task Skilled portion of this section.
d. Factors that Make Task Skilled:
Meal preparation is considered a skilled task when the client's diet requires nurse oversight to administer correctly. Meals must have a modified consistency.
e. Special Considerations:
Documentation must illustrate that the client needs moderate to total assistance to safely complete this task.
7. Hygiene- Hair Care/Grooming a. Included in Task:
Hair care includes shampooing, conditioning, drying, styling, and combing; it does not include perming, hair coloring, or other styling.
b. Usual Frequency of Task: Up to twice daily.
c. Factors that Make Task Personal Care:
PCWs may assist clients with the maintenance and appearance of their hair. Hair care within these limitations includes: shampooing with non-medicated shampoo or medicated shampoo that does not require a physician's prescription; and drying, combing, and styling of hair.
d. Factors that Make Task Skilled:
Hair care is considered a skilled task when the client requires shampoo or conditioner that is prescribed by a qualified physician and dispensed by a pharmacy; or when the client has one or more open wounds or stomas on the head.
e. Special Considerations:
Documentation must illustrate that the client needs moderate to total assistance to safely complete this task. Active and chronic skin issues such as dandruff and cradle cap do not make this task skilled.
8. Hygiene- Mouth Care
a. Included in Task:
Mouth care includes brushing teeth, flossing, use of mouthwash, denture care, or swabbing with a toothette.
b. Usual Frequency of Task: Up to three times daily.
c. Factors that Make Task Personal Care:
A PCW may assist and perform mouth care, including denture care and basic oral hygiene.
d. Factors that Make Task Skilled:
Mouth care is considered a skilled task when the client: is unconscious; has difficulty swallowing; is at risk for choking and aspiration; has decreased oral sensitivity or hypersensitivity; has an injury or medical disease of the mouth; is on medications that increase the risk of dental problems, bleeding, injury, or disease of the mouth; or requires oral suctioning.
e. Special Considerations:
Documentation must illustrate that the client needs moderate to total assistance to safely complete this task. The presence of gingivitis, receding gums, cavities, or other general dental problems does not make mouth care skilled.
9. Hygiene- Nail Care
a. Included in Task:
Nail care includes soaking, filing, and cuticle care.
b. Usual Frequency of Task: Up to one time weekly.
c. Factors that Make Task Personal Care:
A PCW may assist with nail care, which includes soaking of nails, pushing back cuticles with or without utensils, and filing of nails. A PCW may not assist with nail trimming.
d. Factors that Make Task Skilled:
Nail care is considered a skilled task when the client: has a medical condition that involves peripheral circulatory problems or loss of sensation; is at risk for bleeding or is at a high risk for injury secondary to the nail care; or requires nail trimming.
Skilled nail care may only be completed by a CNA who has been deemed competent in nail care for this population.
e. Special Considerations:
Documentation must illustrate that the client needs moderate to total assistance to safely complete this task.
10. Hygiene- Shaving
a. Included in Task:
Shaving includes assistance with shaving of face, legs, and underarms with a safety or electric razor.
b. Usual Frequency of Task: Up to one time daily. Task may be completed with bathing or showering.
c. Factors that Make Task Personal Care:
A PCW may assist a client with shaving with an electric or a safety razor.
d. Factors that Make Task Skilled:
Shaving is considered a skilled task when the client: has a medical condition that involves peripheral circulatory problems or loss of sensation; has an illness or takes medications that are associated with a high risk for bleeding; has broken skin at or near shaving site; has a chronic active skin condition; or is unable to shave him or herself.
e. Special Considerations:
Documentation must illustrate that the client needs moderate to total assistance to safely complete this task.
11. Hygiene- Skin Care
a. Included in Task:
Skin care includes applying lotion or other skin care products, only when not completed in conjunction with bathing or toileting (bladder or bowel). May be provided in conjunction with positioning.
b. Factors that Make Task Personal Care:
A PCW may provide general skin care assistance only when a client's skin is unbroken and when no chronic skin problems are active.
The skin care provided by a PCW must be preventive, rather than therapeutic, in nature. It includes the application of skin care lotions and solutions not requiring a physician's prescription.
c. Factors that Make Task Skilled:
Skin care is considered a skilled task when the client: requires skin care lotions or solutions requiring a physician's prescription; has broken skin, wound(s), or an active chronic skin problem; or is unable to apply product independently due to illness, injury, or disability.
d. Special Considerations:
Skin care completed in conjunction with bathing and toileting, as ordered on the 485 Plan of Care, is not included in this task. Documentation must illustrate that the client needs moderate to total assistance to safely complete this task.
12. Toileting- Bowel Care
a. Included in Task:
Bowel Care includes changing and cleaning an incontinent client, or providing hands-on assistance with toileting. This includes returning the client to pre-bowel movement status, transfers, skin care, ambulation, and positioning related to elimination.
b. Factors that Make Task Personal Care:
A PCW may assist a client to and from the bathroom; provide assistance with bedpans and commodes; provide pericare; or change clothing and pads of any kind used for the care of incontinence.
A PCW may assist a skilled care provider or Unpaid Family Caregiver who is competent in providing this aspect of care.
c. Factors that Make Task Skilled:
Bowel Care is considered a skilled task when: the client is unable to assist or direct care; has broken skin or recently healed skin breakdown (less than 60 days); requires skilled skin care associated with bowel care; or has been assessed as having a high and ongoing risk for skin breakdown.
d. Special Considerations:
A PCW may be aided by a skilled care provider or Unpaid Family Caregiver when required to safely complete Bowel Care with the client. Documentation must illustrate that the client needs moderate to total assistance to safely complete this task.
13. Toileting- Bowel Program
a. Included in Task:
Bowel Program includes emptying the ostomy bag, as ordered by the client's Ordering Provider. This includes skin care at the site of the ostomy and returning the client to pre-bowel program status.
b. Factors that Make Task Personal Care:
A PCW may empty ostomy bags and provide client-directed assistance with other ostomy care only when there is no need for skilled bowel program care, for skilled skin care, or for observation or reporting to a nurse.
A PCW may not perform digital stimulation, insert suppositories, or give an enema.
c. Factors that Make Task Skilled:
Bowel Program is considered a skilled task when: the client requires the use of digital stimulation, suppositories, or enemas; or when the client requires skilled skin care at the ostomy site.
d. Special Considerations:
Documentation must illustrate that the client needs moderate to total assistance to safely complete this task.
14. Toileting- Catheter Care
a. Included in Task:
Catheter Care includes perineal care and emptying catheter bags. This includes transfers, skin care, ambulation, and positioning related to catheter care.
b. Usual Frequency of Task: Up to two times a day.
c. Factors that Make Task Personal Care:
A PCW may empty urinary collection devices such as catheter bags when there is no need for observation or reporting to a nurse; and provide pericare for clients with indwelling catheters.
d. Factors that Make Task Skilled:
Catheter Care is considered a skilled task when: emptying indwelling or external urinary collection devices and there is a need to record and report the client's urinary output to the client's nurse; task involves insertion, removal, and care of all catheters; changing from a leg to a bed bag and cleaning of tubing and base; or if the indwelling catheter tubing needs to be opened for any reason and the client is unable to do so independently.
e. Special Considerations:
Catheter Care may not be the sole purpose of the visit. Documentation must illustrate that the client needs moderate to total assistance to safely complete this task.
15. Toileting- Bladder Care
a. Included in Task:
Bladder Care includes assistance with toilet, bedpan, urinal, or diaper use, as well as emptying and rinsing the commode or bedpan after each use. This includes transfers, skin care, ambulation, and positioning related to bladder care. This task concludes when the client is returned to his or her pre-urination state.
b. Factors that Make Task Personal Care:
A PCW may assist a client to and from the bathroom, provide assistance with bedpans, urinals, and commodes; provide pericare; and change clothing and pads of any kind used for the care of incontinence.
c. Factors that Make Task Skilled:
Bladder care is considered a skilled task when the client: is unable to assist or direct care; has broken skin or recently healed skin breakdown (less than 60 days); requires skilled skin care associated with bladder care; or has been assessed as having a high and ongoing risk for skin breakdown.
d. Special Considerations:
A PCW may assist a skilled care provider or Unpaid Family Caregiver who is competent in providing this aspect of care. Documentation must illustrate that the client needs moderate to total assistance to safely complete this task.
16. Mobility- Positioning
a. Included in Task:
Positioning includes moving the client from a starting position to a new position while maintaining proper body alignment and support to a client's extremities, and avoiding skin breakdown.
b. Factors that Make Task Personal Care:
A PCW may assist a client with positioning when the client is able to identify to the provider, verbally, non-verbally, or through other means including but not limited to, a legally responsible adult or adaptive technologies, when his or her position needs to be changed, and only when skilled skin care is not required in conjunction with positioning. Positioning includes alignment in a bed, wheelchair, or other furniture; and the placement of padding required to maintain proper alignment. The PCW may receive direction from or assist a skilled care provider or Unpaid Family Caregiver who is competent in providing this aspect of care.
c. Factors that Make Task Skilled:
Positioning is considered a skilled task when the client is: unable to communicate verbally, non-verbally, or through other means; or unable to perform this task independently due to illness, injury, disability, or temporary lack of mobility due to surgery. Positioning includes adjusting the client's alignment or posture in a bed, wheelchair, other furniture, assistive devices, or Durable Medical Equipment that has been ordered by a Qualified Physician.
d. Special Considerations:
Positioning and padding may not be the sole purpose for the PC visit. Positioning is not considered a separate task when a transfer is performed in conjunction with bathing, bladder care, bowel care, or other PC Tasks that require positioning.
If PC positioning is required for the completion of a skilled care task, visits must be coordinated to effectively schedule these services. A PCW may be accompanied by a skilled care provider or Unpaid Family Caregiver when required to safely position the client. Documentation must illustrate that the client needs moderate to total assistance to safely complete this task.
17. Mobility- Transfer
a. Included in Task:
Transfers include moving the client from a starting location to a different location in a safe manner. It is not considered a separate task when a transfer is performed in conjunction with bathing, bladder care, bowel care, or other PC Task.
b. Factors that Make Task Personal Care:
A PCW may assist with transfers only when the client has sufficient balance and strength to reliably stand, pivot, and assist with the transfer to some extent. Adaptive equipment, including, but not limited to, wheelchairs, tub seats, and grab bars, and safety devices may be used in transfers if: the client and PCW are fully trained in the use of the equipment; the client, or client's Unpaid Family Caregiver, can direct the transfer step-by-step; or when the PCW is deemed competent by the employer HCA in the specific transfer technique for the client. A gait belt may be used in a transfer as a safety device if the PCW has been properly trained in its use. A lift is not an included safety device and may not be used in PC transfers.
c. Factors that Make Task Skilled:
Transfers are considered a skilled task when the client: is unable to communicate verbally, non-verbally, or through other means; is not able to perform this task independently due to illness, injury, disability, or temporary lack of mobility due to surgery; lacks the strength and stability to stand or bear weight reliably; is not deemed independent in the use of assistive devices or Durable Medical Equipment that has been ordered by a Qualified Physician; or when the client requires a mechanical lift, such as a Hoyer lift, for safe transfer. In order to transfer clients via a mechanical lift, the CNA must be deemed competent in the particular mechanical lift used by the client.
d. Special Considerations:
Transfers may be completed with or without mechanical assistance. Transferring shall not be the sole purpose for the visit. A transfer is not considered a separate task when performed in conjunction with bathing, bladder care, bowel care, or other PC Task. A PCW may be aided by a skilled care provider or Unpaid Family Caregiver when required to safely transfer the client. A PCW may assist the Unpaid Family Caregiver with transferring the client, provided the client is able to direct and assist with the transfer. Documentation must illustrate that the client needs moderate to total assistance to safely complete this task.
I. LIMITATIONS
1. Medicaid clients ages 21 and older are not eligible for Pediatric PC Services.
2. The use of physical Behavioral Interventions such as restraints is prohibited, per CDPHE's consumer rights regulations. 6 C.C.R. 1011-1, Chapter 26, Section 6.
3. All PCWs and HCAs must comply with all applicable Colorado and federal requirements, rules, and regulations.
4. All Pediatric PC Services will be reimbursed at the Medicaid Pediatric PC Services rate, regardless of whether the PCW providing PC Services holds credentials for CNA, RN, or other skilled profession.
5. If a client requires a Skilled Transfer to complete a PC Task, the associated PC Task will be considered skilled in nature. PC Tasks considered skilled in nature are not covered PC Services, and will not be reimbursed by Colorado Medicaid under the Pediatric PC Services benefit.
6. PC Tasks provided as required components of skilled care tasks are not covered PC Services, and will not be reimbursed by Colorado Medicaid under the Pediatric PC Services benefit.
7. Clients eligible for the Pediatric PC Services benefit who are also eligible for the Colorado Department of Human Services Home Care Allowance program, described in rule at 9 C.C.R. 2503-5, Section 3.570, may receive services through one program, but not both.
8. If a PC Task is provided to a client by a PCW and a Skilled Care worker, but only one staff person is required, the PCW will not be reimbursed by Colorado Medicaid under the Pediatric PC Services benefit.
9. If a PC Task is provided to a client by two PCWs from different HCAs, but only one PCW is required, Colorado Medicaid will reimburse solely the HCA with a history of providing that particular PC Task to the client.
10. Two staff may be reimbursed for the same PC service for a client only when two people are required to safely provide the service, two staff were approved by prior authorization for the service, and there is no other person available to assist in providing this service.
11. HCAs may decline to perform a specific task or service, regardless of whether the task is a covered Pediatric PC Service, if the supervisor or the PCW documents a concern regarding the safety of the client or the PCW.
J. PERSONAL CARE WORKER SUPERVISION
1. PCWs must periodically receive onsite supervision by a Registered Nurse, the clinical director, home care manager, or other home care employee who is in a designated supervisory capacity and is available to the PCW at all times. This onsite supervisory visit must occur at least every 90 days, or more often as necessary for problem resolution, skills validation of the PCW, client-specific or procedure-specific training of the PCW, observation of client's condition and care, and assessment of client's satisfaction with services. At least one of the assigned PCWs must be present at the onsite supervisory visit.
2. Each PCW must have a complete and up-to-date personnel file that demonstrates that the PCW has:
a. Signed and dated evidence that he/she has received training and orientation on the HCA's written policies and procedures;
b. Signed and dated evidence that he/she has received training and is competent to provide the client's specific PC Tasks;
c. A signed and dated job description that clearly delineates his/her responsibilities and job duties;
d. Proof that he/she is current and up to date on all training and education required by CDPHE at 6 C.C.R. 1011-1 Chapter 26, Section 8.6;
e. Signed and dated competency information regarding training and skills validation for client-specific personal care and homemaking tasks;
f. Signed and dated evidence that he/she has been instructed in basic first aid, and training in infection control techniques, including universal precautions;
g. Information on any complaints received regarding the PCW, and documentation on the outcome and follow-up of the complaint investigation.
K. PRIOR AUTHORIZATION REQUEST (PAR) REQUIREMENTS
1. Approval of the PAR does not guarantee payment by Medicaid. The presence of an approved or partially approved PAR does not release the HCA from the requirement to bill Medicare or other third party insurance prior to billing Medicaid.
2. All Pediatric PC Services require prior authorization by Colorado Medicaid or its Designated Review Entity using the approved utilization management tool.
3. Pediatric PC Services PARs may be submitted for up to a full year of anticipated services unless: the client is not expected to need a full year of services; the client's eligibility is not expected to span the entire year; or as otherwise specified by Colorado Medicaid or its Designated Review Entity.
4. A PAR will be pended by Colorado Medicaid or its Designated Review Entity if all of the required information is not provided in the PAR, or additional information is required by the Designated Review Entity to complete the review.
5. PARs must be submitted to Colorado Medicaid or its Designated Review Entity in accordance with 10 CCR 2505-10§ 8.058.
6. It is the HCA's responsibility to provide sufficient documentation to support the medical necessity for the requested services.
7. When a PAR includes a request for reimbursement for two staff members at the same time (excluding supervisory visits) to perform two-person transfers or another PC Task, documentation supporting the need for two people and the reason adaptive equipment cannot be used must be included.
8. All other information determined necessary by Colorado Medicaid or its Designated Review Entity to review a request and the appropriateness of the proposed treatment plan must be provided.
L. NON-COVERED SERVICES
The following services are not covered under the Pediatric PC Services benefit:
1. Services that are not prior authorized by the Colorado Medicaid Designated Review Entity;
2. In accordance with Section 1905(a) of the Social Security Act, any services provided by the client's parents, foster parents, legal guardians, spouses, and other persons legally responsible for the well-being of the client;
3. Services provided by an individual under 18 years of age;
4. Services provided by a person not employed by the HCA;
5. Services provided through an Individual Residential Services and Supports (IRSS) or Group Residential Services and Supports (GRSS) program; or in any Medicaid-reimbursed setting, including, but not limited to medical offices, hospitals, hospital nursing facilities, alternative care facilities, and Intermediate Care Facilities for Persons with Intellectual Disabilities (ICF/ID).
6. PC Services that are covered under the client's Individualized Education Program (IEP) or Individual Family Service Plan (IFSP);
7. Tasks that are defined as Skilled Care Services in the Home Health Services Rule at 10 CCR 2505-10§ 8.520;
8. Homemaker services, or tasks that are performed to maintain a household. These tasks are considered to be non-medical tasks and include grocery shopping, laundry, and housekeeping;
9. Exercise and range of motion services;
10. Protective Oversight services.
11. Services provided for the purpose of companionship, respite, financial management, child care, education, or home schooling; for the benefit of someone other than the Medicaid client; that are not justified by the documentation provided by the client's medical or functional condition (even when services have been prior authorized); or that are not appropriate for the client's needs;
12. Visits that occur for the sole purpose of supervising or training the PCW;
13. Any services that are reimbursable by another insurance agency or other state, federal, or private program;
14. PC Services provided during a Skilled Care Services visit;
15. Services provided by the client's Unpaid Family Caregiver; or
16. Assistance with services that are being provided as a reasonable accommodation as part of the Americans with Disabilities Act (ADA), the Rehabilitation Act of 1973, or Part B of the Individuals with Disabilities Education Act (IDEA).
M. DEFINITIONS
The following definitions are applicable only within the scope of this Benefit Coverage Standard.
485 Plan of Care. Refers to a CMS-485 Home Health Certification and Plan of Care, or a form that is identical in content. A 485 Plan of Care is a coordinated plan developed by the Home Care Agency as ordered by the Ordering Provider for provision of services to a client, and periodically reviewed and signed by the physician in accordance with Medicare requirements.
Behavioral Intervention. Techniques, therapies, and methods used to modify or minimize verbally or physically aggressive, combative, destructive, disruptive, repetitious, resistive, self-injurious, sexual, or otherwise inappropriate behaviors outlined on the 485 Plan of Care. Behavioral Interventions exclude frequent verbal redirection or additional time to transition or complete a task, which are part of the general service to the client's needs.
Care Coordination. The planned organization of client care tasks between two or more participants (including the client) involved in a client's care to facilitate the appropriate delivery of health care and other health care support services. Organizing care involves the marshalling of personnel and other resources needed to carry out all required client care tasks, and is managed by the exchange of information among participants responsible for different aspects of care with the understanding that this information is or will be incorporated into the current or future medical care of the client.
Centers for Medicare and Medicaid Services (CMS). The federal government agency that works with states to run the Medicaid program. CMS is also responsible for the Medicare program.
Certified Nurse Aide (CNA). An employee of a Home Health Agency with a CNA certification. A CNA must have a current, active Colorado CNA certification and be employed by a Class A Home Health Agency. The CNA must have completed all required continuing education and training and have verified experience in the provision of Skilled Care Services.
Class A Agency. A Home Care Agency that provides any Skilled Care Service. Class A Agencies may also provide Personal Care Services.
Class B Agency. A Home Care Agency that provides only Personal Care Services. Class B Agencies may not provide any Skilled Care Services.
Colorado Medicaid. Colorado Medicaid is a free or low-cost public health insurance program that provides health care coverage to low-income individuals, families, children, pregnant women, seniors, and people with disabilities. Colorado Medicaid is funded jointly by the federal and state government, and is administered by the Colorado Department of Health Care Policy and Financing.
Cuing. Providing a prompt or direction to assist a client in performing PC Tasks he/she is physically capable of performing but unable to independently initiate.
Designated Review Entity. An entity that has been contracted by the Department to review Prior Authorization Requests (PARs) for medical necessity and appropriateness.
Exacerbation. A sudden or progressive increase in severity of a client's condition or symptoms related to a chronic illness, injury, or disability.
Hands-On Assistance. Performing a personal care task for a client.
Home Care Agency (HCA). Refers collectively to Class A Agencies, which provide Home Health Services, and Class B agencies, which provide Personal Care Services. Home Care Agency is defined in full at 6 CCR 1011-1, Chap. 26 §3.11 . When used in this Benefit Coverage Standard without a Class A or Class B designation, the term encompasses both types of agency.
Home Health Agency (HHA). An agency that is licensed as a Class A Home Care Agency in Colorado that is Medicare certified to provide Skilled Care Services. Agencies must be actively enrolled as a Medicare and Medicaid Home Health provider in order to provide services to Medicaid clients. An agency that is licensed as a Class A Home Care Agency may also provide Personal Care Services based on the agency's policies and procedures.
Home Health Services. Services and care that, due to the inherent complexity of the service, can only be performed safely and correctly by a trained and licensed/certified nurse (RN or LPN), therapist (PT, OT, or SLP), or CNA.
Homemaker Services. General household activities provided in the Residence of an eligible client in order to maintain a healthy and safe home environment for the client, when the person ordinarily responsible for these activities is absent or unable to manage these tasks.
Intermittent Basis. Personal Care Services visits that have a distinct start time and stop time and are task-oriented with the goal of meeting a client's specific needs for that visit.
Medically Necessary. Medical Necessity for Pediatric Personal Care Services is defined at 10 C.C.R. 2505-10, § 8.280.1.
Ordering Provider. A client's primary care physician, personal physician, advanced practice nurse, or other specialist who is responsible for writing orders and overseeing the client's 485 Plan of Care. This may include an alternate physician who is authorized by the Ordering Provider to care for the client in the Ordering Provider's absence.
Personal Care Agency (PCA). A Class B Home Care Agency that is licensed by the Colorado Department of Public Health and Environment.
Personal Care (PC) Services. The provision of assistance, hands-on support with, or supervision of specific Personal Care Tasks to assist clients with activities of daily living.
Personal Care (PC) Tasks. Any of 17 daily living tasks described in the PC Benefit Coverage Standard.
Personal Care Worker (PCW). An employee of a licensed Home Care Agency who has completed the required training to provide Personal Care Services, or who has verified experience in the provision of Personal Care Services for clients, as regulated by the Colorado Department of Public Health and Environment at 6 C.C.R. 1011-1 Section 8.6 . A client's Unpaid Family Caregiver cannot be a PCW for that client.
Prior Authorization Request (PAR). A PAR is a request for determination that covered Medicaid services are medically necessary.
Protective Oversight. Monitoring a client to reduce or minimize the likelihood of injury or harm due to the nature of the client's injury, illness, or disability.
Qualified Physician. A primary care physician, personal physician, or other specialist who is currently licensed and in good standing.
Rendering Provider. The provider administering the service.
Residence. The physical structure in which the client lives. The Residence may be temporary or permanent. A Residence may be the client's own house, an apartment, a relative's home, or other temporary accommodation where the client resides. The Residence may not be a nursing facility or other institution, as defined by CMS and the State of Colorado.
Skilled Care Services. Services and care that, due to the inherent complexity of the service, can only be performed by a trained and licensed/certified nurse (RN or LPN), therapist (PT, OT or SLP), or CNA.
Skilled Nursing Services. Services provided by an actively licensed Registered Nurse, and services provided by a Licensed Practical Nurse under the direction of a Registered Nurse, in accordance with applicable state and federal laws, including but not limited to the Colorado Nurse Practice Act §§ 12-38-101 to-133, C.R.S., and 42 C.F.R 484.30.
Skilled Transfer. Supporting or enabling the movement of a client from place to place when the client does not have sufficient balance and strength to reliably stand and pivot and assist with the transfer to some extent. Adaptive and safety equipment may be used in transfers, provided that the skilled care worker is fully trained in the use of the equipment.
State Plan. An agreement between Colorado and the federal government describing how the Department administers its Medicaid program. The State Plan sets out groups of individuals to be covered, services to be provided, and the methodologies for providers to be reimbursed. It gives an assurance that the Department will abide by federal rules and may claim federal matching funds for its program activities.
Supervision. The act of ensuring that a client is performing a PC Task correctly and safely. Supervision may include actively intervening to ensure that a PC Task is completed without injury.
Unpaid Family Caregiver. A person who provides care to a client without reimbursement by the Department or other entity. Family members of a client will not be reimbursed by the Department for care provided to that client. Family members include, but are not limited to, parents, foster parents, legal guardians, spouses, and other persons legally responsible for the well-being of the client.
Usual Frequency of Task. The number of times a typical person is likely to need a task performed. A task will be performed at the Usual Frequency, unless otherwise specified on the 485 Plan of Care.
10 CCR 2505-10-8.500-A