Idaho Admin. Code r. 16.03.10.302

Current through September 2, 2024

Section 16.03.10.302 - PERSONAL CARE SERVICES: ELIGIBILITY

01.Financial Eligibility. The participant must be financially eligible for medical assistance under IDAPA 16.03.01, "Eligibility for Health Care Assistance for Families and Children," or 16.03.05, "Eligibility for Aid to the Aged, Blind, and Disabled (AABD)."

02.Other Eligibility Requirements. Bureau of Long Term Care (BLTC) will prior authorize payment for the amount and duration of all services when all of the following conditions are met:

a. The BLTC finds that the participant is capable of being maintained safely and effectively in their own home or personal residence using PCS.

b. The participant is an adult for whom a Uniform Assessment Instrument (UAI) has been completed, or a child for whom a children's PCS assessment has been completed;

c. The BLTC reviews the documentation for medical necessity; and

d. The participant has a plan of care that meets the person-centered planning requirements described in Sections 316 and 317 of these rules.

03.State Plan Option. A participant who receives medical assistance is eligible for PCS under the State Medicaid Plan option if the Department finds they require PCS due to a medical condition that impairs their physical, mental function, or independence.

04.Annual Eligibility Redetermination. The participant's eligibility for PCS must be redetermined at least annually under Subsections 302.01. through 302.03 of these rules.

a. The annual financial eligibility redetermination must be conducted under IDAPA 16.03.01, "Eligibility for Health Care Assistance for Families and Children," or 16.03.05, "Eligibility for Aid to the Aged, Blind, and Disabled (AABD)." BLTC will make the medical eligibility redetermination. The redetermination can be completed more often than once each year at the request of the participant, the Self-Reliance Specialist, the Personal Assistance Agency, the personal assistant, the supervising RN, the QIDP, or the physician.

b. The medical redetermination assesses the following factors:

i. The participant's continued need for PCS;

ii. Discharge from PCS; and

iii. Referral of the participant from PCS to a nursing facility.

Idaho Admin. Code r. 16.03.10.302

Effective March 17, 2022