Personal Care Eligibility Requirements 535-05-15

(Revised 10/01/2024 ML #3871)

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An individual wishing to apply for benefits under this chapter must have the opportunity to do so, without delay. The HCBS case manager/DDPM must schedule an appointment for an initial assessment no later than five working days after receiving a request for services and must complete an initial comprehensive assessment no later than ten working days after receiving a request for services. All contacts with an individual must be documented within the narrative in the web-based data collection system.

1. Application for services in service chapter shall be made to the department utilizing "Application for Services," SFN 1047.

   1. An application is a request made to the department or its designee by individual seeking services under this chapter, or by an individual properly seeking services on behalf of another individual. "An individual properly seeking services" means an individual of sufficient maturity and understanding to act responsibly on behalf of the individual for whom services are sought.

   2. The case management entity must accept a referral from an individual who is acting in the best interest of the client and cannot require that the client themselves to actually make the initial request for services. However, the actual applicant must agree to a home visit.

   3. The applicant or their legal representative must sign the application and participate in the eligibility process.

   4. The department or its designee shall provide information concerning eligibility requirements, available services and the rights and responsibilities of applicants and recipients to all who require it.

   5. The date of application is the date the department's designee receives the properly signed application.

   The applicant shall provide information sufficient to establish eligibility for benefits, including a social security number and proof of age, identity, residence, blindness, disability, functional limitation, financial eligibility, and other information required under this chapter.

2. An applicant is eligible for these programs if the Case Management process (comprehensive assessment of needs and care plan development) determines that the applicant meets functional and financial eligibility criteria for MSP PC and requires those tasks/activities allowable within the scope of the services. An initial functional assessment, using the form required by the department, must be completed as a part of the application for benefits under this chapter. A functional assessment must be completed at least annually, and reviewed every 6 months, in conjunction with the eligibility redetermination. The functional assessment must include an interview with the individual in the home where the individual resides unless approval is given to interview the individual in an alternative setting.

3. Authorization to Provide Services, otherwise known as the PreAuth, identifies the specific tasks/activities the provider is authorized to perform for the eligible client and sets forth the scope of the service the client has agreed and understands will be provided.

4. The client is eligible for MSP PC once all eligibility criteria have been met. Continued eligibility is monitored under HCBS Case Management/DD Program Management. At any time there is a question as to whether the client continues to meet functional or financial eligibility criterion, the HCBS case manager/DDPM is to substantiate eligibility.

To qualify for coverage of personal care services, an individual must currently be open to receive Medicaid benefits under traditional Medicaid or receive Medicaid Expansion and be deemed Medically Frail.

And

1. Eligibility criteria for Level A (up to 480 units per month), or Daily Rate care, or Basic Care includes:

1. Be impaired in at least one of the following ADLS of:

1. Bathing
2. Dressing
3. Eating
4. Toileting
5. Continence
6. Transferring
7. Inside Mobility

Or

2. Be impaired in at least THREE of the following IADLs:

1. Meal Preparation
2. Housework
3. Laundry
4. Taking medications

2. Eligibility for Level B (up to 960 units per month) includes:

1. Be impaired in at least one of the following ADLS of:

1. Bathing
2. Dressing
3. Eating
4. Toileting
5. Continence
6. Transferring
7. Inside Mobility

Or

2. Be impaired in at least THREE of the following IADLs:

1. Meal Preparation
2. Housework
3. Laundry
4. Taking medications

 AND

3. Meet the nursing facility level of care criteria set forth at NDAC 75-02-02-09 or meets ICF/MR level of care criteria.

3. Eligibility for Level C (up to 1200 units per month) includes:

1. Be impaired in at least five of the following ADLS of:

1. Bathing
2. Dressing
3. Eating
4. Toileting
5. Continence
6. Transferring
7. Inside Mobility

AND

2. Meet the nursing facility level of care criteria set forth at NDAC 75-02-02-09 or meets ICF/MR level of care criteria.

AND

3. None of the 300 hours (1200 units) approved for personal care services can be allocated to the tasks of laundry, shopping, or housekeeping.

AND

4. Have written prior approval for this service from a HCBS Program Administrator, Aging Services, Department of Health and Human Services. The approval must be updated every six months.

The functional assessment measures the degree to which an individual can perform various tasks that are essential to independent living. Information on each of the ADLs or IADLs can be collected by observation, by direct questioning of the individual, or by interview with a significant other. The case manager shall maintain documentation supporting the level of impairment and shall include the following information if applicable:

1. Reason for inability to complete the activity or task
2. Kind of aid the individual uses (e.g., a grab bar or stool for bathing)
3. Kind of help the individual requires (e.g., preparing the bath, washing back and feet, complete bed bath) and the frequency of the need to have the help (e.g. units of services needed)
4. Who provides the help
5. The individual’s health, safety and welfare needs that need to be addressed
6. Document the anticipated outcome as a result of service provision
7. Other pertinent information