Personal Care Eligibility Requirements 535-05-15

(Revised 01/01/2024 ML #3795)

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IM 5434

To qualify for coverage of personal care services, an individual must have applied for and been found eligible for Medicaid benefits

 

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

  1. Be impaired in at least THREE of the following IADLs:
  1. Meal Preparation
  2. Housework
  3. Laundry
  4. Taking medications
  1. 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

  1. Be impaired in at least THREE of the following IADLs:
  1. Meal Preparation
  2. Housework
  3. Laundry
  4. Taking medications

 AND

  1. Meet the nursing facility level of care criteria set forth at NDAC 75-02-02-09 or meets ICF/MR level of care criteria.
  1. 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

  1. 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

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

AND

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

 

After completing a comprehensive needs assessment the individual’s case manager shall complete Section II of Personal Care Services Plan, SFN 662, to determine if the individual qualifies for personal care services. Section II allows the case manager to determine the level of impairment an individual is experiencing, based on specific medical, emotional and cognitive status. An individual must be impaired (have a score of at least 2) for any 1 ADL, or impaired (a score of at least 1) in 3 of the 4 IADLs meal preparation, housework, laundry, or taking medications. See the Instructions for Completing the Functional Assessment on scoring ADLs and IADLs.

 

The 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. Reasons for inability of a spouse or parent of a minor child to perform the activity or task for the individual
  6. The individual’s health, safety and welfare needs that need to be addressed
  7. Document the anticipated outcome as a result of service provision
  8. Other pertinent information

 

A comprehensive assessment must be completed initially before any personal care services can be authorized and annually thereafter. A review of the individual’s needs must be completed every six months or when there is a significant change in the individual’s needs.