Limitations and Non-covered Services 535-05-25

(Revised 01/01/2024 ML #3795)

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1. Personal care services may not include skilled services performed by persons with professional training.
2. An individual receiving personal care services may not be an inpatient or resident of a hospital, a nursing facility, an intermediate care facility for individuals with intellectual disabilities, a psychiatric residential treatment facility, or an institution for mental disease.
3. Personal care services may not include home delivered meals; services performed primarily as housekeeping tasks; transportation; social activities; or services or tasks not directly related to the needs of the individual such as doing laundry for family members, cleaning of areas not occupied by the individual, or shopping for items not used by the individual.
4. Meal preparation is limited to the maximum units set by the department. Laundry, shopping, and housework tasks when provided must be incidental to the provision of other personal care tasks and cannot exceed 30% of the total time authorized for the provision of all personal care tasks. Personal care service tasks of laundry, shopping, and housekeeping are limited to the maximum units set by the department, and the cap cannot be exceeded under other home and community-based services funding sources.
5. Services provided by a spouse, parent of a minor child, or legal guardian are not covered.
6. Effective 1/1/2021 payment for the tasks of laundry, shopping, housekeeping, meal preparation, money management, and communication requires prior approval for a provider who lives with the individual.

   • The above tasks may be assessed for individuals whose provider is a relative listed under the definition of family home care under subsection 4 of the North Dakota Century Code section 50-06.2 02 or who is a former spouse beginning at the first required contact after 1/1/2021.

   • Prior approval will only be granted for environmental tasks and/or meal preparation when the service exclusively benefits the consumer.

   • Conditions that would exclusively benefit the consumer would include, but are not limited to, maintenance of non-shared spaces, completion of laundry if there is a documented reason it must be completed separately for instance frequent incontinence, and/or authorization of pureeing food or preparing a liquid diet.

7. Care needs of the individual that are outside the scope of personal care services are not covered.
8. Services provided in excess of the services or hours authorized by the case manager in the individual’s approved service plan are not covered.
9. Authorized personal care services may not exceed 120 hours (480 units) per month for Level A Personal Care Services or 240 hours (960 units) per month for Level B Personal Care Services, and 300 hours (1200 units) per month for Level C Personal Care Services.
10. Personal care services may only be provided when the needs of the eligible individual exceed the abilities of a spouse or parent(s) of a minor child to provide such services. Personal care services may not be substituted when a spouse or parent(s) of a minor child refuses or chooses not to perform the service. Personal care services may be provided during periods when a spouse or parent(s) of a minor child is gainfully employed if such services cannot be delayed until the spouse or parent(s) is able to perform them.
11. Personal care services may not be provided for tasks that are otherwise age appropriate or generally needed by an individual within the normal stages of development.
12. Per guidance given by the Centers for Medicare and Medicaid Services in the following 2001 HHS Survey and Certification memo, personal cares can be offered in conjunction with Hospice services.

    https://www.cms.gov/Medicare/Provider-Enrollment-and Certification/SurveyCertificationGenInfo/downloads/SCLetter01-013.pdf

13. The combination of personal care services and hospice service requires approval from the Department. The request must outline the client’s needs, the services that will be provided through Hospice, and the services being requested through MSP PC. The request must also contain an assurance that there is not a duplication of services.
14. The Hospice plan of care must include the need for personal care services and a copy must be maintained in the client’s file.