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Summary of Questions and Answers about LT-Personal Care Services Program from the March 19th BEST OF TIMES RADIO HOUR show.
March 19th, 2005

Questions and Answers regarding Louisiana Medicaid program – Long Term - Personal Care Services

On the March 19th radio talk show of THE BEST OF TIMES RADIO HOUR, which airs on Saturday mornings at 9 am on News Radio 710 KEEL, Radio show host Gary Calligas had Mr. Ray Dawson who works as a Program Manager at the Louisiana Department of Health & Hospitals, assigned to the Medicaid Bureau in the Program Operations section, and handles Long Term – Personal Care Services appeals in behalf of DHH. Mr. Dawson answered the following questions received from radio listeners and readers of THE BEST OF TIMES about the new Louisiana Medicaid entitlement program, Long-Term – Personal Care Services for the elderly and persons with disabilities. For more information about this new program, log onto to website at www.dhh.louisiana.gov or call 225-342-9485.

QUESTIONS & ANSWERS
(As of March 19, 2005)

1. Q: What is the purpose of the Long Term / Personal Care Services
Program?

A: The purpose of the personal care services is to enable an individual whose
needs would otherwise require placement in an acute or long term care facility to remain safely in that individual’s own home. (Source: LAC 50: XV. Chapter 129, §12901, A.)
Paraphrase: The purpose of this program is to (when possible & medically sound) provide help to qualified recipients and let them remain at home rather than put them in a nursing home.

2. Q: Is there a mission to this program?

A: The mission of Medicaid funded personal care services is to supplement the family and/or community supports that are available to maintain the recipient in the community. This service program is not intended to be a substitute for available family and/or community supports.
(Source: LAC 50: XV. Chapter 129, §12901, A.)
Paraphrase: The aim of the program is to assist the family in caring for a qualified recipient, but not to replace the family support(s).

3. Q: What is meant by “available family” and “community supports”?
A: Available family means relatives that reside with or close by a recipient who have been, or are capable of assisting the recipient with their daily living at home, rather than institutionalizing them. Available supports include volunteer organizations and other public programs that are presently assisting a qualified recipient with their daily living in a home setting.

4. Q: Who is eligible for the LT/PCS program and its services?

A: Medicaid recipients who are either
1. At least 65 years old, OR
2. 21 years old or older and disabled

A Medicaid recipient who meets either of these criteria MUST ALSO
● Meet the requirements for nursing facility level of care, AND
● Have the ability to direct their care independently or through a
responsible representative, AND
● Be in a nursing facility and be able to be discharged if community–
based services were available; OR
● Be likely to require nursing facility admission within the next 120 days;
OR
● Have a primary care-giver who has a disability or is over the age of 70;
OR
● Face a substantial possibility of deterioration in mental or physical
condition or functioning if either home and community-based services
or nursing facility services are not provided in less than 120 days.
(Source: LAC 50: XV. Chapter 129, §12905, A. and DHH Handout)

5. Q: What condition(s) can make you disabled?

A: Disabled is defined as meeting the eligibility criteria established by the Social Security Administration for disability benefits. (Source: LAC 50: XV. Chapter 129, §12905, A. and DHH Handout)

6. Q: What is a “responsible representative.”?

A: Responsible representative is defined as the person designated by the recipient to act on his/her behalf in the process of accessing personal care services. (Source: LAC 50: XV. Chapter 129, §12905, A. and DHH Handout)
Paraphrase: This should be that person who is most familiar with a recipient’s medical condition, doctor’s care, hospitalizations, and with the recipient’s abilities to care for themselves. This person should have the authority of the recipient to speak in their behalf and to make decisions concerning the needs and care of a recipient. Emphasize – Wherever and whenever possible, this person (the recipient’s designee) should be present for the in home assessment.

7. Q: What are personal care services?

A: Personal care services are those services that provide assistance with activities of daily living and instrumental activities of daily living. They may be either the actual performance of the personal care task for the individual or supervision and prompting so the individual performs the tasks by themselves. These are activities that help a recipient remain in their community (at home), rather than a nursing home setting. The program is not a medical program, nor does it provide for daily supervision (sitters) for those approved for services.

8. Q: What are “activities of daily living”?

A: By rule and by policy, the Department has established the following as “activities of daily living”:

• Eating
• Bathing
• Dressing
• Grooming
• Transferring (getting in/out of the tub, or from bed to a chair)
• Ambulation (ability whether physically or motorized to move about the recipient’s home, the premises, or outside the home)
• Toileting

9. Q: What are “instrumental activities of daily living?

A: Instrumental activities of daily living are those tasks that, although not absolutely necessary for day to day living, enhance the recipient’s care, to further assist staying in the home. By rule and by policy, the Department has established the following as “instrumental activities of daily living:

● Light housekeeping
● Food preparation and storage
● Grocery shopping
● Laundry
● Reminding the recipient to take medication
● Assisting with scheduling medical appointments when necessary
● Accompanying the recipient to medical appointments where the
recipient is in a very frail condition
● Assisting the recipient to access transportation

10. Q: What services are not covered?

A: Personal care services may not be used to:
● Specialized nursing procedures (e.g. – insertion of feeding tube,
indwelling catheter, tracheostomy care, or injections)
● Skilled nursing services
● Medication administration
● Rehabilitative services
● Specialized aide procedures (e.g. – measuring/recording
vital signs, specimen collection, special skin care, etc.)
● Cleaning areas of home not occupied by recipient
● Food preparation or laundry for anyone other than recipient
● Companionship
● Supervision
● Respite of the primary care giver

11. Q: How do I apply for this program?

A: You begin the process by calling 1 – 866 – 229 – 5222. At that number, you will speak to a representative at Affiliated Computer Services (ACS). ACS contracted with the State of Louisiana to assist in the administration of this program. You need to have the potential recipient’s name, address, and their Medicaid number readily available when you call ACS.

12. Q: Can I start services as soon as I apply?

A: No, services do not start immediately, even if the applicant is already Medicaid eligible. There are four things needed to begin services:

1. Your doctor must complete a medical form, and verify (validate) that the recipient/applicant meets a nursing home level of care;
2. If you meet the nursing home level of care, an employee of ACS will make an appointment with you to come to your home, conduct interviews, and make a written assessment of your situation;
3. A plan of care is developed by the ACS representative, and submitted to the Department so that services may be “officially” approved (this is called “prior authorization”); and
4. You must select a “provider” to perform services at your residence.

13. Q: Who can approve LT/PCS services?

A: Only the Department of Health and Hospitals may approve services. The entire process involves an application, doctor verification, assessment of the recipient’s needs, and care delivery by a provider, and however, services must always be “prior” approved by DHH.

14. Q: What is an “assessment”?

A: An “assessment” is another way of saying that the need for services is evaluated based on a detailed written form and based on oral interviews and observations by the person performing the assessment. The assessment is used to determine the needs of the recipient and to allocate hours based on the need(s). NOTE: The number of authorized service hours is considered on a case-by-case basis as substantiated by the recipient’s service plan and supporting documentation. A PERSON IS NOT AUTOMATICALLY ENTITLED TO 56 HOURS OF LT/PCS SERVICES UPON APPROVAL FOR THE LT/PCS PROGRAM, OR UPON VERIFICATION BY THE DOCTOR THAT A RECIPIENT NEEDS THE SERVICES. (Source: LAC 50: XV. Chapter 129, §12915, A.)

15. Q: What is a “provider”?

A: A “provider” is the organization or entity that comes to a recipient’s home to “provide the services” that have been authorized and approved by the department. When a Medicaid recipient is approved for services under this program, the recipient will receive from the Department a list of approved providers. The decision of which provider to contact and use is left entirely to the recipient and/or there responsible representative.

16. Q: As a “recipient” in the Long Term-Personal Care Services
Program, what are my rights?

A: By federal and state law, DHH rule, and policy, a recipient has the following rights:

● The right to be treated with dignity and respect,
● The right to actively participate in the development of their service plan and the decision-making process regarding service delivery,
● Freedom of choice in the selection of a provider, to include: interviewing and selecting the personal care worker who will provide services, developing the work schedule for their personal care worker, training the personal care worker n the specific skills necessary to maintain the recipient’s independent functioning while safely maintaining him/her in the home, developing an emergency component in the service plan that includes a list of personal care staff who can serves as back-up when unforeseen circumstances prevent the regularly scheduled worker from providing services, signing off on payroll logs and other documentation to verify staff work hours and to authorize payment, evaluating the personal care worker’s job performance and discharging the personal care worker assigned to the provide the services. (Note: You may change providers after 90 days without good cause or at any time with good cause),
● The right to refuse to sign any paper that you do not understand or is not complete,
● The right to receive an accurate explanation of Medicaid personal care services, including a description of the qualifications and covered services,
● The right to file a complaint if you are dissatisfied with the service deliver or the failure to receive your authorized services,
● The right to receive written notification (a notice) of the decision made on your request for services or any changes that may adversely affect your participation in this program, and
● The right to request a “Fair Hearing” if you are dissatisfied with a decision regarding your request for these services.
● (Source: LAC 50: XV. Chapter 129, §12907, A. and DHH Handout)

17. Q: As a “recipient” in the Long Term-Personal Care Services
Program, what are my responsibilities?

A: It is the recipient’s and/or the representative’s obligation:

● To immediately notify the parish Medicaid office and your provider if your address, telephone number or other contact information changes,

● To provide all necessary information requested by DHH, or its agents, including medical and/or psychological information that describe and/or pertain to your disability and service needs,
● To cooperate with DHH or its agents who contact you and visit you in your home to determine what services you need,
● To help the Department or its agents identify any natural and community supports that you are using to assist you in meeting your needs,
● To cooperate with your selected provider by being available to receive services as scheduled,
● To be courteous and respectful to the provider agency staff, and
● To maintain a safe and lawful environment where the services are delivered.
● (Source: DHH LT/PCS Program Handout)

18. Q: Where may the services by received?

A: Personal care services may be provided in the recipient’s home and in another location outside of the recipient’s home if the provision of these services allows the recipient to participate in normal life activities pertaining to the IADL’s cited in the plan of care.

Definition: The recipient’s home is defined as the recipient’s place of residence, including his/her owns house, or apartment, a boarding house, or the house or apartment of a family member or unpaid primary care-giver. A hospital, a mental institution, a nursing facility, or an intermediate care facility for the mentally retarded, are not considered the recipient’s home. (Source: LAC 50: XV. Chapter 129, §12913, A.)

19. Q: How are the services paid for?

A: After the services begin, the provider will bill the Department directly and get paid directly. You will not be paid, and you are not responsible to pay the Provider for approved services.

20. Q: What happens if I get sick and go to the hospital?

A: Once you approved for services, that approval is good for up to one (1) year. If you get sick and go to a hospital, the LT/PCS services will be suspended during your hospitalization and no services may be paid for during the time the recipient is in the hospital.

21. Q: Can the personal care worker do stuff for others if I don’t need the
help on a specific day?

A: ABSOLUTELY NOT. These services may only be provided to the recipient; they may not be shared with or performed for any other person. For example, if laundry is approved for a recipient, the provider may not do the laundry for any other person or family member in the home.

22. Q: Can I get the LT/PCS program if I am enrolled in the DHH Hospice
Program?

A: No.

23. Q: What if I need medical help in my home?

A: You will have to contact your local medical agency, this program
(LT / PCS) does not provide medical services, and the providers will not be paid for performing any medical services.

24. Q: What happens if my health or my support situation changes
after the “in-home” assessment?

A: After the assessment is complete, if the recipient’s health noticeably declines or if the recipient’s family support system diminishes dramatically the recipient or their designated representative should immediately notify ACS that a change in status has occurred. The change(s) must be verified by a representative of the Department, usually the ACS intake person who did the assessment. When services are approved, the recipient will receive “change of status” instructions and a form to utilize to notify the Department of the current health or support situation.

25. Q: Can my family get paid to perform these services?

A: The intent of the program is to supplement the existing support the recipient receives in the home. This is a partnership which supplements what is already in place in the home; it is not an employment program for the family member(s). Any person hired to perform the tasks must first meet the employment criteria for hire that is established by the provider.

26. Q: If a Medicaid recipient meets a “nursing home level of care”,
why don’t they get the 56 hours of services?

A: Because this program is a task oriented program. That is, the assessment will determine separately which activities the recipient needs assistance with. For example, if a recipient is fed through a peg tube, this program will not provide hours for either meal preparation or for eating because of this medical condition.

27. Q: What can be done to ensure that the services get started? Are
there any roadblocks?

A: It is critical to the process that recipients keep appointments made with the ACS staff for the initial assessment, or other visits to the home. It is equally helpful and important that a responsible family member be present at these home visits. Missing appointments will always impede the process.

29. Q: How long does it take from the initial application to getting services?

A: The time from initial application to providing services is different for each case. However, on average, assuming there are no missed appointments and that the recipient’s doctor promptly returns the medical form, presently it takes roughly 90 days from the initial application to the service delivery.

30. Q: Are changes anticipated in the program in the near future?

A: No dramatic changes are in process, however, this program, as with all other health programs are subject to budgetary constraints. It may become necessary in the future to alter this program if funding decreases.

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