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43.4.10.4 Benefits and Limitations
PCS are those services that assist eligible clients in performing ADLs, IADLs, and other health-related functions. The scope of ADLs, IADLs, and health-related functions includes a range of activities that healthy, non-disabled adults can perform for themselves. Typically, developing children gradually and sequentially acquire the ability to perform these ADLs, IADLs, and health-related functions for themselves. If a typically developing child of the same chronological age could not safely and independently perform an ADL, IADL, or health-related function without adult supervision, then the client's parent/guardian is responsible for insuring the client's needs for the ADLs, IADLs, and health-related functions are met.
PCS include direct intervention (assisting the client in performing a task) or indirect intervention (cueing the client to perform a task). ADLs, IADLs, and health-related functions include but are not limited to the following:
PCS do not include the following:
• ADLs, IADLs, or health-related functions that a typically developing child of the same chronological age could not safely and independently perform without adult supervision.
•Services that provide direct intervention when the client has the physical, behavioral, and cognitive abilities to perform an ADL, IADL, or health-related function without adult supervision.
•Services provided to an inpatient or a resident of a hospital, nursing facility, ICF-MR, or an institution for mental disease.
•Duplication of services provided by other programs.
Place of Services
PCS may be provided in the following settings if medically necessary:
•The client's home.
•The client's school.
•The client's daycare facility.
•Any community setting in which the client is located.
Note: For claims filing purposes, the PCS provider must bill POS 2 (home) when submitting claims to TMHP.
The Texas Medicaid Program does not reimburse for duplicate services.
The Texas Medicaid Program does not reimburse providers for PCS that duplicate services that are the legal responsibility of school districts. The school district, through the SHARS program, is required to meet the client's personal care needs while the client is at school. If those needs cannot be met by SHARS or the school district, the school district must submit documentation to the DSHS case manager indicating the school district is unable to provide all medically necessary services. When clients are receiving both PCS and PDN services from an individual person over the same span of time, the combined total number of hours for PCS and PDN are reimbursed according to the maximum allowable rate.
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