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3.8.2.2 Client Eligibility
The PCS benefit is available to Texas Medicaid clients who:
• Are birth through 20 years of age.
•Are enrolled with Texas Medicaid.
•Are eligible for CCP.
•Have physical, cognitive, or behavioral limitations related to a disability or chronic health condition that inhibits the client's ability to accomplish ADLs, IADLs, or health-related functions.
Personal care services include assistance with ADL's and IADL's, as hands-on assistance, cueing, redirecting, or intervening, to accomplish the ADL or IADL when one of the following criteria are met.
•The responsible adult's need to sleep, work, attend school, and meet his/her own medical needs.
•The responsible adult's legal obligation to care for, support, and meet the medical, educational, and psychosocial needs of his/her other dependents.
•The responsible adult's physical ability to perform the PCS.
Clients who are enrolled in a DADS waiver program may also receive PCS if they are eligible for it, as long as the services that are provided through the waiver program and PCS are not duplicated. Clients who are enrolled in the following DADS waiver programs may access the PCS benefits if they meet the PCS eligibility requirements:
•Community Living Assistance and Support Services (CLASS)
•Deaf/Blind Multiple Disabilities (DBMD)
•Community-Based Alternatives (CBA)
•Consolidated Waiver Program (CWP)
•Medically Dependent Children Program (MDCP)
•Texas Home Living Waiver (TxHmL)
•Youth Empowerment Services (YES)
•Home and Community Services (HCS)
Note: Clients who receive HCS Residential Support Services, Supervised Living Services, or Foster/Companion Care Services are not eligible to receive attendant care services from PCS.
Clients must choose the program through which they receive attendant care, if they meet the eligibility requirements of both programs. Clients will be given the following options for the delivery of attendant care services:
•A client can receive all attendant care services through PCS.
•A client can decline PCS and receive all attendant care service through a waiver program, if the waiver program offers attendant care.
Clients who participate in the CDS option are required to choose one CDSA to provide services through PCS and the waiver program. CDSAs will only be permitted to file the financial management services (FMS) fee, also known as the monthly administrative fee, through one program. The CDSA should file the FMS claim through the program that provides the highest reimbursement rate.
Clients who are enrolled in STAR+PLUS receive the PCS benefit or personal attendant services through their STAR+PLUS health plan. Claims for these clients must be submitted to their STAR+PLUS health plans for payment consideration, not to TMHP. The STAR+PLUS health plans accept referrals and provide authorizations for eligible clients. The STAR+PLUS health plans process and reimburse personal attendant services claims for their clients who are 20 years of age or younger. DSHS does not assess or authorize PCS for STAR+PLUS-enrolled clients. TMHP does not process or authorize PCS for STAR+PLUS health plan clients.
TMHP processes and authorizes PCS for STAR waiver and PCCM clients.
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