Table of Contents Previous Next Index

2012 Texas Medicaid Provider Procedures Manual

Children’s Services Handbook : 2. Medicaid Children’s Services Comprehensive Care Program (CCP) : 2.8 Personal Care Services (PCS) (CCP) : 2.8.2 Services, Benefits, and Limitations : 2.8.2.2 Client Eligibility

2.8.2.2
The PCS benefit is available to Texas Medicaid clients who:
Are birth through 20 years of age.
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.
When the client has a functional condition that meets the criteria for PCS, the following needs of the client’s responsible adult will be considered:
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:
Note:
Clients who receive HCS Residential Support Services, Supervised Living Services, or Foster/Companion Care Services are not eligible to receive attendant care services through 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:
Clients who participate in the CDS option for PCS and for a waiver program are required to choose one CDSA to provide services through both programs. 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 must file the FMS claim through the program that provides the highest reimbursement rate.
2.8.2.2.1 Accessing the PCS Benefit
Clients must be referred to DSHS before receiving the PCS benefit. A referral can be made by any person who recognizes a client may have a need for PCS, including, but not limited to, the following:
Referrals to DSHS can be made to the appropriate DSHS Health Service Region, based on the client’s place of residence in the state. Clients, parents, or guardians may also call the TMHP PCS Client Line at 1‑888‑276‑0702 for more information on PCS. PCS providers must provide contact information for the client or responsible adult to DSHS or the TMHP PCS Client Contact Line when making a referral.
Upon receiving a referral, DSHS assigns the client a case manager, who then conducts an assessment in the client’s home with the input and assistance of the client or responsible adult. Based on the assessment, the case manager identifies whether the client has a need for PCS. If the case manager identifies a need for PCS, the client or responsible adult is asked to select a Medicaid-enrolled PCS provider in their area.
Once a provider is selected, the DSHS case manager prior authorizes a quantity of PCS based on the assessment and requests TMHP to issue a prior authorization number (PAN) to the selected PCS provider. The PCS provider uses the PAN to submit claims to TMHP for the services provided. DSHS also contacts the client’s primary practitioner (a licensed physician, APRN, or PA) or primary care provider to obtain a statement of need.
2.8.2.2.2 The Primary Practitioner’s Role in the PCS Benefit
A client who is assessed for the PCS benefit must have a primary practitioner (a licensed physician, APRN, or PA) or a primary care provider who has a therapeutic relationship and ongoing clinical knowledge of the client. The primary practitioner or primary care provider must have established a diagnosis for the client and must provide continuing care and medical supervision of the client. When the DSHS case manager has determined the client has a need for the PCS benefit, the case manager contacts the client’s primary practitioner or primary care provider to obtain a Practitioner Statement of Need (PSON). The PSON certifies the client has a physical, cognitive, or behavioral limitation related to a disability or chronic health condition and is birth through 20 years of age. The PSON must be signed and dated by the primary practitioner or primary care provider within 60 days of the initial start of care (SOC). The primary practitioner or primary care provider must mail or fax the completed PSON to the appropriate DSHS Health Services Region. DSHS keeps the signed and dated PSON in the client’s case management record for the duration of the client’s participation in the benefit.
When a behavioral health condition exists, the primary practitioner may be a behavioral health provider. The primary practitioner must maintain the PSON in the client’s medical record.
In the absence of primary practitioner medical record documentation and a Practitioner Statement of Need to support the client has a physical, cognitive or behavioral health condition impacting the client's ability to perform an ADL or IADL PCS, payment maybe recouped.

Texas Medicaid & Healthcare Partnership
CPT only copyright 2011 American Medical Association. All rights reserved.