4200, Personal Care Services

Revision 22-3; Effective Dec. 1, 2022

Personal care services (PCS) is a benefit under the Early and Periodic Screening, Diagnosis, and Treatment Comprehensive Care Program, known in Texas as the Texas Health Steps Comprehensive Care Program (THSteps-CCP). PCS is available to STAR Kids members from birth through 20. PCS is considered medically necessary when a member requires help with activities of daily living (ADLs), instrumental activities of daily living (IADLs), or health maintenance activities (HMAs) because of physical, cognitive, or behavioral limitations related to the member's disability or chronic health condition. The member's disability or chronic health condition must be substantiated by a practitioner statement of need (PSON). STAR Kids managed care organizations (MCO) may not require PCS providers to obtain a denial or explanation of benefits from a member's primary insurance before seeking reimbursement for PCS.

As defined by law, the scope of ADLs, IADLs, and HMAs includes a range of activities that healthy, nondisabled adults can perform for themselves. Developing children gradually and sequentially acquire the ability to perform ADLs and IADLs for themselves. PCS does not include ADL, IADL or HMA activities that a typically developing child of the same chronological age would not be able to safely and independently perform without adult supervision. As required by law, a member's responsible adult must perform ADLs, IADLs and HMAs on behalf of the individual to the extent that the need to do so would exist in a typically developing child of the same chronological age. Medicaid PCS benefits are limited to situations where the need for assistance to perform the ADLs, IADLs and HMAs is caused by the member's physical, cognitive, or behavioral limitation related to the member’s disability or chronic health condition. PCS includes direct intervention to help the individual perform a task or indirect intervention by cueing the individual to perform a task.

Individuals must have a medical or cognitive need for specific tasks. PCS is medically necessary only when an individual has a physical, cognitive, or behavioral limitation related to the individual’s disability or chronic health condition that affects the individual’s ability to accomplish ADLs, IADLs or HMAs.

PCS includes:

  • Assistance with ADLs and IADLs
  • Nurse-delegated tasks and HMAs within the scope of PCS, as permitted by program policy and 22 Texas Administrative Code Chapter 225 (relating to RN Delegation to Unlicensed Personnel and Tasks not Requiring Delegation in Independent Living Environments for Clients with Stable and Predictable Conditions)
  • Hands-on assistance, cueing, redirecting, or intervening to accomplish the approved PCS task

The amount and duration of PCS is determined by the MCO and must take the following into account:

  • Whether the member has a physical, cognitive or behavioral limitation related to a disability or chronic health condition that affects their ability to accomplish ADLs or IADLs
  • The member's caregiver's need to sleep, work, attend school and meet their own medical needs
  • The member's caregiver's legal obligation to care for, support, and meet the medical, educational and psychosocial needs of other members of the household
  • The member's caregiver's physical ability to perform PCS
  • Whether requiring the member's caregiver to perform PCS will put the member's health or safety in jeopardy
  • The time periods when PCS tasks are required by the member, as they occur over the course of a 24-hour day and a seven-day week
  • Whether or not the need to assist the family in performing PCS on behalf of the member is related to a medical, cognitive or behavioral condition that results in a level of functional ability below what is expected of a typically developing child of the same chronological age
  • Whether services are needed based on the physician’s statement of need and the assessment for personal care described in Section 4210 that follows

PCS may be authorized to support a member's primary caregiver(s) but may not be authorized to supplant a member's natural support, nor to provide a member's total care. PCS may be authorized in an individual or group setting including, but is not limited to the:

  • member's home;
  • home of the primary or other caregiver;
  • member's school;
  • member's day care facility; or
  • community setting in which the member is located.

The MCO must not reimburse PCS that duplicates services that are the legal responsibility of the school district. The school district, through the School Health and Related Services (SHARS) program, must meet the member's personal care needs while the member is at school. However, if those needs cannot be met by SHARS or the school district, documentation must be submitted to the MCO with documentation of medical necessity.

PCS may not be authorized in a hospital, nursing facility, institution providing psychiatric care, or an intermediate care facility for individuals with intellectual or developmental disabilities (ICF/IID).

PCS may not be used as respite, child care, or to restrain a member. PCS may be authorized in a group setting.

A member may not be authorized to receive both PCS and Community First Choice (CFC) services at the same time.

Members who receive services through the following 1915(c) waiver programs receive CFC services through their waiver program and are not eligible to receive PCS through the MCO:

  • Community Living Assistance and Support Services (CLASS);
  • Deaf Blind with Multiple Disabilities (DBMD);
  • Home and Community-based Services (HCS); and
  • Texas Home Living (TxHmL) Program.

4210 Assessment for Personal Care Services

Revision 22-2; Effective September 1, 2022

Sections I, J, K and L of the STAR Kids Screening and Assessment Instrument (SK-SAI) contain assessment questions for personal care services (PCS). Managed care organizations (MCOs) must have a mechanism in place to assist service coordinators in recommending a number of attendant hours. Based on the assessment, the service coordinator develops a recommended service plan for the delivery of PCS. The service coordinator works with the member or their representative to locate an appropriate provider and sends an authorization to the selected provider.

4211 Reassessment for Personal Care Services

Revision 22-2; Effective September 1, 2022

The need for and the amount and duration of personal care services (PCS) must be reassessed every 12 months, or when requested due to a change in the member's health or living condition. The managed care organization must obtain a new practitioner statement of need (PSON) to substantiate the member's continued need for PCS upon each annual reassessment.

4220 Personal Care Services Providers

Revision 22-2; Effective September 1, 2022

Personal care services (PCS) must be provided by an individual who:

  • is 18 years of age or older;
  • is an attendant who:
    • is an employee of a provider organization licensed as a Home and Community Support Services Agency (HCSSA) or organizations licensed to provide home health services or personal assistance services; or
    • is employed by the member or their legally authorized representative (LAR) through the Consumer Directed Services (CDS) option.
  • has demonstrated the competence necessary, when competence cannot be demonstrated through education and experience, to perform the personal assistance tasks assigned by the HCSSA or by the member or the member's responsible adult or LAR acting as employer through the CDS option.
  • is not the responsible adult of the member if the member is under the age of 18; and
  • is not the spouse of the member.