EPSDT Personal Care Services

(See Long Term--Personal Care Services (LT-PCS) for Medicaid beneficiaries ages 65 or older, or age 21 or older with disabilities)

Physician and Personal Care Attendant Agencies

ELIGIBILITY:

The person must be age birth through 20 years (EPSDT eligible) and have been prescribed medically necessary, age appropriate EPSDT-PCS by a practitioner (physician, advance practice nurse, or physician assistant). The practitioner shall specify the health/medical condition that necessitates EPSDT-PCS. An EPSDT eligible shall meet medical necessity criteria which shall be based on functional and medical eligibility and impairment in at least two activities of daily living. To establish medical necessity, the EPSDT eligible must be of an age at which the tasks to be performed by the PCS provider would ordinarily be performed by the individual, if not for being disabled due to illness or injury.

Children’s Choice waiver services and PCS may be performed on the same date, but not at the same time. If the beneficiary is receiving home health, respite, and/or any other related service, the PCS provider cannot provide service at the same time as the other Medicaid covered service provider.

COVERED SERVICES:

  • Basic personal care – toileting & grooming activities.
  • Assistance with bladder and/or bowel requirements or problems.
  • Assistance with eating and food preparation.
  • Performance of incidental household chores, only for the beneficiary.
  • Accompanying, not transporting, beneficiary to medical appointments.
  • Does NOT cover any medical tasks such as medication administration, tube feedings, urinary catheters, ostomy or tracheostomy care.

COMMENTS:

The Personal Care Agency must submit the Prior Authorization request. 

Beneficiaries receiving Support Coordination (Case Management Services) must also have their PCS Prior Authorized by Gainwell Technologies. 

PCS is not subject to service limits. Units approved will be based on medical necessity and the need for covered services.

Beneficiaries receiving Personal Care Services must have practitioner's prescription and meet medical criteria.

Does not include medical tasks.

Provided by licensed providers enrolled in Medicaid to provide personal care services.

CONTACT:

Norma Seguin           225/342-7513