RetiredCareSourcePolicy Provider Billing for Services by a Family Member-AR PASSE- AD-1225

Provider Billing for Services by a Family Member (Arkansas PASSE)

Administrative policy describing requirements, limitations, and eligibility for billing Medicaid services provided by family members under Arkansas PASSE programs; affects Arkansas Medicaid providers, beneficiaries, and family-member caregivers.

Policy Summary

PayerCareSource

PolicyProvider Billing for Services by a Family Member (Arkansas PASSE)

Policy CodePolicy Provider Billing for Services by a Family Member-AR PASSE- AD-1225

Change TypeNo material change

Effective DateDec 1, 2022

Next Review Date

Key ActionEnsure the provider on file with Arkansas Medicaid is the biller; family members employed by that provider must meet Arkansas provider certification and enrollment requirements.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

64/moMax personal care hours (21+)

12/01/2022-10/31/2023Effective period

08/31/2022Issued

Coverage Criteria for Family-Member Provided Services

Coverage criteria for family-member provided services

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ALL of the following

Services must be consistent with the beneficiary's Person-Centered Service Plan (PCSP) and any established benefit limits for that specific service.
All providers, including relatives, must meet Arkansas provider certification requirements, training requirements, and Arkansas Medicaid enrollment requirements.
The provider on file with Arkansas Medicaid is the biller of services; a family member providing care is an employee of that provider and must adhere to provider billing policies and Arkansas Medicaid certification and enrollment requirements.
Nonmedical community supports and services (NCSS) must be rooted in needs identified through the Independent Assessment and included in the beneficiary's PCSP to be covered under PASSE.

ALL of the following

Travel time is not reimbursable when any other adult person accompanying or driving the participant is a family member and is reasonably able to assist the participant in transit.

Coding and Limits

Referenced provider manualsmixed

ARChoices In Home Care Provider Manual	Arkansas Department of Human Services. ARChoices In Home Care Home and (Section referenced)
IndependentChoices Provider Manual, Section 2	Arkansas Department of Human Services. IndependentChoices Provider Manual, Section 2 (Retrieved August 2, 2022)
Personal Care Provider Manual, Sections	Arkansas Department of Human Services. Personal Care Provider Manual, Sections (Section referenced)
Living Choices Assisted Living Provider Manual, Section 2	Arkansas Department of Human Services. Living Choices Assisted Living Provider Manual, Section 2
Private Duty Nursing Provider Manual, Section 2	Arkansas Department of Human Services. Private Duty Nursing Provider Manual, Section 2 (Retrieved August 2, 2022)
Centers for Medicare and Medicaid Services (CMS)	CMS guidance (Retrieved August 2, 2022)
Code of Federal Regulations (ecfr)	Federal authority referenced (Retrieved August 2, 2022)

Coding threshold: State Plan Personal Care

State Plan personal care monthly hour limit64 hours per calendar month for participants aged 21 years and older (limit does not apply to beneficiaries under age 21)

Billing and Provider Eligibility Rules

Billing Rule

Billing, enrollment, and restrictions when family members provide services

The provider listed with Arkansas Medicaid must bill for services delivered by family-member employees; the family member functions as an employee of that enrolled provider and must meet Arkansas provider certification, training, and Medicaid enrollment requirements. Certain relatives — including a beneficiary's spouse, legal guardian, attorney-in-fact, a minor's parent/guardian, or anyone who resides with the beneficiary — are not eligible for reimbursement for specified services (respite, personal care, private duty nursing). Travel time is not reimbursable when another adult accompanying the participant is a family member reasonably able to assist during transit.

The provider on file with Arkansas Medicaid is the biller of services; the family member is an employee of that provider and must adhere to billing rules and Arkansas Medicaid certification and enrollment requirements. [[cite]]
All providers, including relatives, must meet Arkansas provider certification requirements, including training and Medicaid enrollment. [[cite]]
Reimbursement is not permitted for specified relatives (beneficiary spouse; legal guardian; attorney-in-fact; a minor's parent/guardian; anyone residing with the beneficiary) for respite, personal care, or private duty nursing as noted in the policy. [[cite]]
Travel time is not reimbursable if any other adult person accompanying (or driving) the participant is a family member reasonably able to assist the participant in transit. [[cite]]

Key Definitions

Caregiver (definition & notes)

DefinitionAn individual who has responsibility for the protection, in‑home care, or custody of a beneficiary as a result of assuming the responsibility by contract.

Employment and certificationFamily members employed to provide services must be employees of the provider on file with Arkansas Medicaid and meet Arkansas provider certification, training, and Medicaid enrollment requirements.

RestrictionsPersons with legal responsibility (court‑appointed legal guardian, spouse, power of attorney, or income payee) may not serve as a caregiver/employee in certain programs.

PCSP (Person Centered Service Plan)

DefinitionPerson Centered Service Plan (PCSP): a written plan that provides information and support directing the process of care, reflects services and supports to meet needs identified through an assessment of functional need, and enables informed choices and decisions.

Role in coverageServices must be included in the beneficiary's PCSP and comply with any established benefit limits to be covered.

Source of service requirementsPCSP documents the providers of services and supports, including natural supports and paid providers.

Personal Care Services — definition, limits, and exclusions

DefinitionPersonal Care Services: medically necessary services individually designed to assist beneficiaries with physical dependency needs; provided by a personal care aide based primarily on assessed hands‑on needs.

Place of service and exclusionsServices are furnished to beneficiaries who are not inpatients or residents of a hospital, nursing facility, Level II assisted living facility, intermediate care facility for persons with intellectual disabilities, or institution for mental disease; provided in the beneficiary's home or, at the State's option, another location.

Reimbursement exclusions for family membersReimbursement is not permitted for certain family members (beneficiary spouse; legal guardian; attorney‑in‑fact granted authority to direct care; a minor's parent/stepparent/foster parent or anyone acting as a minor's parent; anyone who resides with the beneficiary) for specified services.

Travel time ruleTravel time is not reimbursable if any other adult person accompanying or driving the beneficiary is a family member reasonably able to assist the beneficiary in transit.