CurrentCareSourcePolicy N/A

Relatives or Guardians as Paid Providers

Defines when relatives, guardians, and legally responsible persons may or may not be employed and paid to provide Home and Community-Based Services (HCBS) and related waiver services in Arkansas and describes limits, certification, and program-specific rules affecting members and providers.

Policy Summary

PayerCareSource

PolicyRelatives or Guardians as Paid Providers

Policy CodePolicy N/A

Change TypeAdministrative update (no material changes)

Effective DateNov 1, 2023

Next Review DateN/A

Key ActionEnsure providers (including relatives) meet Arkansas Medicaid certification and enrollment requirements and that the enrolled provider is listed as the biller.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

40Relative weekly cap

14.75State Plan PCS weekly limit (adults 21+)

ARChoices, IndependentChoices, PCSPrograms referenced

No if co-residentRespite residency rule

Coverage criteria and restrictions

Policy Summary

PayerCareSource

PolicyRelatives or Guardians as Paid Providers

Policy CodePolicy N/A

Change TypeAdministrative update (no material changes)

Effective DateNov 1, 2023

Next Review DateN/A

Key ActionEnsure providers (including relatives) meet Arkansas Medicaid certification and enrollment requirements and that the enrolled provider is listed as the biller.

SourceLink

On This Page

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Providers, including relatives, must meet all Arkansas provider certification, training, and Medicaid enrollment requirements; the provider on file with Arkansas Medicaid is the biller and the family member is an employee of that provider and must adhere to provider policies, procedures, certification, and enrollment requirements.

Services must be delivered according to the member's Person Centered Service Plan (PCSP) and any established benefit limits for the specific service; Administrative Policy does not guarantee payment if contract conflicts exist.

Relatives and legally responsible individuals may not be paid for more than 40 hours per week (7-day period) of support/care to a member; this 40-hour cap applies regardless of number of households, number of parents, or actual hours provided.

Providers employing relatives or legally responsible individuals must maintain a staffing backup plan; guardians are recommended to use respite at least monthly and relatives/legally responsible individuals should not provide services if a different individual is the member's designated representative.

Program-specific prohibitions (one or more may apply)

ARChoices: All ARChoices services may be provided by a beneficiary's relative unless stated otherwise in the ARChoices Provider Manual; however, respite may not be provided by an individual living in the member's home; travel time is not reimbursable if the accompanying adult is a family member reasonably able to assist; reimbursement is not permitted for services provided by a legal guardian, beneficiary spouse, or attorney-in-fact authorized to direct care.
IndependentChoices: Follows Arkansas Medicaid Personal Care Provider Manual. State Plan Personal Care Services for participants aged 21 and older are limited to 14.75 hours per week (64 hours per month); the hour limit does not apply to members under age 21.
Living Choices (Assisted Living): Attendant care services may only be provided by a certified personal care aide who is not a legally responsible family member or legally responsible caregiver (e.g., spouse, attorney-in-fact).
Personal Care Services (PCS - State Plan): PCS must be provided by an individual who is not a member of the beneficiary's family; excluded family members include beneficiary spouse, a minor's parent/stepparent/foster parent or anyone acting as a minor's parent, legal guardian of the beneficiary, and attorney-in-fact granted authority to direct care; travel time is not reimbursable if accompanied by a family member reasonably able to assist.
Private Duty Nursing (PDN): The following may not be paid PDN providers: spouse, a minor's parent or anyone acting as a minor's parent, a minor's guardian or anyone acting as a minor's guardian, an adult's guardian or anyone acting as an adult's guardian, and anyone who resides with the beneficiary.

Respite-specific rules: Respite care is intended for unpaid caregivers; an individual living in the member's home is not allowed to serve as a respite provider for that member.

Limits, caps, and referenced sources

Referenced manuals and sourcesmixed

ARChoices In Home Care Home and Community-Based 2176 Waiver Provider Manual, Sections I, II and IV	ARChoices In Home Care Home and Community-Based 2176 Waiver Provider Manual, Sections I, II and IV. Arkansas Department of Human Services. Accessed July 13, 2023.
Community and Employment Support Waiver, AR.0188.RO6.01	Community and Employment Support Waiver, AR.0188.RO6.01. Accessed July 13, 2023.
CMS: State medicaid plans and waivers	Centers for Medicare & Medicaid Services (CMS): State medicaid plans and waivers. Accessed July 13, 2023.
Health and Human Services: Home & Community Based Services Authorities	Health and Human Services: Home & Community Based Services Authorities.
Independent Choices Provider Manual, Section II	Independent Choices Provider Manual, Section II. Arkansas Department of Human Services. Accessed July 13, 2023.
Living Choices Assisted Living Provider Manual, Section II	Living Choices Assisted Living Provider Manual, Section II. Arkansas Department of Human Services. Accessed July 13, 2023.
Personal Care Provider Manual, Section II	Personal Care Provider Manual, Section II. Arkansas Department of Human Services. Accessed July 13, 2023.
Private Duty Nursing Provider Manual, Section II	Private Duty Nursing Provider Manual, Section II. Arkansas Department of Human Services. Accessed July 13, 2023.

inv-03: State Plan Personal Care weekly limit — 14.75 hours/week (64 hours/month) for participants aged 21+.

State Plan PCS weekly limit (ages 21+)14.75 hours per week (64 hours per calendar month)

Age applicabilityLimit applies to participants aged 21 years and older; does not apply to members under age 21.

Source programApplies to State Plan Personal Care Services as referenced under IndependentChoices/State Plan PCS.

inv-04: Relative caregiver weekly payment cap — 40 hours/week.

Relative caregiver weekly payment capRelatives and legally responsible individuals cannot be paid for more than 40 hours per week (7-day period).

ScopeCap applies regardless of number of households, number of parents, or actual hours provided; applies to parents/guardians of minor members as well.

Payment aggregationIndividuals will not be paid for more than 40 hours per week even if providing assistance in multiple roles (e.g., parent and paid spouse).

Provider enrollment, billing, and prohibitions

Billing Rule

Provider enrollment and billing

All providers, including relatives, must meet Arkansas Medicaid provider certification and enrollment requirements. The provider entity on file with Arkansas Medicaid is the billing entity and must follow Arkansas Medicaid billing, certification, and enrollment rules. Family members employed by a provider are considered employees of that billing entity and must adhere to that provider's policies and procedures. Providers must maintain documentation supporting enrollment, training, staffing, and backup plans, and must bill only for services and hours authorized by the member's plan of care and applicable benefit limits.

The provider on file with Arkansas Medicaid is the billing entity.
All providers (including relatives) must complete required Arkansas Medicaid certification and enrollment and meet training requirements.
Family members employed by a provider are employees of that provider and must follow the provider's billing policies and Arkansas Medicaid rules.
Providers must have staffing backup plans when employing relatives or legally responsible individuals.
Providers and employed family members cannot be paid for more than 40 hours per week for supportive living/personal care services to the same member; total paid hours across roles are capped at 40 hours/week.

Denial Risk

Prohibited family providers

Certain family members and legally responsible individuals are prohibited from being paid providers for specific Arkansas Medicaid programs and services. Prohibited individuals include spouses, legal guardians, attorneys-in-fact who have authority to direct the member's care, anyone who resides with the beneficiary, a minor's parent/stepparent/foster parent or anyone acting as a minor's parent, and an adult's guardian or anyone acting as an adult's guardian. Additionally, a beneficiary's court-appointed guardian, power of attorney, or income payee may not serve as a paid caregiver/employee for the member.

Spouse of the beneficiary — prohibited as a paid provider.
Legal guardian or conservator of the beneficiary — prohibited.
Attorney-in-fact with authority to direct care — prohibited.
Anyone who resides with the beneficiary — prohibited.
Minor's parent, stepparent, foster parent, or anyone acting as a minor's parent — prohibited for PDN and certain PCS.
Court-appointed guardian, power of attorney, or income payee — may not serve as a caregiver/employee where prohibited by program rules.
Respite providers cannot be an individual living in the member's home.

Program and role definitions

inv-07: ARChoices services (waiver) — ARChoices: HCBS outpatient services to prevent nursing home placement for qualifying adults.

ARChoices definitionHome and community-based outpatient services to prevent nursing home placement among ages 21 through 64 with a physical disability, those requiring an intermediate level of care in a nursing facility, or 65 years of age or older requiring an intermediate level of care in a nursing facility.

Program purposeIntended to provide HCBS outpatient supports to allow qualifying adults to remain in the community rather than in nursing facilities.

Relation to family providersARChoices allows relatives to provide services unless the ARChoices Provider Manual states otherwise; respite cannot be provided by someone living in the member's home.

inv-08: Direct care worker definition — An individual paid to provide direct care services to a member (Direct Support Staff or Professional).

Direct care worker definitionAn individual paid to provide direct care services to a member (Direct Support Staff or Professional).

RoleProvides direct personal assistance and support services to members as part of HCBS or waiver programs.

TerminologyReferred to in source as Direct Support Staff or Professional.

inv-09: Caregiver definition — An individual responsible for protection, in-home care, or custody of a beneficiary by contract.

Caregiver 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.

ContextsIncludes individuals recruited and managed by the beneficiary under IndependentChoices and other arrangements where a contract establishes responsibility.

DistinctionSeparate from legally responsible persons (e.g., guardians) who have court-appointed authority.

inv-10: Person Centered Service Plan (PCSP) — Total plan of care made in accordance with 1915(c) waiver and 1915 state plan service requirements.

PCSP definitionThe total plan of care made in accordance with the planning process as described in the 1915(c) waiver requirements for Home and Community-Based Services (42 CFR §441.301(c)) and 1915 State Plan Services (42 CFR §441.725).

FunctionServes as the member's plan of care that services must follow to be provided and reimbursed.

Program linkageUsed to determine service delivery and compliance with established benefit limits for waiver and State Plan services.

inv-11: Personal Care Services (PCS) — Medically necessary services authorized by DHS to assist beneficiaries with physical dependency needs.

Personal Care Services (PCS)Medically necessary services authorized by Department of Human Services professional staff or designated contractor(s) and individually designed to assist beneficiaries with physical dependency needs.

AuthorizationServices must be authorized by DHS professional staff or designated contractors and delivered according to the member's PCSP and any established benefit limits.

Program examplesPCS is referenced alongside State Plan PCS under IndependentChoices and other HCBS programs with specific hour limits and eligibility criteria.