CurrentFidelis CarePolicy N/A

Personal Care Services (PCS) — Minimum Needs Requirements and Coverage Criteria

Defines coverage, eligibility, authorization, billing, and operational requirements for Personal Care Services for Fidelis Care members receiving community-based long term services in New York State.

Policy Summary

PayerFidelis Care

PolicyPersonal Care Services (PCS) — Minimum Needs Requirements and Coverage Criteria

Policy CodePolicy N/A

Change TypeNew minimum needs requirements (effective 9/1/2025)

Effective DateSep 1, 2025

Next Review DateN/A

Key ActionInitiate initial authorization requests by contacting NYIAP or refer members to a Fidelis Care Intake Coordinator to schedule an NYIAP assessment.

SourceLink

POLICY UPDATE CHANGES

New Minimum Needs Requirements for Personal Care Services (PCS) go into effect September 1, 2025.

>=120 daysmin CBLTSS need duration

2+ ADLsADL assistance threshold

1+ ADLDementia supervision threshold

90claim timeliness (days)

HHAeXchange required

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Coverage Criteria for Personal Care Services (PCS)

Initial Eligibility under New Minimum Needs Requirements (effective 9/1/2025)

Covered when ALL of the following are met

Duration requirement: Member must be in need of Community Based Long Term Services and Supports (CBLTSS) for more than 120 days> 120 days

From new minimum needs requirements effective 9/1/2025

Functional need general: At least limited assistance with physical maneuvering with more than two activities of daily living (ADLs)> 2 ADLs with limited assistance

Applies to general PCS applicants

Dementia-specific requirement: For individuals with a Dementia or Alzheimer's diagnosis: at least supervision with more than one ADL> 1 ADL with supervision

Requires DOH-5821 (Alzheimer's/Dementia Form) documentation at each assessment; diagnosis must be made by an M.D. or D.O.

Individuals granted Plan Legacy Status are not assessed under the new Minimum Needs Requirements; instead, they will continue to be evaluated using the legacy eligibility criteria. Refer to Managed Long Term Care Policy 25.04 for the Legacy Criteria and determination process. This exception is explicitly noted in the PCS guidance and applies to members who have been designated as having Plan Legacy Status.

Covered Personal Care Services are limited to the performance of nutritional and environmental support functions and, for Level II services, associated personal care functions as listed in the policy. Services that fall outside these defined categories — i.e., that are not nutritional, environmental support, or Level II personal care functions (such as tasks not included in the lists like advanced clinical procedures) — are not described as covered under this PCS policy.

Coding and Billing Codes

Nursing AssessmentHCPCSCovered

T1001

LHCSA Nursing Assessment (Nursing Assessment including PRI & Intense cases)

Level I (Housekeeping)HCPCSCovered

S5130U1

Level I (housekeeping) - per 15 mins

Level II (Personal Care)HCPCSCovered

T1019U1	Level II - per 15 mins
T1019U3	Level II Mutual Case (multiple) - per 15 mins
T1019U2	Level II Shared Aide (up to two) - per 15 mins
T1019U4	Level II - Hard to Serve - per 15 mins

Live-in Level IIHCPCSCovered

T1020	Live In Level II - Per Diem (1 unit per day)
T1020U2	Live In Level II Mutual Case (multiple) - Per Diem (1 unit per day)
T1020U5	Live In Level II - Two Client Hard to Serve - Per Diem (1 unit per day)

Nursing SupervisionHCPCSCovered

G0162

Nursing Supervision of Personal Care Providers - one per visit (6-month aide supervisor)

inv-09: Minimum PCS need duration — > 120 days

Minimum duration for initial PCS eligibility> 120 days (member must be in need of CBLTSS for more than 120 days)

Effective date for new requirementSeptember 1, 2025

Applies toIndividuals initially seeking Personal Care Services (PCS)

Exception / legacy statusIndividuals granted Plan Legacy Status continue to be assessed using Legacy Criteria (see Managed Long Term Care Policy 25.04)

Definitions

inv-17: Personal Care Services (PCS) — overview of included assistance functions

Definition of PCSAssistance with personal hygiene, dressing, feeding, nutritional and environmental support functions essential to maintaining health and safety at home.

Typical personal care functions (Level II)Bathing, dressing, grooming, toileting, walking, transferring, feeding, medication administration, routine skin care, use of assistive devices, changing simple dressings.

Nutritional & environmental support functionsMaking/changing beds, light household cleaning, dishwashing, laundry, shopping for the member if needed, preparing meals (including modified diets), listing needed supplies, essential errands.

Assessment requirementNeed for PCS determined by Community Health Assessment (CHA) and Clinical Appointment (CA) with Physician's Order via NYIAP.

inv-18: CBLTSS — Community Based Long Term Services and Supports context for eligibility

Provider Actions, Authorization & Documentation Requirements

Prior Authorization

Initial authorization via NYIAP

Members requesting initial authorization for Personal Care Services will be referred to a Fidelis Care Intake Coordinator to assist with contacting the New York State Independent Assessor Program (NYIAP) for initial assessment and referral to Fidelis Care Intake. Providers or members may also call NYIAP directly at (855) 222-8350 (Mon–Fri 8:30AM–8:00PM; Sat 10:00AM–6:00PM).

Note

Placeholder — Not applicable / not specified

Not applicable / not specified.

Documentation Required

Dementia/Alzheimer's documentation — DOH-5821 required

Individuals with a Dementia or Alzheimer’s diagnosis assessed under the Minimum Needs Requirements must provide documentation of the diagnosis at each assessment using the Alzheimer’s Disease or Dementia Form (DOH-5821). The DOH-5821 must include the individual’s name, date of birth, diagnosis(es), diagnosis ICD-10 code(s), practitioner name, and practitioner license number. The diagnosis must be made by a physician (M.D. or D.O.); the physician does not need to be a NYS Medicaid Provider.

Background

Personal Care Services (PCS) provide in-home assistance essential to maintaining a member's health and safety, including help with personal hygiene, dressing, feeding, and nutritional and environmental support. PCS must be shown to be necessary through a Community Health Assessment (CHA) and a Clinical Appointment (CA)September 1, 2025, new Minimum Needs Requirements apply: initial applicants must need Community Based Long Term Services and Supports (CBLTSS) for more than 120 days and either require limited assistance with physical maneuvering for more than two ADLs or, for members with Dementia/Alzheimer's, require supervision with more than one ADL. Documentation of a Dementia/Alzheimer's diagnosis must be provided on the DOH-5821 form at each assessment.