CurrentMontana Department of Public Health & Human ServicesPolicy AB-CFC/PAS 403

Agency-Based Community First Choice and Personal Assistance Services (AB-CFC/PAS) Coverage Criteria

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Governs eligibility, service location, covered ADL/IADL services, limits, and attendant/provider rules for Montana Medicaid members receiving agency-based Community First Choice and Personal Assistance Services.

Policy Summary

PayerMontana Department of Public Health & Human Services

PolicyAgency-Based Community First Choice and Personal Assistance Services (AB-CFC/PAS)

Policy CodePolicy AB-CFC/PAS 403

Change TypeNo material changes

Effective DateJul 1, 2015

Last ReviewJul 1, 2015

Next Review Date

Key ActionObtain MPQH authorization and submit amendments to MPQH for any request to exceed weekly limits for bathing, meal preparation, or exercise.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

3Bathing limit

300Meal prep (min/wk)

210Exercise (min/wk)

ADL required

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CurrentMontana Department of Public Health & Human ServicesPolicy AB-CFC/PAS 403

Agency-Based Community First Choice and Personal Assistance Services (AB-CFC/PAS) Coverage Criteria

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Sign up for Montana Department of Public Health & Human Services Policy AB-CFC/PAS 403 alerts

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Policy Summary

PayerMontana Department of Public Health & Human Services

PolicyAgency-Based Community First Choice and Personal Assistance Services (AB-CFC/PAS)

Policy CodePolicy AB-CFC/PAS 403

Change TypeNo material changes

Effective DateJul 1, 2015

Last ReviewJul 1, 2015

Next Review Date

Key ActionObtain MPQH authorization and submit amendments to MPQH for any request to exceed weekly limits for bathing, meal preparation, or exercise.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

3Bathing limit

300Meal prep (min/wk)

210Exercise (min/wk)

ADL required

Coverage Criteria for AB-CFC/PAS

Covered Services with Authorization Criteria

Covered when ALL of the following are met:

Eligibility and setting: Member resides at home and services are provided in the member's home or local community; AB-CFC/PAS provides hands‑on assistance with Activities of Daily Living (ADL) and selected Instrumental Activities of Daily Living (IADL). The Agency‑Based model applies when the member elects agency responsibility for training, attendant management, and nurse supervision.

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Assessment and authorization: A Service Profile completed by a Mountain Pacific Quality Health (MPQH) registered nurse documents member needs; MPQH authorizes time for ADL tasks based on the direct hands‑on assistance required (from cuing/prompting to total assistance).

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Service limits and amendment requirement: Bathing, meal preparation, and exercise are subject to weekly limits (bathing: 3 baths per week; meal preparation: 300 minutes per week; exercise: 210 minutes per week). If a member's medical condition requires additional baths or additional meal‑prep or exercise time, the provider agency must submit an amendment request to MPQH for additional authorization.

[chunks 6,7]

IADL and related services dependency: IADL tasks (including shopping and household tasks), medical escort, Personal Emergency Response System (PERS), and Skill Acquisition may be authorized only when the member is receiving ADL tasks.

[chunk 10]

Service location and scope constraints: ADL services must be provided in the member's home; some IADLs may be provided in the community but are limited to specified activities (e.g., shopping for essential items, medical escort, community integration (CFC‑only), off‑site laundry). Shopping must be for items essential to the member's health or nutrition, conducted locally with the member present when able, and not for entire household needs; community integration requires a hands‑on need during the activity and cannot be transportation only.

[chunks 2,8]

Immediate family members are not eligible to be reimbursed as Personal Care Attendants (PCAs). Immediate family member is defined as a spouse and the natural, adoptive, or foster parent of a minor child. PCAs must be employees of the provider agency; PCAs cannot operate as independent contractors. Providers must therefore ensure PCA payroll and contracting arrangements reflect agency employment and must not bill Montana Medicaid for attendant services delivered by an immediate family member.

Shopping by a PCA is limited to items essential to the member's health care and nutritional needs and should be done at a local grocery store or pharmacy or in conjunction with an authorized medical escort or community integration activity. The PCA must shop with the member present unless the member’s condition prevents safe travel. PCAs may not shop for the entire household or for items not associated with the member’s specific health care or nutrition (for example, stopping at the bank, post office, or video store). Shopping services should only be provided when informal supports (family or others) are unavailable.

Service Limits and Coding-related Limits

inv-04: Bathing limit

Bathing limit3 baths per week

inv-05: Meal preparation limit

Meal preparation limit300 minutes per week

inv-06: Exercise limit

Exercise limit210 minutes per week

Provider Requirements, Authorization, and Documentation

Prior Authorization

MPQH authorization and amendment requirement

MPQH (Mountain Pacific Quality Health) must authorize time for ADL tasks; if a member requires additional baths beyond three per week, meal preparation beyond 300 minutes/week, or exercise beyond 210 minutes/week, the CFC/PAS provider agency must submit an amendment request to MPQH to authorize the extra time.

MPQH authorizes time for ADL tasks based on direct assistance required.
Amendments are required for additional baths (beyond 3/week), meal preparation time beyond 300 minutes/week, or exercise beyond 210 minutes/week.

Step Therapy

ADL required before IADL/PERS/Skill Acquisition

IADL tasks, medical escort, Personal Emergency Response System (PERS), and Skill Acquisition may only be authorized and provided when the member is authorized to receive ADL tasks.

Providers must ensure ADL authorization is in place before requesting authorization for IADLs, medical escort, PERS, or Skill Acquisition.

Background

Agency-Based Community First Choice and Personal Assistance Services (AB-CFC/PAS) provides hands-on assistance to help Medicaid members remain in the community by supporting Activities of Daily Living (ADLs) and select Instrumental Activities of Daily Living (IADLs). Services are person-centered and tailored from a member Service Profile completed by a Mountain Pacific Quality Health (MPQH) registered nurse, who authorizes time for ADL tasks based on the member’s direct assistance needs. AB-CFC/PAS is delivered in the member’s home or local community under an agency-based model when the member chooses agency management of attendants and nursing supervision, and includes service limits and authorization requirements to ensure appropriate scope and oversight.

Key Definitions

inv-14: Activities of Daily Living (ADL)

Included ADLsBathing; personal hygiene; transferring; positioning; mobility; eating (including tube feedings); dressing; toileting; assistance with exercise; self-administered medication assistance (including reminders); meal preparation

inv-15: Instrumental Activities of Daily Living (IADL)

IADL definitionActivities that support and enhance a member's independence in the community, such as shopping for essential items and household tasks (including laundry)

Community First Choice IADL examplesShopping for essential items; household tasks (including laundry); community integration; correspondence assistance; yard hazard removal

PASA IADL examplesShopping for essential items; household tasks (including laundry)

Policy Summary

PayerMontana Department of Public Health & Human Services

PolicyAgency-Based Community First Choice and Personal Assistance Services (AB-CFC/PAS)

Policy CodePolicy AB-CFC/PAS 403

Change TypeNo material changes

Effective DateJul 1, 2015

Last ReviewJul 1, 2015

Next Review Date

Key ActionObtain MPQH authorization and submit amendments to MPQH for any request to exceed weekly limits for bathing, meal preparation, or exercise.

SourceLink

On This Page

Documentation Required

MPQH-completed Service Profile required

The member Service Profile must be completed by an MPQH registered nurse; MPQH uses the Service Profile to authorize time for ADL tasks based on the time it takes a PCA to provide direct assistance or cueing/prompting.

Service Profile completion by an MPQH RN is required.
MPQH bases ADL time authorizations on direct hands-on assistance or on authorized time for cueing/prompting as documented in the Service Profile.

Documentation Required

Document member needs via Service Profile and PCP

Document the member's needs and service requirements in the member Service Profile and through the person-centered planning (PCP) process; use the Service Profile to reflect direct assistance needs that determine ADL time authorizations.

Person-centered planning (PCP) must document member choice and service preferences.
Service Profile documents specific needs used to justify time authorized for ADL tasks.

Denial Risk

Submit MPQH amendment when exceeding limits — denial risk

If services will exceed published weekly limits (bathing, meal preparation, exercise), the provider agency must submit an amendment request to MPQH (refer to CFC/PAS 719); failure to obtain an MPQH amendment may result in denial of the additional services.

Bathing over 3 times/week, meal preparation over 300 minutes/week, or exercise over 210 minutes/week require an amendment request to MPQH.
Not obtaining the required amendment creates a risk that services beyond limits will be denied.

Note

Timing for 180-day re-evaluation and annual visits

Ensure required 180-day re-evaluations and annual visits are completed while the member is in-state; the member cannot be out of state when these visits are due, and the provider agency may need to complete the visit prior to a trip to avoid jeopardizing authorization.

Member must not be out of state when the 180-day re-evaluation and annual visits are due.
If services are provided out of state, notify the agency and adjust the Service Plan; provider may complete required visits prior to the trip or contact the Regional Program Officer if unable to properly oversee services during travel.

inv-16: Personal Emergency Response System (PERS)

PERS definitionAn electronic, telephonic, or mechanical system to summon assistance in an emergency situation

inv-17: Skill Acquisition

Skill Acquisition definitionA CFC-only service to support a member in achieving independence in a CFC‑approved ADL or IADL task within a three‑month timeframe

Authorization conditionService may be authorized when the member is expected to learn the skill and achieve independence within three months