Jul 12, 2010

Personal Care Assistant Services for Children with Developmental Disabilities Restored

Thursday, July 08, 2010
Advocacy Center settles lawsuit with Agency for Health Care Administration
In late 2009, as part of the transition for personal care assistant (PCA) services for children from the Developmental Disabilities (DD) Waiver to Medicaid state plan, the prior authorization process changed. Those being transitioned began to go through the Agency for Health Care Administration’s (AHCA) peer review organization, KePRO. This change meant that such PCA would not count against the DD Waiver Tier caps.

As part of the change to the delivery of PCA services, AHCA began processing requests for PCA services under a different prior service authorization process and under a different handbook – the AHCA Home Health Services Handbook. AHCA assigned its peer review organization KePRO to conduct the prior service authorizations. KePRO’s decisions resulted in a wave of reductions and terminations of the service for many children, primarily those with a diagnosis of autism.

In response to this pattern of reductions and terminations, the Advocacy Center filed a class action lawsuit against the Agency for Health Care Administration in March 2010. The lawsuit challenged the reductions and terminations of PCA hours for children under 21 who have a diagnosis of autism. The court held a preliminary injunction hearing on May 19, 2010. Subsequent to the hearing, the parties agreed to mediate the case. The Advocacy Center then settled the case under the following terms:

The State agreed to identify any person whose personal care assistant (PCA) services KePRO had reduced in the last twelve months, (through June 7, 2009) and to reinstate each person’s PCA services to the former level. The State further agreed to notify each individual that their hours were being reinstated and that their cases would be re-reviewed by KePRO (or any successor peer review organization). These notices will tell each recipient that if they believe their hours have not been reinstated, they can contact a specific person at AHCA.
The State also agreed that any future notices that reduce or terminate a person’s hours of personal care assistant (PCA) services would contain the following explanations and details:

The specific prong of the State's definition of medical necessity that justifies the reduction or any specific exclusion the State is using to justify the reduction,
The exact language of the specific prong of the medical necessity definition or exclusion that is being used to reduce the services; and
The specific number of hours of personal care services the recipient will receive during each day of the week during the certification period.
The State also agreed to change the definition of Personal Care Assistant (PCA) Services in its Home Health Services Handbook at page 2-22 second paragraph (and in any subsequent revision of the Handbook) to include the following:

"In accordance with federal law, AHCA will pay for such other necessary health care, diagnostic services, treatment and other measures described in Section 1905(a) {42 USC 1396d(a) of the Social Security Act} to correct or ameliorate defects and physical and mental illnesses and conditions discovered by the screening services, whether or not such services are covered under the State plan."
Tips for Families
When requesting personal care assistant (PCA) services, please be aware that the Centers for Medicare and Medicaid Services’ (CMS) State Medicaid Manual in § 4480 describes PCA in broad terms. CMS defines PCA as incorporating not only the basic activities of daily living (ADLs) but also instrumental activities of daily living (IADLs). CMS defines ADLs as including eating, bathing, dressing, toileting, transferring, and maintaining continence and IADLs as more complex life activities and include personal hygiene, light housework, laundry, meal preparation, transportation, grocery shopping, using the telephone, medication management, and money management.

See: http://www.cms.gov/Manuals/PBM/itemdetail.asp?filterType=none&filterByDID=-99&sortByDID=1&sortOrder=ascending&itemID=CMS021927&intNumPerPage=10

If you receive notification of a reduction or termination of personal care services from KePRO, please contact the Advocacy Center for assistance.