Under the 21st Century Cures Act, a $6.3 billion piece of legislation that was signed into law under the Obama administration, Medicaid-funded providers nationwide will be required to adopt new technology to document care delivered in the communities they serve. In an effort to curb fraud, waste and abuse, agencies who provide personal care services will be required to electronically capture the following information next year:
Date of service
Location of service
Individual providing service
Type of service
Individual receiving service
Time the service begins and ends
For purposes of the electronic visit verification (EVV) requirement under SSA section 1903(l), the definitions of “personal care services” and “self-directed personal assistance services” at 42 CFR §§ 440.167 and 441.450 apply, as do any state-specific definitions of the term or similar terms (e.g., personal attendant services, personal assistance services, attendant care services, etc.) in CMS- approved state plan amendments, waivers, and demonstration projects under section 1915(c), (i), (j), or (k), and section 1115. States should also refer to descriptions of the service in CMS guidance, such as the State Medicaid Manual (CMS Manual Pub. #45) section 4480. The definition of “personal care services” is not uniform across all the authorities under which it can be covered as a Medicaid benefit, but in general, it consists of services supporting Activities of Daily Living (ADL), such as movement, bathing, dressing, toileting, and personal hygiene. Personal care services can also offer support for Instrumental Activities of Daily Living (IADL), such as meal preparation, money management, shopping, and telephone use.
Personal care services that are provided to inpatients or residents of a hospital, nursing facility, intermediate care facility for individuals with intellectual disabilities, or an institution for mental diseases, and personal care services that do not require an in-home visit, are not subject to the EVV requirement. CMS is aware that PCS are provided in a variety of settings, including in congregate residential programs such as group homes, assisted living facilities, etc. Stakeholders have questioned whether the EVV requirements apply to PCS provided in those settings offering 24 hour service availability. CMS interprets the reference in the statute to an “in-home visit” to exclude PCS provided in congregate residential settings where 24 hour service is available. This interpretation recognizes inherent differences in service delivery model where an employee of a congregate setting furnishes services to multiple individuals throughout a shift, and services provided to an individual during an in home “visit” from someone coming to a home to provide PCS as specified in the EVV statute. Consistent with this difference in service delivery model, typical reimbursement for services provided in these congregate settings utilizes a per diem methodology, rather than discrete per “visit” or per service payment structures. Therefore, CMS finds that services provided in a congregate residential setting are distinct from an “in home visit” subject to EVV requirements under the statute.
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