BMS Provider Manual, Chapter 517 Personal Care Services — Covered Services, Prior Authorizations, Billing, Payments, and Service Limitations (Sections 517.16–517.20)

What this rule requires your agency to do

• 1ADL/IADL tasks provided in the community may not exceed 20 hours per month (§517.16.3.D).(BMS Provider Manual, Chapter 517 Personal Care Services — Covered Services, Prior Authorizations, Billing, Payments, and Service Limitations (Sections 517.16–517.20))
• 2Environmental maintenance (housekeeping, dishes, laundry, etc.) may not exceed one-third of the time spent providing PC services (§517.16.2.C).(BMS Provider Manual, Chapter 517 Personal Care Services — Covered Services, Prior Authorizations, Billing, Payments, and Service Limitations (Sections 517.16–517.20))
• 3The PC direct-care worker cannot perform professional skilled services, including sterile dressing care, colostomy irrigation, tracheostomy care, suctioning, injections (including insulin), administering any medications, catheterizations, or tube feedings (§517.16.3).(BMS Provider Manual, Chapter 517 Personal Care Services — Covered Services, Prior Authorizations, Billing, Payments, and Service Limitations (Sections 517.16–517.20))
• 4Direct care PC services (T1019) are limited to 210 hours (840 units) per month, require prior authorization, are 1:1, and require a Plan of Care log signed and dated by the Direct Care Worker, the provider agency RN, and the member (§517.16.3).(BMS Provider Manual, Chapter 517 Personal Care Services — Covered Services, Prior Authorizations, Billing, Payments, and Service Limitations (Sections 517.16–517.20))
• 5Ongoing RN Assessment and Care Planning (T1002) is limited to six 15-minute units per month, and a person-centered face-to-face PC Assessment signed and dated by the RN and the member must be conducted every six months (§517.16.2).(BMS Provider Manual, Chapter 517 Personal Care Services — Covered Services, Prior Authorizations, Billing, Payments, and Service Limitations (Sections 517.16–517.20))
• 6The initial/annual member assessment (T1001) is limited to one per 300 days and all activities must be conducted by the provider agency RN, who must develop the POC with the member using the BMS approved PC Standards of Care (§517.16.1).(BMS Provider Manual, Chapter 517 Personal Care Services — Covered Services, Prior Authorizations, Billing, Payments, and Service Limitations (Sections 517.16–517.20))
• 7PC services may not be charged while a member is inpatient (nursing home, hospital, rehabilitation or other facility) or incarcerated, and cannot be billed when the member is staying out of state (§517.19).(BMS Provider Manual, Chapter 517 Personal Care Services — Covered Services, Prior Authorizations, Billing, Payments, and Service Limitations (Sections 517.16–517.20))
• 8A Personal Care Agency must not stop direct care services without first consulting the OA, and at no time may a PC provider fail to provide PC services for 30 calendar days without initiating a transfer to a provider who can meet the member's needs (§517.16.3).(BMS Provider Manual, Chapter 517 Personal Care Services — Covered Services, Prior Authorizations, Billing, Payments, and Service Limitations (Sections 517.16–517.20))