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DHCF Initiates Action Plan to Strengthen the Integrity of the DC Medicaid Personal Care Aide Benefit
(Washington, DC)- Today, the Department of Health Care Finance (DCHF) held its first meeting with key stakeholders to discuss the new action plan to strengthen program integrity and control costs in the personal care aide (PCA) benefit of the DC Medicaid program. DHCF Director Wayne Turnage and other DHCF management fielded questions and concerns from about thirty participants.
“The new plan is necessitated by programmatic reviews indicating a need to better manage utilization and understand increasing claims for reimbursement of personal care services,” stated Turnage. “Currently, spending for personal care services under the Medicaid State plan benefit has increased from $71 million in FY08 to $110 million in FY10. That is a 27 percent annual increase in spending for these services. Our plan is an aggressive approach to put this key Medicaid benefit back on track.”
Under the DC Medicaid program, personal care services provides hands-on care to individuals with established disabilities who require assistance to perform the everyday activities that most people can perform for themselves. These activities include bathing, dressing, feeding themselves or using the restroom.
DC Medicaid offers personal care services through three Medicaid benefits: as a routine benefit under the DC Medicaid State plan, and under two waiver programs that offer more intensive services to persons with physical and intellectual disabilities.
“The federal Medicaid program identifies personal care as an optional benefit that states may choose to provide, but are not required to offer,” said DHCF Director Wayne Turnage. “DHCF’s goal is to preserve these Medicaid benefits in our program and ensure that we provide these services in the correct amount to those who need them."
The action plan calls for short and long-term solutions. The short-term actions will include greater physician involvement in prescribing PCA services, stronger assessment tools to aid in care planning, and implementing a more reliable process for approving requests for extended PCA services. More substantial modifications and longer term solutions will involve a combination of state plan amendments and regulations, the added functions of an Administrative Service Organization (ASO), and a review of the Elderly and Persons with Disabilities (EPD) waiver to ensure its effectiveness and that the program is working in concert with the state plan PCA and nursing home benefits.
There are several major reasons for these changes. Under current regulations, personal care services are ordered by a physician. It does not require the prescriber to document the need on a standard form which outlines a specific diagnosis or functional limitation. There is no assessment tool to determine the exact number of hours potentially required by a beneficiary.
To solve the problem, the DHCF will undertake actions in three phases. The short-term (30 day) action plan will include steps to change the way that services are ordered by having them first prescribed by a physician using a standard form that requires the physician to give a diagnosis that certifies the need for personal care services. DHCF will adopt a new assessment tool which will determine the exact number of hours of personal care services required by a beneficiary. DHCF will implement a stronger clinical review of the prior authorization request.
During the short-term action phase, DHCF has already begun to meet with stakeholders to obtain input and share ideas on ways to best provide the services to those truly in need.
DHCF’s long-term action plan will include utilizing the outcomes of meetings with stakeholders to develop and document a plan for coordinating personal care services and other nursing facility benefits. DHCF will also publish a final rule to strengthen the integrity of the personal care services under state plan benefit through improved monitoring and oversight.
The Department of Health Care Finance (DHCF) is the District of Columbia’s state Medicaid agency. The mission of the Department of Health Care Finance is to improve health outcomes by providing access to comprehensive, cost-effective and quality healthcare services for residents of the District of Columbia.