Revised - June 2025

Introduction

Agency Model Personal Care (PC) services are medically oriented tasks provided as an alternative to nursing facility care and designed to meet the maintenance needs of individuals with chronic health conditions. PC services must be reasonable according to the participant's condition and functional capacity. Home and Community Based Services (HCBS) providers enrolled as PC providers with the Department of Social Services (DSS), Missouri Medicaid Audit and Compliance Unit (MMAC) deliver the services.

Purpose

Agency Model PC services are funded through the Medicaid State Plan and are designed to assist with activities of daily living (ADL) and/or instrumental activities of daily living (IADL). They are provided as an alternative to nursing facility placement to persons for adults and individuals with disabilities. PC is also provided in a Residential Care Facility (RCF) or Assisted Living Facility (ALF).

Eligibility

All participants must meet the following eligibility criteria:

• At least 18 years of age
• In active Medicaid status (Medicaid Eligibility)
  • Participants who are eligible for Medicaid on a spenddown basis may be authorized to receive PC during periods when they meet their spenddown liability.
  • A participant is responsible for the cost of services received during periods of time when they have not met their spenddown liability.
  • Participants who receive Medicaid due to eligibility for Blind Pension (BP) may be authorized for PC.
  • Participants in a ‘Transfer of Property penalty’ may be authorized for PC.
  • Authorization of PC does not meet the requirements for an individual to be eligible for Home and Community Based (HCB) Medicaid.
  • Have an appropriate Medicaid Eligibility (ME) code.
  • Meet nursing facility level of care.

Authorization

PC units shall be authorized as outlined below:

• Authorized in 15-minute units
• Consistent with the PC tasks to be completed on a regular basis
• Reasonable for the amount of PC units authorized

When developing a Person Centered Care Plan (PCCP) the following shall be taken into consideration:

• PC shall be included in the overall cost of care for the participant as referenced in the HCBS Cost Maximums policy
• PC services shall not exceed 60% of the cost maximum
  • The combination of agency model PC and CDS shall not exceed 60% of the cost maximum.

• The 60% cost maximum can be exceeded by the cost of APC and RN visits, but only up to the full monthly cost of 100%.

  NOTE: When the PCCP includes an authorization for RN services, the cost of one RN visit shall be excluded from the calculation of a PCCP’s cost.

• When the combination of PC, other State Plan services, and an HCBS Waiver e.g., Aged and Disabled Waiver (ADW) or Independent Living Waiver (ILW) exceeds 100% of the monthly cost maximum, approval is required from the Bureau of Federal Programs (BFP).
  • The appropriate supervisor for the Division of Senior and Disability Services (DSDS) staff shall review all PCCP requests over the 100% cost maximum to ensure the participant’s unmet needs require the amount of service requested.
  • If documentation supports the request, the case shall be forwarded to BFP for consideration and approval prior to authorization over 100% of the cost cap.
    • Pending the approval from BFP to exceed the cost maximum, PC services in combination with other State Plan or ADW or ILW services can be authorized up to 100% of the cost maximum.

• When a PCCP includes Adult Day Care authorized through the ADW or the Adult Day Care Waiver (ADCW), the total cost of care cannot exceed 100% of the cost maximum.

  NOTE: Pursuant to federal guidelines, a participant can only be enrolled in one HCBS waiver at a time, regardless of which department administers the waiver program.

Restrictions

The following outlines guidance to adhere to:

• The individual providing the service is an employee of the HCBS provider and cannot be a member of the immediate family of the participant. An immediate family member is defined as a parent, sibling, child by blood, adoption, or marriage (step-child), spouse, grandparent or grandchild.
• Participants authorized for certain services through the Department of Mental Health (DMH) may not be eligible for services as outlined in this policy. Staff shall refer to the DMH Service Coordination policy for guidance on coordination of services for participants authorized for DMH services.

Tasks

Suggested times and frequencies have been developed with the care needs of an average or typical participant in mind. In the development of the PCCP, consideration shall be given regarding the size of the home, geographic location, specific participant limitations, formal and informal supports, and other factors that might affect the amount of time necessary to complete required tasks.

PC services may include any of the following tasks:

• Self-administration of medication is defined in 19 CSR 30-83.010 (46) as the act of actually taking or applying medication to oneself. For example, the time spent handing the medication container and water to the participant so the participant can self-administer their medications would be appropriately calculated in the time for this task. (Suggested time 1 unit/day for self-administration of medications taken up to 3 times daily; 2 units/day for medications taken 4 or more times daily)
• Refer to the RCF/ALF Personal Care – State Plan (Agency Model) policy for self-administration of medication in a RCF/ALF setting.

NOTE: Encouragement (prompting and cueing) and instruction of participants in self-care may be a component of the tasks described above; however, encouragement and instruction do not constitute a task in and of themselves.

Revised - March 2025

Introduction

Advanced Personal Care (APC) (Agency Model) services are maintenance services provided in a participant’s home to assist with activities of daily living (ADL) when this assistance requires devices and procedures related to altered body functions.

Purpose

The authorization of APC services is funded through the Medicaid State Plan. These medically oriented services are designed to meet the physical and maintenance needs of participants with chronic and stable conditions. APC may also be provided in a Residential Care Facility (RCF) or Assisted Living Facility (ALF) through State Plan (Agency Model).

Eligibility

All APC participants must meet the following eligibility criteria:

• At least 18 years of age
• Meet nursing facility level of care (LOC)
• In active Medicaid status:
  • Participants eligible for Medicaid on a spenddown basis may be authorized to receive APC when they meet their spenddown liability.
  • A participant is responsible for the cost of services received during periods of time when they have not met their spenddown liability.
  • Participants who receive Medicaid due to eligibility for Blind Pension (BP) may be authorized for APC.
  • Participants in a ‘Transfer of Property penalty’ may be authorized for APC.
  • Authorization of APC does not meet the eligibility requirements for an individual for Home and Community Based (HCB) Medicaid.
• Have an appropriate Medicaid Eligibility (ME) Code

Authorization of APC

When authorizing APC, the following shall apply:

• APC shall be authorized in increments of 15-minute units
• APC units shall be consistent with the APC tasks to be completed regularly
• The number of APC tasks identified shall be reasonable for authorized APC units
• APC shall be included in the overall monthly cost of care
• APC is provided by HCBS providers enrolled as a Personal Care-Agency Model provider.
• The APC staff is an employee of the HCBS provider and cannot be a member of the immediate family of the participant. An immediate family member is defined as a parent, sibling, child by blood, adoption, or marriage (stepchild), spouse, grandparent, or grandchild.

Cost Maximum

APC authorized together with other Medicaid State Plan Home and Community Based Services (HCBS) and Aged and Disabled Waiver (ADW), services shall not exceed 100% of the average statewide monthly cost for care in a nursing facility without prior approval of the Bureau of Federal Programs (BFP).

• If the documentation supports the request, the case shall be forwarded to BFP for consideration and approval before authorization over 100% of the cost cap
• Pending BFP approval to exceed the cost cap, APC services, combined with other State Plan or ADW services, can be authorized up to 100% of the cost cap
• When a PCCP includes Adult Day Care authorized through the ADW or the Adult Day Care Waiver (ADCW), the total cost of care cannot exceed 100% of the cost cap

NOTE: When the care plan includes RN services, the cost of one RN visit shall be excluded from calculating a care plan’s cost. When the combination of State Plan and ADW services exceeds the 100% cost maximum, the appropriate supervisor for the Division of Senior and Disability Services (DSDS) staff shall review all person-centered care plan (PCCP) requests over the 100% cost cap to address the participant’s unmet needs.

Restrictions

Participants authorized for certain services through the Department of Mental Health (DMH) may not be eligible for services as outlined in this policy. Staff shall refer to the Service Coordination Policy for guidance on coordinating services for participants authorized for DMH services.

Allowable Services

Participants who meet eligibility requirements may be authorized for any of the following services:

• Aseptic Dressings: (Suggested time 15 minutes per ordered instance)
  • Application of dressings to superficial skin breaks or abrasions as directed by a licensed nurse
  • Application of medicated (prescription) lotions and ointments to unbroken skin, including stage 1 decubitus
• Assistance with Transfer Device: (Suggested time 15 minutes per instance)
  • Use of an assistive device for transfers
• Bowel/Bladder Program: (Suggested time 15 minutes per ordered instance)
  • Administration of prescribed bowel programs, including suppositories and sphincter stimulation per protocol and prepackaged enemas for participants without contraindicating rectal or intestinal conditions
  • Catheter Hygiene: (Suggested time 15 minutes per instance)
  • Changing of bags, soap and water hygiene around the site of external, indwelling, and suprapubic catheters
  • Removal of external catheters, skin inspection, and catheter reapplication
• Non-Injectable Medications: (Suggested time 15 minutes per ordered instance)
  • Manual assistance with non-injectable medications may include opening a medicine lockbox, steadying the participant’s hand/arm for ear and eye drops, finger sticks for blood sugar monitoring and reading levels and when prompting is required to take medication
• Ostomy Hygiene: (Suggested time 15 minutes per instance)
  • Changing of bags, soap and water hygiene around a well-healed ostomy site (including tracheostomies, gastrostomies, and colostomies)
• Passive Range of Motion: (Suggested time 15 minutes per ordered instance)
  • Administration of movement of a joint through its full range of motion, delivered by the care plan

NOTE: Encouragement (prompting and cueing) and instruction of participants in self-care may be a component of the task; however, encouragement and instruction do not constitute a task in and of themselves.

Revised - July 2026

Introduction

Nurse visits are provided by Home and Community Based Services (HCBS) providers participating in the Personal Care Agency Model for participants authorized for Personal Care (PC), Advanced Personal Care (APC), or Consumer Directed Services (CDS) services. During visits, the nurse may assess the participant’s health, review the care plan, supervise the personal care aide, or provide maintenance or preventive services. Concerns or changes in the participant’s condition are communicated to the participant, the aide, and DSDS staff. When needed, the nurse recommends updates to the care plan to support the participant’s safety and ability to remain at home. These visits offer ongoing monitoring for individuals with stable, chronic conditions and are not intended to replace services that should be provided through home health care.

Eligibility

To be eligible for nurse visits, all participants must meet the following criteria:

• At least 18 years of age
• Have an appropriate Medicaid Eligibility (ME) code
• Meet nursing facility level of care
• In active Medicaid status 
• Participants who are eligible for Medicaid on a spenddown basis may be authorized to receive nurse visits during periods when they meet their spenddown liability.
• A participant is responsible for the cost of services received during periods of time when they have not met their spenddown liability. 

In addition, participants who receive Medicaid due to eligibility for Blind Pension (BP) or are in a ‘Transfer of Property penalty’, may be authorized for nurse visits.

NOTE: The authorization of nurse visits does not meet the requirement for an individual to be eligible for Home and Community Based (HCB) Medicaid.

Authorization

• An immediate family member is defined as a parent, sibling, child by blood, adoption, or marriage (stepchild), spouse, grandparent or grandchild.
• A maximum of 26 nurse visits will only be provided in a six-month authorization period
• Authorized nurse visits reimbursed through the HCBS program shall not include nursing services that should be billed to another program (i.e., home health or skilled nursing services), or visits made to determine if a participant qualifies for HCBS services.
• When a service need is detected that requires skilled nursing care, the provider shall forward information to the participant's physician. The physician may then issue home health orders as appropriate.
• Participants authorized for certain services through the Department of Mental Health (DMH) may not be eligible for services as outlined in this policy 
• DSDS staff shall refer to the DMH Service Coordination policy for guidance on coordinating services for participants authorized for DMH services.

NOTE: When a provider change occurs, the new provider shall only be authorized for the nurse visit(s) remaining within an existing authorization period. 

Cost Maximum

Authorized nurse visits shall be included in the overall cost of care (HCBS Cost Maximums) with the following exceptions: 

• The cost of authorized nurse visits is not included in the 60% monthly maximum cost for basic PC
• The cost of one (1) authorized nurse visit is not included in the 100% monthly cost for basic PC
• The cost of two nurse visits shall be excluded from the calculation of a PCCP cost when nurse visits are authorized for General Health Evaluations (GHE) only 

NOTE: The electronic case record system will automatically exclude the nurse visit(s) from the calculation of the PCCP.

• Nurse visits authorized together with other Medicaid State Plan HCBS, i.e., Agency Model PC, CDS, Advanced Personal Care (APC), and Aged and Disabled Waiver Services (ADW) shall not exceed 100% of the monthly cost for care in a nursing facility without prior approval from the Bureau of Federal Programs (BFP).
• When the combination of State Plan and ADW services (excluding Adult Day Care) exceeds the 100% cost maximum: 

• The appropriate supervisor for DSDS staff shall review all PCCP requests to ensure unmet needs require the amount of service requested.

  If documentation supports the request, it shall be forwarded to BFP for consideration and approval prior to authorizing over 100% of the cost maximum.

• Authorized nurse visits in combination with other state plan or ADW services can only be authorized up to 100% of the cost maximum until approval is given by BFP to exceed the 100% maximum

NOTE: When a PCCP includes Adult Day Care, authorized through the ADW or the Adult Day Care Waiver (ADCW), the total cost cannot exceed 10cds0% of the cost maximum.

General Health Evaluations

All participants receiving Agency Model PC and APC shall be authorized a minimum of two (2) nurse visits annually to perform General Health Evaluations (GHE) as required by MO State Statute 192.2475.14 RSMo.   The semi-annual nurse visits are necessary for the delivery and supervision of the individual providing services to ensure quality of care, assessment of the participant’s health, and adequacy of the participant’s PCCP.

Excluded from the requirement for semi-annual nurse visits are those participants authorized for:

• Personal Care Services (Agency Model) in a Residential Care Facility (RCF) or Assisted Living Facility (ALF)
• Aged and Disabled Waiver services only
• Personal Care Assistance (Consumer-Directed Model) only
• Independent Living Waiver only 
• Adult Day Care Waiver only
• Structured Family Caregiving Waiver

Participants with a documented need for other nursing tasks shall not be authorized for separate semi-annual nurse visits. DSDS or its designee shall inform the provider that the General Health Evaluation (GHE) and Level of Care Recommendation form shall be completed during the regularly scheduled nurse visit in the 4^th and 10^th months following the (re)assessment, as outlined in the General Health Evaluation Chart below.   

When authorizing the GHEs in the electronic case record, select only the first month of the GHE. The second month will automatically populate.

DSDS or its designee shall review the GHEs to help guide assessment and care planning processes. If the participant is identified as needing a change in their care plan, whether an increase or decrease in services, the nurse shall notify the Person Centered Care Planning team of the recommended changes.

Regular Nurse Visits

For authorized nurse visits other than the required semi-annual GHE visits, DSDS or its designee must verify and document that no other person is willing and able to provide the service. Such documentation may include, but is not limited to:

• Participant lives alone 
• Lack of capable family support 
• Unwillingness/incapability of other available individuals to provide the needed services
• Resident of RCF or ALF requires services beyond what is normally included in the monthly room and board reimbursement to the facility, RCF/ALF PC

In addition to increased supervision of the aide, and assessment of the participant’s health and adequacy of the care plan, authorized nurse visits may also include the following: 

• Medications
• Filling insulin syringes weekly for diabetics who can self-inject the medication but cannot fill their own syringes. 
• Documentation must be sufficient to establish that the participant has a diabetic condition impairment that prevents the participant from independently filling syringes.
• Oral medication set-ups in divided daily compartments for participants who self-administer prescribed medications but need assistance and monitoring due to confusion or disorientation.

• Documentation must be sufficient to establish the need for medication and that the participant is disoriented or confused. Although self-control of prescription and over-the-counter medications

  may be allowed in an RCF or ALF with written permission from the resident’s physician and allowed by facility policy, this task would not be applicable for RCF and ALF residents who are authorized for Personal Care in an RCF or ALF. 

• Monitoring Skin Condition
• Check for possible skin breakdown due to immobility, incontinence, or other needs as described below.
• Unable to turn and position self
• Limited ability to ambulate, with long periods of time sitting or lying in one position, or is documented to be incontinent
• History of decubitus ulcers, poor circulation evidenced by edema or discolored extremities, and diabetes
• Documentation must be sufficient to establish the participant is at risk of skin breakdown.
• Nail Care
• Monthly visits to provide nail care for diabetic participants or participants with other medically contraindicating conditions, including but not limited to participants:
• Taking anticoagulant medication, such as Coumadin
• Diagnosed with peripheral vascular disease
• Diagnosed with a condition causing foot or nail deformities that need specialized treatment
• Diagnosed with a compromised immune system (e.g. HIV and chemotherapy patients)
• Documentation shall be sufficient to establish the participant has a medical condition AND is unable to perform this task.

Other Nursing Care

Participants may receive nurse visits for specific tasks when their needs cannot be met and are not reimbursable through the home health program. DSDS or its designee shall approve nurse visits for “other” non-routine nursing tasks after consultation with the participant, provider nurse, DSDS supervisor and, as necessary, the physician. 

The “other” nursing tasks may include, but are not limited to:

• Administration of injectable medications (other than insulin)
• Venipunctures
• Catheter changes
• Enemas (only when not utilizing a prepackaged enema)
• Wound dressing changes
• Central line dressing/flush/blood draws

Providers with written documentation should upload it to the participant’s electronic case record and include documentation in case notes.

NOTE: It is not necessary for DSDS or its designee to obtain copies of a physician’s orders prior to the authorization of a nurse visit or adding a task to a nurse visit. 

Advanced Personal Care

All APC participants shall be authorized for a monthly nurse visit to evaluate the adequacy of service delivery and ensure the participant's needs and conditions are met. All APC participants shall be authorized for a monthly nurse visit to evaluate the adequacy of service delivery and ensure the participant's needs and conditions are met. APC aides providing the services shall be trained in the APC tasks they deliver. During the monthly visit, the nurse assesses the APC aide’s ability to carry out the services. 

If a participant is not authorized for weekly nurse visits, an additional nurse visit shall be authorized during the first full month of the APC aide's on-the-job training. DSDS staff or its designee shall select the Train APC task for the one-time visits.

Participants who receive weekly nurse visits shall not have the Train APC task selected. In these circumstances, the Train APC should be authorized as an RN visit for the one-month authorization period. The task should be performed by the nurse during the regular nurse visit as needed.

The Train APC task is to be completed as follows:

• Once during the first full month of an initial authorization of APC, or following the addition of an APC task to the care plan 
• At the time of an APC provider change
• When requested by the provider (e.g., when aides change), to provide on-the-job training of the APC aide

When developing the PCCP, two RN visits must be added as outlined: 

• One unit is entered for Train APC and two units for Eval APC. 
• The Evaluate APC task must be authorized for two units during the first month to allow the provider to bill separately for both the training and the evaluation of the APC aide, as these will occur during two separate visits.

NOTE: To prevent duplicate prior authorizations, the start and end dates of each authorization must not overlap.

Example Of APC Authorization With A Monthly RN Visit

1st RN Authorization

2nd RN Authorization

Example Of APC Authorization With Weekly RN Visit

1st RN Authorization

2nd RN Authorization

Example Of APC Authorization With No Monthly Or Weekly Nurse Visits

1st RN Authorization

2nd RN Authorization

Introduction

Personal Care (PC) services are maintenance services provided to residents of Residential Care Facilities (RCF) or Assisted Living Facilities (ALF) to assist with activities of daily living (ADL). Services are authorized to eligible residents when the resident's needs exceed the facility's minimum obligations as established in the licensure requirements.

RCFs or ALFs are responsible, at a minimum, for the basic human needs of its residents. The facilities are also responsible for assuring the resident's PC needs are met through the resident's resources or other available resources. The facilities are responsible for 24-hour protective oversight of residents and room and board. The reimbursement the facility receives from the resident (Supplemental Security Income (SSI), Social Security Administration (SSA), etc.) and a supplemental cash grant from the Department of Social Services (DSS) is intended to cover safe shelter needs (including housekeeping, basic linens, and the maintenance thereof) and nutritional needs (food and food preparation).

Purpose

RCF/ALF Personal Care services are designed to support residents' additional needs in this setting and are funded through Medicaid State Plan. Basic Personal Care, Advanced Personal Care and Authorized Nurse Visits are all allowable service types offered to residents with an identified need that goes above and beyond the facility's basic requirements.

Eligibility

All PC participants must meet the following eligibility criteria to receive services in an RCF/ALF:

• At least 18 years of age
• In active Medicaid status:
  • Participants eligible for Medicaid on a spenddown basis may be authorized to receive services during periods they meet their spenddown liability.
  • A participant is responsible for the cost of services received during periods of time when they have not met their spenddown liability.
  • Participants who receive Medicaid due to eligibility for Blind Pension (BP) may be authorized for services in the RCF or ALF.
    • Participants in a ‘Transfer of Property penalty’ may be authorized for services in the RCF or ALF.
  • Have an appropriate Medicaid Eligibility (ME) Code.
• Meet nursing facility level of care (LOC)

Referrals

Referrals for PC services shall be made to the Department of Health and Senior Services (DHSS), Division of Senior and Disability Services (DSDS). DSDS shall screen and process the referral as appropriate, utilizing the same timeframes as all other HCBS.

HCBS participants requesting PC services may make a referral by contacting the HCBS Customer Service Center. Providers should initiate referrals by utilizing the Online HCBS Referral Form. In instances when referrals cannot be submitted online, referrals can be submitted by completing the Home and Community Based Services Referral Form. In addition to the referral forms, referrals may include a Physician’s Prescription for Personal Care.

Assessment

When arriving at an RCF/ALF and completing a (re)assessment, DSDS staff or its designee shall:

• Announce themselves to facility staff and indicate the intent of the visit before meeting with the current or potential participant
• Document the room condition where the current or potential participant resides in case notes
• DSDS or its designee must review the participant’s facility chart to verify information that will assist in determining the (LOC) and assistance needed. Items to verify include but are not limited to:
  • Diagnosis and frequency of mental health physician visits
  • Physician-ordered treatments, medications, or special diets the participant receives
• Make other collateral contacts, including, but not limited to, RCF or ALF staff (Administrator/manager, licensed nurse, PC aide who provides daily services), family, friends, legal representatives, or physicians to obtain information to complete the assessment process
• Make decisions regarding the authorization of PC services in consultation and agreement with the participant, the participant’s legal representative (if applicable), and the participant’s physician
• Ensure the services authorized shall reinforce and enhance the participant's current formal and informal support system
  • Reimbursement for PC services cannot duplicate what is covered in other reimbursements to the facility (e.g., routine linen changes and meal preparation).

Authorization

RCF/ALF PC services are also governed by the average statewide monthly cost for care in a nursing facility. PC units shall be authorized as outlined below:

• PC services shall not exceed 60% of the cost maximum
• The 60% cost maximum can be exceeded by the cost of APC and RN visits, but only up to the full monthly cost of 100%
• All combined PC services shall not exceed 100% of the average statewide monthly cost for care in a nursing facility

NOTE: When the care plan includes authorization for RN services, the cost of one RN visit shall be excluded from the calculation of a care plan’s cost.

Tasks

Residents who meet the necessary Medicaid eligibility requirements may be authorized for any of the following combinations of services provided.

Basic Personal Care

Basic Personal Care (PC) services in RCF/ALF shall be authorized in 15-minute units and are generally medically oriented tasks designed to meet the physical and maintenance needs of participants with chronic, stable conditions. PC may include the following tasks:

• Bathing
  • Direct assistance with bathing and shampooing hair that requires active participation by the aide. (e.g. hands-on washing assistance, assistance in or out of the bath, gathering supplies/clean clothing, etc.) (Suggested time 15-45 minutes per bath)
• Dietary
  • Direct assistance with meal preparation, feeding and clean up. Dietary shall be authorized when the participant has a physician-ordered specialized diet. Dietary may also be authorized if the participant needs assistance with feeding, cutting up food, carrying a tray to the table, opening containers, etc. Authorization of service units must be based on the participant’s specific needs. (Suggested time 15- minutes per meal)
  • DSDS or its designee shall review any physician-ordered diet before authorizing units for dietary needs. No units shall be authorized for meal preparation and clean-up unless facility staff exceeds licensure requirements.
• Dressing/Grooming
  • Direct assistance with dressing and undressing, combing hair, nail care, oral hygiene, shaving, and assisting with prosthetics. (Suggested time 15 minutes per dressing instance)
• Medically Related Household Tasks
  • Assistance with required cleaning that goes above and beyond the minimum housekeeping requirements of the facility. Time may be authorized if the participant has a medically related need that requires the facility staff to clean a resident’s living area more often than usual (e.g. profuse bodily secretions, excess bodily fluids from incontinence, destructive tendencies, hoarding, etc.). DSDS or its designee can authorize services to clean the resident’s living area and launder the resident’s clothes and linens. (Suggested time 15-minutes per instance)
• Mobility and Transfer
  • Direct assistance with mobility, transfer, and ambulation when the participant can at least partially bear their weight. (Suggested time 5-10 minutes per instance)
• Self-Administration of Medications
  • Direct assistance with medications and applying nonprescription topical ointments or lotions (e.g. the time spent handling the medication container, including inhalers, medicines for nebulizers, ointments/lotions, steadying the participant’s hand/arm to get oral medication and inhalants to mouth, and water to the participant. (Suggested time 1 unit/day for self-administration of medications taken up to 3 times daily; 2 units/day for medications taken 4 or more times daily)
    • Medication administration is not a covered task within the PC program. The self-administration of medication task does not include the time required by facility staff to administer the medication. Administration of medication is defined in 19 CSR 30-86.042(51) as delivered to a resident their prescription medication either in the original pharmacy container or for internal medication, removing an individual dose from the pharmacy container and placing it in a small container or liquid medium for the resident to remove from the container and self-administer.
• Toileting
  • Direct assistance with toileting tasks. This may include assistance using or transferring to/from the toilet, commode, bedpan, urinal, cleansing after use and assistance with incontinence episode(s) (The suggested time is 5 minutes multiplied by times per day based upon the suggested frequency needed).
    • Encouragement (prompting and cueing) and instruction of participants in self-care may be a component of the services; however, encouragement and instruction do not constitute a task in and of themselves.

Advanced Personal Care

Advanced Personal Care (APC) services shall be authorized in 15-minute units and are medically oriented tasks designed to meet the physical and maintenance needs of participants with a chronic, stable condition when such assistance requires devices and procedures related to altered body functions. APC may include the following tasks:

• Aseptic Dressings
  • Application of dressings to superficial skin breaks or abrasions as directed by a licensed nurse. (Suggested time 15 minutes per ordered instance)
  • Application of medicated (prescription) lotions and ointments to unbroken skin, including stage 1 decubitus. (Suggested time 15 minutes per ordered instance)
• Bowel Program
  • Administration of prescribed bowel programs, including suppositories and sphincter stimulation per protocol and prepackaged enemas for participants without contraindicating rectal or intestinal conditions. (Suggested time 15 minutes per ordered instance)
• Catheter Hygiene
  • Changing of bags, soap and water hygiene around the site of external, indwelling, and suprapubic catheters. (Suggested time 15- minutes per instance)
  • Removal of external catheters, skin inspection, and catheter reapplication. (Suggested time 15- minutes per instance)
• Non-Injectable Medications
  • Manual assistance with non-injectable medications, as set up by a licensed nurse, may include opening a medicine lockbox, steadying the participant’s hand/arm for ear and eye drops, finger sticks for blood sugar monitoring and reading levels and when prompting is required to take medication. (Suggested time 15 minutes per ordered instance)
• Ostomy Hygiene
  • Changing of bags, soap and water hygiene around a well healed ostomy site (including tracheostomies, gastrostomies, and colostomies). (Suggested time 15- minutes per instance)
• Passive Range of Motion
  • Administration of movement of a joint through its full range of motion, delivered in accordance with the care plan. (Suggested time 15 minutes per ordered instance)

Authorized Nurse Visits

Authorized Nurse Visits (RN) are authorized by the visit. No minimum or maximum time is required to constitute a visit. RN services are maintenance or preventative services provided by a Registered Nurse (RN) or a Licensed Practical Nurse (LPN) under an RN's or physician's direction.

Authorized Nurse Visit tasks may include:

• Evaluate APC Care Plan
  • All APC participants shall be authorized for an RN visit monthly to evaluate the adequacy of the authorized services to meet the participant’s needs and assess the APC aide’s ability to carry out the authorized services.
• Other RN Care
  • Monitor skin condition(s)
  • Nail care: Monthly visits to provide nail care for diabetic participants or participants with other medically contraindicating conditions, including but not limited to participants:
    • Taking anticoagulant medication
    • Diagnosed with peripheral vascular disease
    • Diagnosed with a compromised immune system
  • Administration of injectable medications (other than insulin)
  • Venipunctures
  • Catheter changes
  • Enemas (only when not utilizing a prepackaged enema)
  • Central line dressing/flush/blood draws

Revised - January 2026

Introduction

Personal Care Assistance Consumer Directed Services (CDS) is a Home and Community Based Services (HCBS) program offered through the Division of Senior and Disability Services (DSDS). CDS is available to participants who can direct their own care and can live independently. CDS participants select an HCBS provider that is enrolled as a CDS provider with the Department of Social Services (DSS), Missouri Medicaid Audit and Compliance (MMAC) Unit. Payment is made to the HCBS provider on behalf of the participant. The HCBS provider processes payroll, on behalf of the participant, to the individual providing the services.

Authorization of Personal Care Assistance is funded through both the Consumer-Directed Model Medicaid State Plan and the Independent Living Waiver (ILW). This policy addresses State Plan services only. Refer to the ILW Policy for additional information regarding services through the ILW.

Purpose

CDS provides assistance with activities of daily living (ADL) and/or instrumental activities of daily living (IADL) provided as an alternative to nursing facility placement to persons with a physical disability.

Eligibility

All CDS participants must meet the following eligibility criteria:

• Be at least eighteen (18) years of age
• Be physically disabled, as defined by 19 CSR 15-8.100
  • Loss of, or loss of use of, all or part of the body's neurological, muscular, or skeletal functions to the extent the person requires the assistance of another person to accomplish routine tasks.
• Be able to self-direct their CDS
• In active Medicaid status
  • Participants eligible for Medicaid on a spenddown basis may be authorized to receive CDS during periods when they meet their spenddown liability.
    • During periods when the participant has not met their monthly spenddown liability amount, the participant and provider may make a private arrangement for the continued delivery of services. In these instances, the participant is responsible for the cost of services received.
  • Participants who receive Medicaid due to eligibility for Blind Pension (BP) may be authorized for CDS.
  • Participants in a ‘Transfer of Property penalty’ may be authorized for CDS.
  • Authorization of CDS does not meet the requirements for an individual to be eligible for Home and Community Based (HCB) Medicaid.
• Have an appropriate Medicaid Eligibility (ME) Code
• Meet nursing facility level of care (LOC)
• Have not been previously involved in Medicaid fraud

Self-Directed Determination

A current or potential CDS participant is required to have the ability to direct their care per 208.903.1.(4), RS Mo. Consumer directed is defined as the hiring, training, supervising, and directing of the personal care attendant. Section 208.909.1, RSMo states that current or potential participants must be able to fulfill the following responsibilities:

• Supervise the personal care attendant
• Verify the wages to be paid to the personal care attendant
• Monitor proper Electronic Visit Verification (EVV) usage
• Notify DSDS staff or its designee of any changes affecting the CDS Person-Centered Care Plan (PCCP) or the participant’s place of residence
• Report any problems resulting from the quality of services rendered by the personal care attendant to the participant’s provider
  • It shall be reported to DSDS staff or its designee if the problem cannot be resolved through the provider.
• Report to DSDS significant changes in participant’s health and/or ability to self-direct their care

Documentation shall be provided in the participant’s electronic case record if it is determined that a current or potential participant requesting CDS cannot direct their care or fulfill the responsibilities of a CDS participant. Examples of documentation may include, but are not limited to:

• Responses to questions from the current or potential participant during the assessment process that need further clarification. Questions are to be posed to the current or potential participant.
  • If another individual responds on behalf of the current or potential participant, this must be documented in the case notes.
• Completion of the Self Direction Assessment questions
  • If the Self Direction Assessment Questions are utilized, answers to the questions shall be provided as an exhibit if the current or potential participant appeals the decision that they cannot self-direct services.
• Completion of the St. Louis University Mental Status (SLUMS) exam. This may be utilized when there is a concern regarding an individual’s ability to self-direct.
  • The instructions to the SLUMS provide background information on the exam, clarifies when the exam shall be utilized, and defines further evaluation which must be pursued.
• Statements or medical records from the current or potential participant’s healthcare professional documenting any functional limitations preventing the individual from self-directing
  • The Healthcare Professional Inquiry may be utilized when there are concerns regarding the current or potential participant’s ability to self-direct. The response received from the Healthcare Professional Inquiry shall be documented and uploaded to the electronic case record along with other self-direction determination documents if utilized.

If a thorough review of all available information has taken place and the current or potential participant cannot self-direct, Adverse Action procedures shall be followed, and DSDS staff or its designee shall advise that individual and/or the authorized representative of other available options. The Collateral Contacts Policy outlines the various services available through alternative HCBS. Current or potential participants shall be advised that Personal Care (PC) and Advanced Personal Care (APC) services are comparable to services available through the CDS program.

• DSDS staff or its designee shall document the discussions held regarding the availability of other services.

Restrictions and Limitations

CDS shall not be authorized to pay for services when:

• The primary benefit is to a household unit.
• The task is one that household members may reasonably be expected to share or do for one another unless the task is above and beyond typical activities provided for a household member without a disability.
• CDS does not include any task that must be performed/ trained by a licensed professional (i.e., skilled nursing, therapies ordered by a physician, etc.).
• A physically disabled person who can direct their care but has a cognitive impairment that requires a designated person to assist with the administration of the program can only be authorized through the ILW.
• Participants authorized for self-directed services through the Department of Mental Health (DMH) are not eligible for services as outlined in this policy. Staff shall refer to the Service Coordination Policy for guidance on coordinating services for participants authorized for DMH services.
• Individuals who reside in a nursing facility, Residential Care Facility (RCF) or Assisted Living Facility (ALF) licensed by DHSS, Division of Regulation and Licensure (DRL) are not eligible for CDS.
• The ‘CDS Restricted’ checkbox in the participant’s electronic case record has been checked. This box can be checked when:
  • DSDS staff followed the procedures outlined in the Adverse Action policy and Appeal and Hearing Process. Services shall not be closed until the 10-day appeal time frame has passed, and the participant has not appealed, or until the Department of Social Services (DSS), Division of Legal Services (DLS) has made its final decision for the appeal hearing affirming the adverse action.
  • As appropriate, all current authorization(s) for CDS shall be closed, and other HCBS that may meet the participant's needs have been offered to the participant, e.g., Agency Model.
• The attendant shall not:
  • Have been involved in Medicaid fraud previously
  • Be a current CDS participant
• Participants can exercise individual choice in deciding who provides their CDS. The CDS participant is the attendant’s employer-of-record.
  • The attendant may be a family member. However, the attendant cannot be the participant’s spouse or legal guardian.

NOTE: An individual with a guardian or conservator cannot be rejected for CDS solely for that reason. Explanation for the need of a guardian or conservatorship can justify the reason to reject CDS due to cognitive inabilities to self-direct. DSDS staff or its designee shall obtain a copy of the appointment order.

Authorization

The following is an overview of CDS authorizations and tasks:

• CDS shall be authorized in 15-minute units
• CDS shall be included in the overall cost of care for the participant as referenced in the HCBS Cost Maximums policy
• CDS shall not exceed 60% of the cost maximum
  • The combination of CDS and agency model PC shall not exceed 60% of the cost maximum.
• The 60% cost maximum can be exceeded by the cost of APC and RN visits, but only up to the full monthly cost of 100%.

NOTE: When the care plan includes RN services, the cost of one RN visit shall be excluded from the overall care plan cost.

• When the combination of CDS, other State Plan services, and an HCBS Waiver (e.g., Aged and Disabled Waiver (ADW) or ILW) services exceed the cost maximum by the cost of the waiver services:
  • The appropriate supervisor for the DSDS staff shall review all PCCP requests over the 100% cost maximum to ensure the participant’s unmet needs require the amount of service requested.
  • If documentation supports the request, the case shall be forwarded to the Bureau of Federal Programs (BFP) for consideration and approval prior to authorization over 100% of the cost maximum.
  • Pending the approval from BFP to exceed the cost maximum, CDS in combination with other State Plan or ADW services can be authorized up to 100% of the cost maximum, excluding PC and/or CDS, which may never exceed 60% of the cost maximum.

NOTE: When a PCCP includes Adult Day Care authorized through the ADW or the Adult Day Care Waiver (ADCW), the total cost of care cannot exceed 100% of the cost maximum.

Under federal guidelines, a participant can only enroll in one (1) HCBS Waiver at a time, regardless of what agency administers the waiver program.

Tasks

CDS provides “hands-on” assistance with physical tasks that benefit the participant and are based on the participant's physical limitations. No time can be authorized for the following:

• Stand-by assistance, prompting, or cueing
• Respite care or for time spent waiting for a participant at any appointment

CDS may include any of the following tasks:

• Assistance with Transfer Device
  • Use an assistive device for transfers
• Bathing
  • Direct assistance with bathing and shampooing hair that requires active participation by the aide (e.g., hands-on washing assistance, assistance in or out of the bath, gathering supplies/clean clothing, etc.)
• Bowel/bladder
  • o Administration of prescribed bowel programs, including the use of suppositories and sphincter stimulation per protocol and pre-packaged enemas for participants without contraindicating rectal or intestinal conditions
• Catheter hygiene:
  • Changing bags and soap and water hygiene around the site of external, indwelling, and suprapubic catheters.
  • Removal of external catheters, inspect skin, and reapply catheter
• Change linens
• Clean bath
• Clean floors
• Clean kitchen
• Cleaning/maintaining equipment
  • Wheelchairs, bedside commodes, shower chairs and nebulizer machines, etc
• Dressing/grooming:
  • Direct assistance with dressing and undressing, combing hair, nail care, oral hygiene, shaving, and assisting with prosthetics
• Essential correspondence
• Essential transportation, including all essential shopping/errands (regardless if the participant is with the CDS attendant), medical appointments, school, or employment, etc.
  • For the participant to be eligible for transportation assistance, there must also be an identified need for personal care assistance, even if that need is met by supports other than CDS.
  • CDS Transportation does not include transporting to medical appointments when that appointment is covered under the Non-Emergency Medical Transportation (NEMT) program. To determine if NEMT covers the medical appointment, contact the NEMT provider at 1-866-269-5927.
• Laundry (home)
• Laundry (off-site)
• Make bed
• Meal prep/eating
  • Direct assistance with meal preparation, feeding and clean up.
• Medications
  • Direct assistance with medications (e.g., the time spent handling the medication container, including inhalers, medication for nebulizers, ointments/lotions, steadying the participant’s hand/arm to get oral medication and inhalants to mouth, and water to the participant)
• Mobility/transfer
  • Direct assistance with mobility, transfer, and ambulation when the participant can at least partially bear their weight
• Ostomy hygiene
  • Changing bags and soap and water hygiene around an ostomy site (including tracheostomies, gastrostomies, and colostomies, all with a well-healed stoma)
• Passive Range of Motion
  • Passive range of motion (non-resistive flexion of joint within normal range) delivered in accordance with the care plan
• Tidy and Dust
• Toileting
  • Direct assistance with toileting tasks. This may include assistance using or transferring to/from the toilet, commode, bedpan, urinal, cleansing after use and assistance with incontinence episode(s). (The suggested time is 5 minutes multiplied by the number of times assistance is given per day based upon the suggested frequency needed)
• Trash
• Treatments
  • Eye drops, rubbing creams or lotions that are prescribed or non-prescribed
• Turning/positioning
• Wash dishes

Calculating Essential Transportation

Essential transportation is entered on the care plan as minutes per month. To calculate essential transportation, the total number of minutes needed per day is multiplied by the number of days per month. Utilize the chart below to determine the number of days per month based on the frequency per week.

Calculation Formula: number of minutes per day x number of days per month = number of minutes per month

NOTE: To account for months with 5 weeks, the formula always calculates based on a five-week month.

The total number of minutes should be entered on the care plan.

Example: 90 minutes, once a week: 90 x 5 = 450 minutes

Example: 60 minutes, twice a week: 60 x 10 = 600 minutes

Example: 60 minutes, three times a week: 60 x 15 = 900 minutes

Example: If there is an unexpected outing, such as a medical appointment not covered by NEMT, the additional time for the appointment should be calculated and added to the current authorization for essential transportation.

Revised - January 2018

Adult Day Care Waiver (ADCW) is the continuous care and supervision of a disabled adult in a licensed adult day care setting. Services include but are not limited to assistance with activities of daily living, planned group activities, food services, client observation, skilled nursing services as specified in the plan of care, and transportation. Planned group activities include socialization, recreation and cultural activities that stimulate the individual and help the participant maintain optimal functioning. The provider must arrange or provide transportation to the adult day care facility at no cost to the participant. Reimbursement will be made for up to 120 minutes per day of transportation related to transporting an individual to and from the Adult Day Care (ADC) setting. Meals provided as part of ADC shall not constitute a "full nutritional regimen" (3 meals per day).

• Authorization of the ADC is funded through the Adult Day Care Waiver (ADCW).
• All ADCW participants must meet the following eligibility criteria:
  • Between the ages of eighteen (18) to sixty-three (63) years of age;
    • Initial authorizations are restricted to those participants between the ages of eighteen (18) to sixty-two (62). Those participants age sixty-three shall be authorized for ADC services through the Aged and Disabled Waiver (ADW).
  • In active Medicaid status (Medicaid Eligibility).
    • Participants who are eligible for Medicaid on a spenddown basis may be authorized to receive the ADCW during periods when they meet their spenddown liability.
    • A participant is responsible for the cost of services received during periods of time when they have not met their spenddown liability.
    • Participants who receive Medicaid due to eligibility for Blind Pension (BP) may not be authorized for the ADCW.
    • Participants in a ‘Transfer of Property penalty’ may be authorized for the ADCW.
    • Authorization of the ADCW does not meet the requirements for an individual to be eligible for Home and Community Based (HCB) Medicaid.
  • Have an appropriate Medicaid Eligibility (ME)  code; and
  • Meet nursing facility level of care.
• ADCW services shall be authorized for:
  • Up to 10 hours per day for a maximum of 5 days per week of which no more than 120 minutes, or eight (8), 15 minute units per day may be related to transporting an individual to and from the ADC setting.

ADCW shall be included in the overall cost of care, HCBS Cost Maximums, for the participant.

ADCW authorized together with other Medicaid State Plan HCBS [i.e., Basic Personal Care (PC), Advanced Personal Care (APC), Authorized Nurse Visits (RN), and Consumer-Directed Model Personal Care (CDS)] shall not exceed 100% of the average statewide monthly cost for care in a nursing facility.

NOTE: When the care plan includes an authorization for RN services, the cost of one RN visit shall be excluded from the calculation of a care plan’s cost.

• ADCW is provided by ADC settings licensed by DHSS, Division of Regulation and Licensure (DRL) with a Medicaid provider agreement with the Department of Social Services (DSS), Missouri Medicaid Audit and Compliance Unit (MMAC). Payment is made to the ADCW provider on behalf of the participant.

Restrictions

• Individuals who reside in a nursing facility, Residential Care Facility (RCF) or Assisted Living Facility (ALF) licensed by DHSS DRL, are not eligible for ADCW.
• Participants authorized for certain services through the Department of Mental Health (DMH) may not be eligible for services as outlined in this policy. Staff shall refer to the DMH Service Coordination Policy for guidance on coordination of services for participants authorized for DMH services.

Services

• Services received from the ADC are determined by the individual plan of care developed by the participant, ADC personnel, and the participant’s physician. The individual plan of care is developed every six (6) months by the ADC and includes the amount, duration, and scope of treatment and services to be provided. The individual plan of care shall be available to Division of Senior and Disability Services (DSDS) staff or its designee upon request. Depending on the individual plan of care, the participant may receive the following organized services as a component of receiving the ADCW:
  • Leisure-time and exercise activities - planned recreational and social activities;
  • Counseling services - assistance to participants and families with personal, social, family or adjustment problems;
  • Rehabilitative services - occupational, physical, and speech therapy;
  • Activities of daily living - such as assistance with walking, toileting, or feeding;
  • Medication management and nursing services - by a licensed nurse;
  • Meals - to include physician ordered special or modified diets and snacks; and
  • Up to 10 hours per day for a maximum of 5 days per week of which no more than eight (8), 15 minute units per day may be related to transporting an individual to and from the adult day care setting.

Revised - April 2011

Chore services are short-term, intermittent tasks necessary to maintain a clean, sanitary and safe home environment as determined by the Assessor to be critical in maintaining the participant’s health and safety. Chore services must be reasonable and necessary according to the condition of the functional capacity of the participant. Limited ability of the participant to perform necessary tasks shall be thoroughly documented. Chore services are mutually identified as necessary by the participant and the Assessor and based on information obtained during the assessment process.

• Authorization for Chore is funded through the Aged and Disabled Waiver (ADW) only.
• All Chore participants must meet the following eligibility criteria:
  • At least 63 years of age;
  • In active Medicaid status (Medicaid Eligibility)
    • Participants who are eligible for Medicaid on a spenddown basis may be authorized to receive Chore services during periods when they meet their spenddown liability.
    • A participant is responsible for the cost of services received during periods of time when they have not met their spenddown liability.
    • Authorization of Chore does meet the requirement for an individual to be eligible for Home and Community Based (HCB) Medicaid.
  • Have an appropriate Medicaid Eligibility (ME) Codes; and
  • Meet nursing facility level of care.
• Chore Services shall be provided only when the participant and other household members are incapable of performing and when no other relative, caregiver, landlord, community or volunteer agency, or third party payor is capable of or responsible for providing such tasks.
  • In the case of rental property, the responsibility of the landlord shall be explored prior to any authorization of services.

• Chore services shall be authorized in 15-minute units.

  • Chore units authorized shall be consistent with the identified Chore tasks to be completed for the short term or intermittent authorization period to ensure the participant’s health and safety.
  • Chore services shall be included in the overall cost of care (HCBS Cost Maximums) for the participant.
  • Chore services authorized together with other Home and Community Based Services (HCBS) shall not exceed 100% of the average statewide monthly cost for care in a nursing facility, without prior approval of the state agency.

         NOTE: The cost of one RN, when RN is authorized on a monthly basis, shall be excluded from the calculation of a care plan's cost.

  • When the combination of State Plan and Aged and Disabled Waiver services exceed the 100% cost maximum:
    • The Assessor’s nurse shall review all person-centered care plan requests over the 100% cost cap to ensure the participant’s unmet needs require the amount of service requested.
    • If documentation supports the request, the case shall be forwarded to the state agency for approval prior to authorization over the 100% of the cost cap.
    • Pending the approval from the state agency, to exceed the cost cap, HCBS can be authorized up to the 100% of the cost cap.
• Chores services are provided by HCBS providers that are enrolled as an ADW provider with the Department of Social Services (DSS), Missouri Medicaid Audit and Compliance Unit (MMAC). Payment is made to the HCBS provider on behalf of the participant.
• The individual providing the service is an employee of the HCBS provider and cannot be a member of the immediate family of the participant. An immediate family member is defined as a parent; sibling; child by blood, adoption, or marriage (step-child); spouse; grandparent or grandchild.
• Restrictions:
  • Individuals who reside in a nursing facility, Residential Care Facility (RCF) or Assisted Living Facility (ALF) licensed by DHSS, Division of Regulation and Licensure, or any group home or residential type facility, licensed by the Department of Mental Health (DMH), are not eligible for Chore services.
  • Participants who receive Medicaid due to eligibility for Blind Pension (BP) are not eligible for Chore services.
  • Participants in a ‘Transfer of Property penalty’ are not eligible for Chore services.
  • Participants receiving services through any other HCBS waiver are not eligible for Chore services funded through the Aged and Disabled Waiver.
• Chore services may include and of the following activities: 
  • Wash walls and woodwork;
  • Clean closets, basement and attics;
  • Shampoo rugs;
  • Air mattresses and bedding;
  • Spray for insects within the home, using over-the-counter supplies; and
  • Provide rodent control within the home (setting traps or using over-the-counter supplies).