Home and Community Based Services Manual


3.05 Basic Personal Care – State Plan (Agency Model)

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:

Dietary

Assistance with meal preparation and cleanup and assistance with eating/feeding. Consideration shall also be given to the participant’s ability to prepare a light meal such as sandwiches, soups, and salads and/or the availability of home-delivered meals. (Suggested time 10-60 minutes – Suggested frequency 1-7 x/week)

Dressing/Grooming

Assistance with dressing and grooming including help with dressing and undressing, combing hair, nail care, oral hygiene and denture care, and shaving. (Suggested time 15 minutes – Suggested frequency 1-7 x/week)

Bathing

Assistance with bathing, including shampooing hair. (Suggested time 30-45 minutes – Suggested frequency 1-7 x/week)

Toileting/Continence

Assistance in going to the bathroom and changing bed linen. May also include the changing of bed linens for participants with medically related limitations that prohibit the completion of this task. Mobility and transfer to the bathroom should be included and delivered as needed. (Suggested time 5-10 minutes – Suggested frequency as needed)

Mobility/Transfer

Assistance with transfer and ambulation when the participant can at least partially bear their own weight. Actual lifting of the participant is not an appropriate task. (Suggested time 5-10 minutes – Suggested frequency as needed).

Self-Administration of Medications

Assistance with self-administration of medication and applying nonprescription topical ointments or lotions.

  • 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.

Medically Related Household Tasks

Includes the tasks outlined under Homemaker (ADW) services.

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.

 

 

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