Home and Community Based Services Manual


3.10 Advanced Personal Care - State Plan (Agency Model)

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.

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