Covered Services

Covered Services A. The Division of Medicaid covers medically necessary personal care services (PCS) only for early and periodic screening, diagnosis and treatment (EPSDT)-eligible beneficiaries when: 1. Ordered and directed by the beneficiary’s primary physician or appropriate physician specialist. 2. Prior authorized by the Division of Medicaid or designee. 3. The required service(s) exceed the level of services provided through the home health benefit. 4. Provided in a setting in which the beneficiary’s normal life activities take place. 5. All medical and home environment criteria are met. 6. Are directly related to the beneficiary's illness or disability. 7. Services can be safely provided by only one (1) Certified Nursing Assistant (CNA) and do not require the assistance of a second (2nd) CNA. 8. The beneficiary: a) Is medically stable to receive PCS managed safely in a non-institutional setting where normal life activities take place, b) Has a documented illness or disability that requires the assistance of a CNA in order to safely perform activities of daily living, and c) Requires more individual and continuous care than is available from a visiting CNA through intermittent home health care. 9. The home environment is conducive to appropriate growth and development for the beneficiary’s age group and be conducive to the provision of appropriate medical care. 10. There must be at least one (1) parent or other caregiver capable of and willing to be trained to assist in the provision of care for the beneficiary and the parent or caregiver must: a) Provide evidence of parental or family involvement and an appropriate home situation including, but not limited to, a physical environment and geographic location for the beneficiary’s medical safety. b) Have a reasonable plan for an emergency situation including, but not limited to: 1) Power and equipment backup for equipment necessary to the medical care of the beneficiary, 2) Access to a working telephone, and 3) Available transportation adequate to safely transport the beneficiary. c) Comply with the plan of care, physician office appointments and/or other ancillary services. B. The level of care required to meet the beneficiary's needs is determined by the referring physician. C. PCS services are covered only when provided: 1. By a CNA: a) With a current Mississippi certification, b) Employed by a private duty nursing (PDN) provider that is approved by the Division of Medicaid to provide CNAs, and c) Have at least one (1) year of experience providing the type of care required by the beneficiary’s medical condition. 2. Under the supervision of an RN and at the direction of the beneficiary’s physician, and 3. In a non-institutional setting where normal life activities take place. D. PCS are covered: 1. On short-term basis for beneficiaries in need of parent and/or caregiver training in order to reside in the home and community, or 2. On a long-term basis for beneficiaries that require substantial and complex care that exceeds the level of service available from the home health benefit in order to remain in the home and community setting.