DPSS ePolicy

To convert existing policy to the new webpage - No content changes.

Revision of existing policy and/or form(s).

What Changed?

1. The pay-rate for unlicensed personal care providers has been clarified; and
2. Examples of provider payments for personal care services has been added. 

Personal care services are defined in Title 22, CCR, Section 51183(a)(b) as services needed by the beneficiary to accomplish daily living activities.

Beneficiaries may apply out-of-pocket expenses for personal care needs towards meeting a current or future month Share of Cost (SOC), except for services provided through the In-Home Supportive Services (IHSS) program.

Reminder:  Out-of-pocket costs for in-home personal care services is not an allowable income deduction for Medi-Cal.

What Eligibility Workers Should Know About Medi-Cal Beneficiaries Receiving IHSS

1. IHSS is a benefit of Medi-Cal and as such, personal care and/or ancillary services are a provision of the program;
   
2. No more than 283 hours of care is allowed per month;
   
3. Personal care needs that exceed the allowable hours of care are classified as an “unmet need” and the excess care is not paid for by IHSS;
   
4. An expense that is applied towards the Medi-Cal SOC prior to processing the 1st provider timesheet in any month will:
   • Reduce the amount deducted from the IHSS provider’s paycheck; and
   • Reduce the amount the IHSS recipient is responsible to pay his/her provider.
5. Except for persons receiving IHSS-Residual (IHSS-R) benefits, any unmet Medi-Cal SOC is automatically deducted from the IHSS provider’s wages and applied towards the IHSS recipient’s Medi-Cal SOC.
   
   • The IHSS recipient is responsible for paying his/her provider the amount deducted from the provider’s wages.
     
   • The deducted amount paid by the IHSS recipient to his/her provider may not be used as an expense to meet a remaining SOC.
     
   • The wages paid by an IHSS-R recipient to his/her provider may be used as an expense to meet his/her Medi-Cal SOC.

Meeting A Medi-Cal SOC

1. An allowable expense may be applied towards meeting a SOC.
   
2. Unpaid expenses, including personal care services, may be used to meet a current or future month SOC (Hunt vs Kizer rules apply).
   
3. Once an expense is applied towards the SOC, it will reduce or eliminate the SOC amount in MEDS.

Previous policy required that a “Personal Care Needs Assessment” be conducted and approved by an IHSS Social Worker (SW).  Policy also allowed that costs for these services could be used as an income deduction for Medi-Cal.

Policy no longer limits the performance of a “Personal Care Needs Assessment” to an IHSS SW, but now allows the task to be performed by a doctor or nurse case manager.  In addition, since IHSS is a benefit of Medi-Cal, personal care services as an income deduction is no longer allowed.  Instead, an out-of-pocket personal care service expense may only be applied towards meeting a Medi-Cal SOC.

Terms and Descriptions

Personal Care Service

Services required for a beneficiary to accomplish the activities of daily living in accordance with a plan of treatment (i.e., assistance with walking, bathing, grooming, dressing, etc.).

Ancillary Service

Domestic services provided in conjunction with personal care services (i.e., washing, sweeping, dusting, vacuuming, etc.).

Unmet Need

IHSS hours which have been assessed but are over the maximum number of hours allowed (283 per month) by the IHSS program.

Unlicensed Personal Care Provider

An individual providing personal care services who is not associated with a personal care agency.  This individual is often unlicensed/not certified and usually provides services that do not require licensing/certification.

The following guidelines apply to out-of-pocket personal care service expenses:

Conditions and Requirements

 Unmet Need

An IHSS recipient who has unmet need hours has the option to pay for those services at their own expense.

Personal Care Service

1. The services provided must be solely for the health care and/or medical treatment of the beneficiary.
   
2. The services (not provided through IHSS) must be prescribed by a physician or nurse case manager.
   
   • The services must be deemed as necessary to prevent the individual from being moved to a long-term care facility;
     
   • The documentation provided by the physician/nurse case manager must state that the individual may remain safely in their home with the provision of the personal care services; or
     
   • The services may be part of the IHSS assessment, but not provided through the IHSS program.
3. The plan of care prescribed by the physician or nurse case manager must include at least one personal care service if ancillary services are included.

Applying an Out-of-Pocket Expense

1. Proof of an incurred expense is needed before it can be applied towards the SOC.
   
2. The expense can be applied towards the SOC even if it is not paid.
   
3. The expense can be applied towards the SOC even if the IHSS assessed hours are not used.
   
4. The cost for unmet needs assessed by IHSS may be used to meet the Medi-Cal SOC.
   
5. Following the Hunt vs Kizer guidelines, the expense can be applied to a future month's SOC, up to a year from the date for the service was provided.  This applies if the bill remains unpaid and the beneficiary is responsible for payment (refer to e-Policy for Hunt vs Kizer Administrative Release).

Assessment of a Personal Care Service Need

1. The assessment may be performed by IHSS, but the services may not be provided through the IHSS program.
   
2. It is not mandatory that the needed care be assessed by IHSS.  The assessment can be done by a physician or nurse case manager.

Provider of Care

1. It is not required that the care be provided by an IHSS provider.
   
2. The provider of care may be an IHSS caregiver providing hours beyond those paid by the IHSS program.
   
3. The provider of care may be a licensed personal care agency or unlicensed individual (i.e., friend, relative).

Provider Pay Rate for Personal Care Services

1. There is no designated pay rate for services provided by an individual associated with a licensed personal care agency.
   
2. The pay rate for an unlicensed individual is not to exceed the rate typically charged (prevailing rate) by a licensed agency in the city where services are provided.  (See Example 4)

Verification of an Incurred Expense

The following are examples of acceptable verification that an expense was incurred:

1. Receipts indicating the services rendered and the provider’s information.
   
2. Invoices showing payments billed to the beneficiary for services from the provider.
   
3. Cancelled checks to the provider accompanied by timesheets or other documentation specifying the services rendered and the provider information.
   
4. Credit card statements showing payments to the provider accompanied by timesheets or other documentation showing the care provided.

Note:  The verification must include the date of service.

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