Clarification on Family Supplementation of PCS Medicaid Benefit

Tuesday, October 1, 2019

On Jan. 29, 2013, NC Medicaid issued a memorandum giving guidance on the subject of Guidance for Family Supplementing Payment to the Medicaid Benefit. Several adult care home (ACH) providers have recently referenced this memorandum when inquiring about payment supplements specifically related to the provision of Personal Care Services (PCS) to recipients of special assistance. 

Questions received have focused on the ability of ACH providers to charge beneficiaries for additional PCS hours provided to the beneficiary beyond the hours awarded by the independent assessment. 

As described in regulation 10A NCAC 13F .0704, providers are prohibited from requiring additional charges to a special assistance beneficiary for State plan PCS defined in NC Clinical Coverage Policy 3L unless the beneficiary or their legal representative voluntarily chooses to personally purchase additional services not covered by Medicaid.

NC Medicaid recognizes there may be circumstances when individuals would like assistance in excess of what is considered medically necessary. Beneficiaries or their legally responsible representative may voluntarily choose to pay for these services; however, any requirement or coercion that special assistance beneficiaries or their legal representative pay for PCS-like services beyond their awarded hours is prohibited. 

Author: 
Medicaid Long-Term Services and Supports/PCS, (919) 855-4340