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Assessing Eligibility for the North Carolina Medicaid Personal Care Services

Definitions, Acronyms and Abbreviations

1915(i): A section of the Social Security Act enacted in 2007 for the purpose of allowing State Medicaid programs to provide home and community based services under the Medicaid State Plan. Through the 1915(i) option, it is not necessary for a state to apply for a waiver in order to provide these services.

24 x 7: A statement of availability of systems, communications, and/or supporting resources every hour (24) of each day (7 days weekly) throughout every year for periods specified herein. Where reasonable downtime is accepted, it will be stated herein. Otherwise, 24x7 implies no loss of availability of systems, communications, and/or supporting resources.

Activities of Daily Living (ADLs): The physical functions that an individual performs each day include bathing, dressing, mobility, toileting, and eating.

Adult Care Home (ACH): Assisted living residences having seven or more beds that provide 24-hour scheduled and unscheduled personal care services to all residents.

Change of Status Review: A re-assessment required because of a significant change in the recipient's unmet need for assistance with ADLs and other support services provided under the PCS Program.

Continuous Quality Improvement (CQI): The process of designing program monitoring and evaluation activities, identifying program problems and deficiencies, correcting or remediating those problems and deficiencies, and continually improving the quality of care and services provided to Medicaid recipients under the PCS Program.

DD: Developmental disability

Department or DHHS: The North Carolina Department of Health and Human Services

Division of Health Services Regulation (DHSR): The state agency responsible for licensing and regulating home care agencies, adult care homes, family care homes, and supervised living homes.

Division or DMA: Division of Medical Assistance; the state Medicaid agency

Family Care Home (FCH): An assisted living residence having two to six beds that provides 24-hour scheduled and unscheduled personal care services to all residents

Functional Limitation: A limitation in the individual's capacity to perform ADLs independently because of a physical, cognitive, or health-related impairment

Health Home: Part of the managed-care model which provides a primary care physician for each recipient and all services are provided by the same Provider.

Home Care Agency: A public or private entity licensed by the state to provide in-home personal care services

HIPAA: Health Insurance Portability and Accountability Act of 1996 that provides federal regulations for the protection and security of confidential health information.

IHPCS: In-Home Personal Care Services; Personal Care Services delivered by a Home Health or In-Home Care Entity

Instrumental Activities of Daily Living (IADLs): Light housekeeping tasks directly related to the approved ADL assistance as approved by the Independent Assessment Entity and as specified on the recipient's plan of care, such as cleaning up after a bath or meal

Medically Stable: The recipient has reached a point in his or her medical treatment where a life-threatening or serious injury, disease, medical condition, or cognitive impairment has been brought under control and the recipient no longer requires medical care, services, supervision, or monitoring from a licensed health care professional and can live safely at home under his or her current living conditions.

MI: Mental illness

Nursing Services: Professional services provided by a registered nurse (RN) or a licensed practical nurse (LPN) under the supervision of a registered nurse

PCS: Personal Care Services.

Personal Care Aide: An individual who is a paraprofessional and who provides personal care services

Personal Care Services: Hands-on assistance, cueing, coaching, and other assistance provided by a paraprofessional that assists individuals to perform ADLs, IADLs, and related activities, as defined in the Medicaid Clinical Coverage Policy for PCS.

Physician Referral: The referral the recipient's primary care physician or other referring practitioner sends to Liberty Healthcare of North Carolina to initiate an independent assessment that will determine the recipient's qualification for PCS.

PR (Private Residence): A home or apartment privately owned or privately rented by the recipient, his or her family, or unrelated individual who is providing a home for the recipient, and does not include any facility, group home, or other living arrangement that provides room and board and other services under any public assistance program

Program Re-assessment or Continuation Review: The reassessment of the PCS program participants conducted prior to the end of his or her current authorization period (review date or anniversary date) to determine if he or she continues to qualify for services and, if the recipient does continue to qualify for services, to determine the amount of care to be provided for the following authorization period

Provider: A public or private entity that is licensed as a home care agency, adult care home, family care home, special care unit, or supervised living home by the North Carolina Division of Health Services Regulation (DHSR) and enrolled with Medicaid to furnish PCS under this PCS Program

Provider Referral: The referral Liberty Healthcare of North Carolina sends to a recipient's PCS provider of choice after the recipient is determined to qualify for PCS.

Recipient: An individual qualified for Medicaid who is receiving services under the Medicaid PCS Program.

Special Care Units (SCU): A unit that specializes in caring for people with Alzheimer's and dementia.

State: The State of North Carolina and its agencies

Supervised Living Home (SLH): A group home of under seven beds that provides a 24-hour living environment in a non-hospital setting that includes room, board, supervision, and personal assistance for individuals receiving short-term transitional services for mental illnesses or developmental disabilities.