5003.1 Except as provided in Section 5003.8, PCA services shall not be initiated or provided on a continuing basis by a Provider without a PCA Service Authorization from DHCF or its designated agent that, for each beneficiary, identifies the amount, duration and scope of PCA services authorized and the number of hours authorized.

5003.2 A Medicaid beneficiary who is seeking PCA services for the first time shall submit his or her request for a PCA Service Authorization to DHCF or its designated agent in writing, accompanied by a copy of the physician's written order for PCA services that complies with the requirements set forth in Section 5006.

5003.3 DHCF or its designated agent shall be responsible for conducting a face-to-face assessment of each beneficiary using a standardized assessment tool to determine each beneficiary's need for assistance with activities of daily living that the beneficiary is unable to perform. The assessment shall:

(a) Confirm and document the beneficiary's functional limitations and personal goals with respect to long-term care services and supports;

(b) Be developed in consultation with the beneficiary and/or the beneficiary's representative;

(c) Document the beneficiary's unmet need for services taking into account the contribution of informal supports and other resources in meeting the beneficiary's needs for assistance;

(d) Document the amount, frequency, duration, and scope of PCA services needed; and

(e) Specify the expected outcome(s) of the delivery of the PCA services.

5003.4 Based upon the results of the face-to-face assessment conducted in accordance with Section 5003.3, DHCF or its authorized agent shall issue to the beneficiary a PCA Service Authorization that specifies the amount, frequency, duration, and scope of PCA services authorized to be provided to the beneficiary.

5003.5 Authorization for PCA services in accordance with these rules, when provided through the DC Medicaid program's State Plan PCA benefit, shall not exceed eight (8) hours per day or one thousand and forty (1,040) hours in any twelve (12) month period, unless specifically authorized by DHCF or its agent in accordance with this section.

5003.6 If authorized, PCA services may be provided seven (7) days per week.

5003.7 DHCF or its designated agent shall conduct the initial face-to-face assessment following the receipt of a request for service authorization and shall conduct a reassessment at least every one hundred and eighty (180) days or upon significant change in the beneficiary's condition. A request for service authorization may be made by a Medicaid beneficiary, the beneficiary's representative or a Provider.

5003.8 For beneficiaries who were receiving PCA services on the effective date of these rules, the provisions of Sections 5003.1 through 5003.7 pertaining to assessments and PCA Service Authorizations shall take effect on a phased-in basis on a schedule to be established by DHCF not to exceed twelve (12) months from the effective date of these rules.

5003.9 If, based upon the assessment conducted pursuant to this Section, a beneficiary is found to be ineligible for PCA services, or the amount, duration or scope of PCA services is reduced, DHCF or its agent shall issue a Beneficiary Denial or Reduction of Services Letter informing the beneficiary of his or her right to appeal the denial or reduction of services in accordance with federal and District law and regulations.

SOURCE: Final Rulemaking published at 50 DCR 3957 (May 23, 2003); Notice of Final Rulemaking published at 59 DCR 1760, 1765 (March 2, 2012); as amended by Final Rulemaking published at 60 DCR 15537 (November 8, 2013).