7. Services Explained
This guide serves to briefly explain all the services offered through Medicaid. See the Service Plan guide information on how to create the Services in the PCSP and see the LTSS Service Request Tool guide on how to submit requests after a visit!
Adult Daily Living Services (Adult Day Care/Adult Day Program, ADC/ADP)
Adult Daily Living services are designed to assist Participants in meeting, at a minimum, personal care, social, nutritional and therapeutic needs. Adult Daily Living services can be utilized for 4 or more hours per day (full or half day programs) on a regularly scheduled basis for between 1 to 6 days per week, or as specified in the service plan, in a non-institutional, community-based center encompassing both health and social services needed to ensure the optimal functioning of the Participant. Staff at the ADC will assist participant with ADL’s and some IADL’s based on participant need (e.g. bathing, dressing, grooming, toileting, incontinence care, medication management, eating, meal preparation, walking, locomotion) as well as offering socialization opportunities.
Assistive Technology service is an item, piece of equipment or product system — whether acquired commercially, modified or customized — that is needed by the Participant, as specified in the Participant’s PCSP and determined necessary in accordance with the Participant’s assessment. The service is intended to ensure the health, welfare and safety of the Participant and to increase, maintain or improve a Participant’s functioning in communication, self-help, self-direction, life-supports or adaptive capabilities. Assistive Technology is limited to:
- Services consisting of purchasing, leasing or otherwise providing for the acquisition of Assistive Technology devices for Participants.
- Services consisting of selecting, designing, fitting, customizing, adapting, applying, maintaining, repairing or replacing Assistive Technology devices. Repairs are covered when it is more cost effective than purchasing a new device.
- Electronic systems that enable someone with limited mobility to control various appliances, lights, telephone, doors and security systems in their room, home or other surroundings.
- Training or technical assistance for the Participant, paid caregiver and unpaid caregiver.
- An independent evaluation of the Assistive Technology needs of a Participant. This includes a functional evaluation of the Assistive Technology needs and appropriate services for the Participant in his/her customary environment.
- Ancillary supplies, software and equipment necessary for the proper functioning of Assistive Technology devices, such as replacement batteries and materials necessary to adapt low-tech devices. This includes applications for electronic devices that assist Participants with a need identified through the evaluation described below.
- If the Participant receives Speech, Occupational or Physical Therapy or Behavior Support services that may relate to, or are impacted by, the use of the Assistive Technology, the Assistive Technology must be consistent with the Participant’s behavior support plan or Speech, Occupational or Physical Therapy service. Assistive Technology devices must be recommended by an independent evaluation or physician’s prescription. This service excludes those items that are not of direct medical or remedial benefit to the Participant. Recreational items are also excluded.
Community Integration (CI)
Community Integration (CI) is a short-term, goal-based support service designed to assist Participants in acquiring, retaining, and improving self-help, communication, socialization and adaptive skills necessary to reside in the community. Community Integration can include cueing and on-site modeling of behavior to assist the Participant in developing maximum independent functioning in community living activities.
Community Integration is goal-based and situational to assist individuals in achieving maximum function during life-changing events such as a transition from a Nursing Facility, moving to a new community or from a parent’s home, or a change in condition that requires new skill sets. Services and training must focus on specific skills and be related to the expected outcomes outlined in the Participant’s service plan. Services must be provided at a 1:1 ratio.
Counseling about whether having a job will increase the participant’s ability to support themselves and/or have a net financial benefit
Review of the participant’s interests and strengths to identify potential career options
Employment Skills Development
Learning and work experiences, including volunteer work, where the participant can develop strengths and skills to be able to get a job that pays good wages.
Support to help learn a new job and keep a job that pays. Could include helping the participant to develop natural supports in the workplace and working with employers or employees, coworkers, and customers to make it possible for the participant to have a paid job.
Help in finding potential jobs and helping the participant get a job that fits what they want and can do and the employer’s needs
Home adaptations are physical adaptations to the residence of the participant to ensure their safety and increase independent functioning in the home. The request for an evaluation for a home modification (NOT the home modification item itself) must be included in your PCSP and be determined necessary by the participant’s assessment. (See Home Mod, DME/SME process document for specifics). Potential home adaptations PHW offers are the following:
- Ramps (from street, sidewalk, or house)
- Handrails and grab-bars in the home
- Specialized electrical or plumbing systems necessary to accommodate the participant’s medical equipment/supplies (not for home repairs)
- Outside railings
- Accessible alert systems (fire/smoke/CO2) for those with sensory issues
- Vertical lifts
- Portable lifts
- Track lifts
- Widened doorways, hallways, and landings
- Swing-clear and expandable offset door hinges
- Flush Entries and Leveled thresholds
- Slip-resistant flooring
- Bathroom adaptations
- Kitchen modifications
- Stair gliders (rental stair glide available)
- Raised electrical switches and sockets
Home Delivered Meals (HDM)
Home Delivered Meals provides prepared meals, that are typically frozen, to Participants who cannot prepare or obtain nutritionally adequate meals for themselves, or when the provision of such meals will decrease the need for more costly supports to provide in-home meal preparation. Home Delivered Meals must be specified in the service plan, as necessary, to promote independence and to ensure the health, welfare and safety of the Participant. Maximum amount of HDM’s per day is 2.
Home Health Services
Home Health Services consist of the following components: Home Health Aide Services, Nursing Services, Physical Therapy, Occupational Therapy and Speech and Language Therapy.
Home Health Services
Direct services prescribed by a physician to enable the Participant to integrate more fully into the community and to ensure the health, welfare and safety of the Participant. The physician’s order must be obtained every sixty (60) days for continuation of service. Home Health Aide services are provided by a home health aide who is supervised by a registered nurse. Home Health Aide activities include, personal care, performing simple measurements and tests to monitor a Participant’s medical condition, assisting with ambulation, assisting with other medical equipment and assisting with exercises taught by a registered nurse, licensed practical nurse or licensed physical therapist Home Healthcare Aide services cannot be provided simultaneously with Personal Assistance Services, Adult Daily Living Services, or Respite Services.
Direct services prescribed by a physician that are needed by the Participant to integrate more fully into the community and to ensure the health, welfare and safety of the Participant. Nursing services are within the scope of the State’s Nurse Practice Act and are provided by a registered professional nurse, or licensed practical nurse under the supervision of a registered nurse, licensed to practice in the State. The physician’s order must be obtained every sixty (60) days for continuation of service. Nursing services are individual, and can be continuous, intermittent, or short-term based on the individual’s assessed need.
Physical Therapy services are direct services prescribed by a physician that assist Participants in the acquisition, retention or improvement of skills necessary to enable the Participant to integrate more fully into the community and to ensure the health, welfare and safety of the Participant. Training caregivers and developing a home program for caregivers to implement the recommendations of the therapist are included in the provision of services. The physician’s order to reauthorize the service must be obtained every sixty (60) days for continuation of service. Physical Therapy can be provided by a licensed physical therapist or physical therapist assistant as prescribed by a physician.
Occupational Therapy services are direct services prescribed by a physician that assist Participants in the acquisition, retention or improvement of skills necessary to enable the Participant to integrate more fully into the community and to ensure the health, welfare and safety of the Participant. Training caregivers and developing a home program for caregivers to implement the recommendations of the therapist are included in the provision of services. The physician’s order must be obtained every sixty (60) days for continuation of service. Occupational Therapy services can be provided by a licensed occupational therapist or an occupational therapist assistant.
Speech and Language Therapy
Speech and Language Therapy services are direct services prescribed by a physician that assist Participants in the acquisition, retention or improvement of skills necessary to enable the Participant to integrate more fully into the community and to ensure the health, welfare and safety of the Participant. Training caretakers and development of a home program for caretakers to implement the recommendations of the therapist are included in the provision of Speech and Language Therapy services. The physician’s order to reauthorize the service must be obtained every sixty (60) days for continuation of service. This service can include the evaluation, counseling, habilitation and rehabilitation of individuals whose communicative disorders involve the functioning of speech, voice or language, including the prevention, identification, examination, diagnosis and treatment of conditions of the human speech language system. Speech and Language Therapy services also include the examination for, and adapting and use of augmentative and alternative communication strategies.
Non-Medical Transportation (NMT)
Non-medical transportation assists participants attend doctor’s appointments, take personal trips, or attend ADC. Medical Transportation Management (MTM) is the only provider for NMT, and NMT must be added to every PCSP (unless the client receives over 16 hours of care per day). Participants can use MTM as a ride service or in the form of a SEPTA pass. SEPTA passes are provided monthly, while general NMT allows the participant to call and schedule a ride as needed.
Personal Assistance Services/Participant Directed Option (PAS/PDO)
Personal Assistance Services primarily provide hands-on assistance (in the form of a Caregiver) to Participants that are necessary, as specified in the Care Plan, to enable the Participant to integrate more fully into the community and ensure the health, welfare and safety of the Participant. This service can be provided in either Agency Model (PAS) or Participant Directed Model (PPL/Public Partnership). This service will be provided to meet the Participant’s needs, as determined by an assessment, in accordance with Department requirements and as outlined in the Participant’s PCSP. Personal Assistance Services are aimed at assisting the individual to complete tasks of daily living that would be performed independently if the individual had no disability. These services include:
- Hands on assistance with activities of daily living (e.g. eating, bathing, dressing, personal hygiene)
- Cueing to prompt the Participant to perform a task
- Providing supervision to assist a Participant who cannot be safely left alone (e.g. participant diagnosed with dementia who has a history of wandering or unsafe behavior)
- Health maintenance activities provided for the Participant, such as bowel and bladder routines, ostomy care, catheter, wound care and range of motion
- Routine support services, such as meal planning, keeping of medical appointments and other health regimens needed to support the Participant
- Assistance with IADL’s (e.g. meal preparation, clean home, laundry, shopping, etc)
- Assistance and implementation of prescribed therapies
Personal Emergency Response System (PERS)
PERS is an electronic device which enables Participants to secure help in an emergency. The Participant wears a portable “help” button to allow for mobility in the form of a necklace or bracelet. The system is connected to the person’s phone and programmed to signal a response center once a “help” button is activated. The response center is staffed by trained professionals that then link the participant with Emergency Medical Services as needed. The PERS vendor must provide 24-hour staffing, by trained operators of the emergency response center, 365 days a year.
PERS services are limited to those individuals who: Live alone, are alone for significant parts of the day as determined in consideration of their health status, disability, risk factors, support needs and other circumstances or live with an individual that may be limited in their ability to access a telephone quickly when a Participant has an emergency.
Pest eradication services will be available to make a Participant’s home fit for the Participant to live there. Pest Eradication Services are intended to aid in maintaining an environment free of insects, rodents, and other potential disease carriers to enhance safety, sanitation and cleanliness of the Participant’s residence. The service may be considered for inclusion in the PCSP for a Participant transitioning to the community. It can also be made available on an ongoing basis if necessary as determined by the Service Coordinator (SC) and documented in the PCSP. That documentation needs to include the amount, duration and scope of services as determined by the SC, as well as what the specific pest is that needs to be eradicated (e.g. roaches, bed bugs, mice, rats). The service cannot be made available as a preference of the Participant to remove something on a property that has no impact on the Participant living there.
Services provided to support participants on a short-term basis due to the absence or need for relief of informal, unpaid caregivers (e.g. participants informal support is going on vacation). Respite care is provided in a facility and if a participant is requesting “respite” to be provided at home it is documented as a temporary increase in PAS services.
Already pre-populated in the PCSP as well as SPCF. Service Coordination assesses participants needs, makes requests for services to the MCO, provides oversight of current participant services, and links the participant with community resources.
Specialized and Durable Medical Equipment (SME/DME)
Specialized Medical Equipment and Supplies are services or items that provide direct medical or remedial benefit to the Participant and are directly related to a Participant’s disability. These services or items are necessary to ensure health, welfare and safety of the Participant and enable the Participant to function in the home, community with greater independence. This service is intended to enable Participants to increase, maintain, or improve their ability to perform activities of daily living. Specialized Medical Equipment and Supplies are specified in the Participant’s PCSP and determined necessary in accordance with the Participant’s assessment. (See Home Mod, DME/SME process document for specifics)
- These include items like diapers, briefs, blood sugar test strips, incontinence pads, and nutritional supplements.
DME/SME Items and Services that go through the participants PCP are:
- Bed Pans
- BP Cuffs
- BS Monitors
- Compression Stockings
- Diapers (size needed)
- Elevated Leg Pillows
- Hospital beds
- O2 Tanks
- Pull Ups
- Raised Toilet Seat
- Reusable Protective Underwear
- Shower Chairs
- Shower Transfer Bench
- Hoyer Lifts
- Hearing Aids
Exceptional Durable Medical Equipment
- Exceptional DME is defined as DME that has an acquisition cost of $5,000 or more and is either Specially Adapted DME or other DME that is designated as exceptional DME by the Department annually by notice in the Pennsylvania Bulletin. Exceptional DME can either be purchased or rented.
- ”Specially Adapted DME” is DME that is uniquely constructed or substantially adapted or modified in accordance with the written orders of a physician for the particular use of one resident, making its contemporaneous use by another resident unsuitable.
- The list of Exceptional DME that has been designated by the Department is as follows:
- Air fluidized beds. The pressure relief provided by this therapy uses a high rate of airflow to fluidize fine particulate material (for example, beads or sand) to produce a support medium that has characteristics similar to liquid.
- Powered air flotation bed (low air loss therapy). A semi-electric or total electric bed with a fully integrated powered pressure-reducing mattress which is characterized by all of the following: An air pump or blower with a series of interconnected woven fabric air pillows which provides sequential inflation and deflation of the air cells or a low interface pressure throughout the mattress allowing some air to escape through the support surface to the resident.
- Augmentative communication devices. Used by participants who are unable to use natural oral speech as a primary means of communication. The specific device requested must be appropriate for use by the participant and the participant must demonstrate the abilities or potential abilities to use the device selected. Portable devices need to supplement, aid or serve as an alternative to natural speech for participants with severe expressive communication disorders. Non Portable devices may be covered only if required for visual enhancement or physical access needs that cannot be accommodated by a portable device.
- Ventilators (and related supplies) used by participants 21 years of age and older who require full ventilator support for a minimum of 8 hours per day to sustain life.
TeleCare integrates social and healthcare services supported by innovative technologies to sustain and promote independence, quality of life and reduce the need for nursing home placement. By utilizing in-home technology, more options are available to assist and support individuals so that they can remain in their own homes and reduce the need for re-hospitalization. TeleCare services are specified by the service plan, as necessary to enable the Participant to promote independence and to ensure the health, welfare, and safety of the Participant and are provided pursuant to consumer choice.
Health Status Measuring and Monitoring TeleCare Services
Uses wireless technology or a phone line, including electronic communication between the Participant and healthcare Provider focused on collecting health related data (i.e. vital signs information such as pulse/ox and blood pressure that assists the healthcare Provider in assessing the Participant’s condition) and providing education and consultation; must be ordered by a primary physician, physician assistant, or nurse practitioner; includes installation, daily rental, daily monitoring and training of the Participant, their representative and/or employees who have direct Participant contact; monitoring service activities must be provided by trained and qualified home health staff in accordance with required provider qualifications; and have a system in place for notification of emergency events to designated individuals or entities.
Activity and Sensor Monitoring TeleCare Services
Employs sensor-based technology on a 24 hour/7 day basis by remotely monitoring and passively tracking Participants’ daily routines and may report on the following: wake up times, overnight bathroom usage, bathroom falls, medication usage, meal preparation and room temperature; includes installation, monthly rental, monthly monitoring, and training of employees who have direct Participant contact; and ensures there is a system in place for notification of emergency events to designated individuals.
Medication Dispensing and Monitoring TeleCare Services
Assists Participants by dispensing and monitoring medication compliance; and utilizes a remote monitoring system personally pre-programmed for each Participant to dispense, monitor compliance and provide notification to the provider or family caregiver of missed doses or non-compliance with medication therapy.
Therapeutic and Counseling Services
Therapeutic and counseling services are services that assist individuals to improve functioning and independence, are not covered by the Medicaid State Plan, and are necessary to improve the individual’s inclusion in their community. Therapeutic and counseling services are provided by professionals and/or paraprofessionals in cognitive rehabilitation therapy, counseling, nutritional counseling and behavior management. The service may include assessing the individual, developing a home treatment/support plan, training family members/staff and providing technical assistance to carry out the plan, and monitoring of the Participant in the implementation of the plan. This service may be delivered in the Participant’s home or in the community as described in the service plan.
Cognitive rehabilitation therapy
Focuses on the attainment/re-attainment of cognitive skills. The aim of therapy is the enhancement of the Participant’s functional competence in real-world situations. The process includes the use of compensatory strategies, and use of cognitive orthotics and prostheses. Services include consultation, ongoing counseling, and coaching/cueing. Services are provided by an Occupational Therapist, licensed Psychologist, licensed Social Worker, licensed Professional Counselor, or a home health agency that employs them.
Non-medical counseling services provided to Participants in order to resolve individual or social conflicts and family issues. While counseling services may include family participants, the therapy must be on behalf of the Participant and documented in his/her service plan. Services include initial consultation and ongoing counseling performed by a licensed psychologist, licensed social worker, or licensed professional counselor. If there is a mental health or substance abuse diagnosis, including adjustment disorder, the State Plan, through the Office of Mental Health and Substance Abuse Services, will cover the visit outside of the home and community-based services waiver up to pre-specified limits.
Assists the Participant and/or their paid and unpaid caregivers in developing a diet and planning meals that meet the Participant’s nutritional needs, while avoiding any problem foods that have been identified by a physician. The service may include initial assessment and reassessment, the development of a home treatment/support plan, training and technical assistance to carry out the plan, and monitoring of the Participant, caregiver and any Providers in the implementation of the plan. Services include counseling performed by a Registered Dietitian or a Certified Nutrition Specialist. Nutritional Consultation services may be delivered in the Participant’s home or in the community, as specified in the service plan. The purpose of Nutritional Consultation services is to improve the ability of Participants, paid and/or unpaid caregivers and providers to carry out nutritional interventions. Nutritional counseling services are limited to 90-minutes (6 units) of nutritional consultations per month. Plans may exceed the 90-minute limit at their discretion and own cost.
Includes the completion of a functional behavioral assessment; the development of an individualized, comprehensive behavioral support plan; and the provision of training to individuals, family members, and direct service providers. Services include consultation, monitoring the implementation of the behavioral support plan and revising the plan as necessary. Behavior therapy services are provided by a licensed psychologist, licensed social worker, licensed behavior specialist, or licensed professional counselor.