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Spotlight On... Medicaid Personal Care Services

Though bathing, light housework, or meal preparation may not be readily associated with the Medicaid program, these types of services - called personal care services (PCS) - allow many elderly people and those with disabilities or chronic or temporary conditions to remain in their homes and maintain basic quality of life.

Eligible beneficiaries can receive PCS under Medicaid State plan options or waivers. The services must be provided at home or another approved location and follow a specific plan-of-care. Personal care services are typically performed by care attendants, a career that is expected to grow substantially over the next few years along with the costs to Medicaid for PCS. Already in the past 6 years, Medicaid costs for PCS increased by 35 percent, totaling approximately $12.7 billion in 2011.

OIG is committed to ensuring that adequate safeguards exist to prevent fraud, waste, and abuse in this important and growing benefit. Over the past 6 years, OIG issued 23 reports on the topic of PCS and conducted numerous investigations involving PCS fraud. Our latest product, an OIG Portfolio entitled Personal Care Services: Trends, Vulnerabilities, and Recommendations for Improvement, synthesizes this body of work and offers new and comprehensive recommendations to address vulnerabilities.

A nurse serving an elderly man lunch in his home

As described in the Portfolio, our audit and evaluation work revealed a pattern of improper PCS payments linked to lack of compliance with State policies and requirements and found that existing controls designed to prevent improper payments are ineffective. Furthermore, PCS fraud -- including many cases when the care attendants and the beneficiaries act as co-conspirators to scam the Medicaid system -- is on the rise, representing more cases investigated by State Medicaid Fraud Control Units than any other type of Medicaid fraud.

Therefore, OIG recommends that the Centers for Medicare & Medicaid Services (CMS) take action to address these concerns. In addition to implementing the recommendations found in previous reports that have yet to be adopted, the OIG personal care services portfolio proposes several new recommendations for programmatic improvement. First, CMS should more effectively leverage its authorities to oversee the Medicaid PCS program by a) making qualification standards for PCS care attendants more consistent, b) requiring care attendants to be enrolled or registered with the State, c) requiring dates, times, and attendants' identities to be listed on PCS claims to Medicaid, and d) expanding Federal requirements and guidance to reduce variation of requirements for claims documentation, beneficiary assessments, plans of care, and supervision of attendants across States. OIG also recommends that CMS issue guidance to States regarding adequate prepayment controls and provide States with the data they need to identify overpayments occurring when beneficiaries are receiving institutionalized care. Finally, CMS should consider whether additional program controls are needed.

In response, CMS generally expressed that more needs to be done to address these concerns, but only explicitly agreed with the recommendation to provide States with more data for identifying overpayments. OIG maintains that the recommended actions are necessary to protect the integrity of the Medicaid PCS program and ensure that vulnerable populations continue to have access to this vital benefit.

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