Analysis of calendar years 2016 and 2017 data from the Washington State Developmental Disabilities Administration indicates that approximately 10% of all clients receiving personal care services experience a reduction in the number of personal care hours awarded compared to the previous year. Approximately 48.5% of individuals experience an increase in hours awarded and 41.5% of clients see no change in the amount of hours awarded.
For those with questions about a change or reduction in hours, the following clarifies how the whole process works.
Requesting Personal Care
Clients who are eligible to receive Medicaid may also request an assessment to determine if they meet functional eligibility requirements to receive personal care services. Personal care services refers to physical and verbal assistance provided to a client who requires supports with Activities of Daily Living (ADLs) (ex. Bathing, Eating, Toileting, and Transfers) and Instrumental Activities of Daily Living (IADLs) (ex. Shopping, Meals, Housework).
Assessment
Washington State must conduct an assessment to evaluate the client’s abilities and support needs. This information is then used to determine the amount of personal care hours a client is authorized to receive. This assessment must be conducted at least once a year or when a significant change is reported in the client’s support needs.
Chapter 388-106 WAC contains information about the algorithm governing how assessment scores are used to determine a service classification level and number of hours a client is eligible to receive each month.
Upon completion of the assessment, the case manager reviews assessment results with the client and their legal representative/guardian, if they have one.
Planned Action Notice
Upon completion of the assessment and implementation of the client’s person-centered service plan, the case manager provides the client and their legal representative with a document called a Planned Action Notice (PAN). DDA sends a PAN to clients anytime a decision is made by the DDA related to the clients DDA services including:
- Service actions (Continuations, increases, reductions, terminations, denial, and withdrawals)
- Eligibility determinations, waiver
- Choice of provider.
PANs provide information to help understand what decision was made, why a decision was made, and what you can do if you disagree with the decision. They are always sent before an action takes effect.
PANs are always sent to at least two people: the client and his/her representative (parent, guardian, or person designated as the client’s Necessary Supplemental Accommodation (NSA)).
Each PAN includes:
- The date the decision is effective.
- The decision made by DDA.
- The reason DDA made the decision.
- The authority (WACs, Rules) followed to make the decision.
- The client’s appeal rights and timelines.
Appeal Rights
Every PAN explains how and when to appeal if the client disagrees with DDA’s decision. You have the right to appeal within 90 days or 10 days, depending on whether or not the client wants to continue receiving services during the appeal.
If a client wants to continue receiving services during the appeal, the client/legal representative has a minimum of 10 days to request an administrative hearing by the “Appeal by Date.” If the appeal is denied, the client may be responsible for repaying the cost of services for 60 days.
Everyone has 90 days to appeal the decision.
Appeals are heard by Administrative Law Judges who review the client/legal representative’s appeal to ensure that the Department followed all required rules for service determination and due process notification.
Personal Care Results Comparison (PCRC) Report
Clients and their legal representative/guardian are provided a copy of the Personal Care Results Comparison (PCRC) report at the time they are given their Planned Action Notice. The PCRC report tells the client/legal representative how many personal care hours he/she was eligible to receive from his/her last assessment and how many he/she is eligible to receive from their new assessment. This can help identify what has changed in the client’s support needs from their previous assessment to their current one.
Exception to Rule (ETR)
Clients and their legal representative may request an exception-to-rule (ETR) if they believe that their child has exceptional needs that they do not feel are captured in the assessment. Information on how to request an exception to rule is provided to the client/legal representative. ETRs are then reviewed by a committee for approval, partial approval, or denial.
