Overview of NH Medicaid’s Personal Care Attendant Services Program
New Hampshire’s Personal Care Attendant Services (PCAS) Program is a statewide Medicaid program for adults and seniors who due to a physical disability, chronically require a wheelchair for mobility. The term, “physical disability”, is used loosely, as program participants do not have to designated as disabled by the Social Security Administration. Examples of potential physical disabilities for PCAS include severe arthritis, cancer, stroke, multiple sclerosis, muscular dystrophy, and cerebral palsy. Intended to assist these persons in living independently, a personal care attendant (caregiver) provides assistance with daily living activities in one’s home and / or workplace. These activities might include bathing, personal hygiene, dressing, mobility, medication assistance, light housecleaning, and preparing meals.
Program participants can reside in their home or that a loved one. In most cases, they cannot live in an adult foster care home or an assisted living facility.
PCAS are participant-directed, which means the program participant or their authorized representative recruits, hires, schedules, trains, and even fires, the “personal care attendant” of their choosing. One can hire a friend or relative, including one’s adult child or spouse, given they are not their durable power of attorney. Personal care attendants must attend an Attendant Care Education Orientation, which is provided by Granite State Independent Living (GSIL), and are overseen by a GSIL registered nurse. A financial management services agency handles the financial aspects of employment responsibilities, such as tax withholding, background checks, and caregiver payments.
New Hampshire’s Personal Care Attendant Services are provided under the state’s Regular State Plan Medicaid program. PCAS is an entitlement; meeting the state’s Medicaid eligibility requirements guarantees one will receive assistance.
While home and community based services (HCBS) can be provided via a Medicaid Waiver or a state’s Regular Medicaid plan, HCBS through Medicaid State Plans are an entitlement. Put differently, meeting the program’s eligibility requirements guarantees an applicant will receive benefits. On the other hand, HCBS via Medicaid Waivers are not an entitlement. Waivers have a limited number of participant enrollment slots, and once they have been filled, a waitlist for benefits begins. Furthermore, HCBS Medicaid Waivers require a program participant require the level of care provided in a nursing home, while State Plan HCBS do not always require this level of care.
Benefits of Personal Care Attendant Services
Follows is a list of activities with which one might receive assistance via PCAS. An individualized care plan determines the exact activities with which one receives assistance.
– Changing Bed Linen
– Grocery Shopping
– Light Housecleaning
– Meal Preparation / Clean Up
– Medication Assistance
– Personal Hygiene / Grooming – i.e., shaving, nail care, skin care, oral hygiene
– Service Animal Care
– Toileting – includes toilet use, changing adult diapers, emptying catheter bags, ostomy care
– Transferring – i.e., from bed or chair to wheelchair
Eligibility Requirements for NH’s Personal Care Attendant Services
Applicants for PCAS must be New Hampshire residents, 18+ years old, medically stable, and chronically require a wheelchair for mobility. Furthermore, they must be their own legal guardian and able to self-direct their own care or have an authorized representative to do so on their behalf. Additional eligibility criteria follows.
Financial Criteria: Income, Assets & Home Ownership
In 2023, the individual applicant income limit is $928 / month. For married couples, regardless of if one spouse or both are applicants, the income limit is $1,372 / month.
In 2023, the asset limit is $1,500 for a single applicant, as well as a married couple (with one or both spouses as applicants).
Some assets are not counted towards Medicaid’s asset limit. These generally include an applicant’s primary home, household furnishings and appliances, personal effects, and a vehicle.
While there is a 60-month Look-Back Rule in which Medicaid checks past asset transfers of those applying for Nursing Home Medicaid or home and community based services via a Medicaid Waiver, it is not relevant for New Hampshire’s Personal Care Attendant Services Program.
The home is often the highest valued asset a Medicaid applicant owns, and many persons worry that Medicaid will take it. For Personal Care Attendant Services, the home is exempt (non-countable), given the applicant lives in it or has Intent to Return. However, there are other New Hampshire Medicaid programs, such as the Choices for Independence Waiver and Nursing Home Medicaid, that also have a home equity interest limit for home exemption. Learn more.
Medical Criteria: Functional Need
While many Medicaid long-term care programs require an applicant need a Nursing Facility Level of Care (NFLOC), PCAS does not. The need for assistance, however, must be “medically necessary”. To make this determination, a registered nurse from Granite State Independent Living (GSIL) completes a Self Care Functional Evaluation (SCFE). An applicant must require a minimum of 2 hours of personal care assistance daily and require help with at least 2 of 7 Activities of Daily Living (ADLs). This includes 1) bathing / grooming 2) dressing / undressing 3) eating 4) passive range of motion exercise 5) taking medication 6) mobility / transferring (i.e., from a bed to a chair) 7) toileting. The applicant must be able to participate in completing their ADLs. Furthermore, a physician must authorize the need for PCAS.
While a person with Alzheimer’s disease or a related dementia could meet the functional criteria for PCAS, a diagnosis of dementia in and of itself does not mean one will do so.
Qualifying When Over the Limits
Having income and / or assets over Medicaid’s limit(s) does not mean an applicant cannot still qualify for NH Medicaid. There are a variety of planning strategies that can be used to help persons who would otherwise be ineligible to become eligible. Some of these strategies are fairly easy to implement, and others, exceedingly complex. Below are the most common.
New Hampshire has a Medically Needy Program for Medicaid applicants who have high medical expenses relative to their income. Also known as a spend-down program, applicants are permitted to spend “excess” income on medical expenses and health care premiums, such as Medicare Part B, in order to meet Medicaid’s medically needy income limit (called a protected income level). The amount that must be “spent down” can be thought of as a deductible. Once one’s “deductible” has been met, the Personal Care Attendant Services Program will pay for care services and supports.
When persons have assets over the limit, one option is to “spend down” excess assets. Examples include paying off debt, making home improvements, and purchasing pre-paid funeral and burial expense trusts called Irrevocable Funeral Trusts (IFTs). A Medicaid-Compliant Annuity, which takes a lump sum of assets and converts them into an income stream, can also lower countable assets. There are additional Medicaid planning strategies available when the applicant has assets exceeding the limit.
Inadequate planning or improperly implementing a Medicaid planning strategy can result in a denial or delay of Medicaid benefits. Professional Medicaid Planners are educated in the planning strategies available in New Hampshire to meet Medicaid’s financial eligibility criteria without jeopardizing Medicaid eligibility. Furthermore, while Medicaid’s 60-month Look-Back Rule does not apply to NH’s Personal Care Attendant Services, it is not unusual that one require more extensive care, such as home and community based services via a Medicaid Waiver or Nursing Home Medicaid, in the future. For these programs, the Look-Back Rule is relevant, and violating it results in a Penalty Period of Medicaid ineligibility. While there are many Medicaid planning strategies, they should only be implemented with careful planning and well in advance of the need for long-term care. However, there are some workarounds, and Medicaid Planners are aware of them. For these reasons, it is highly suggested one consult a Medicaid Planner for assistance in qualifying for Medicaid when over the income and / or asset limit(s). Find a Medicaid Planner.
How to Apply for Personal Care Attendant Services
Before You Apply
Prior to submitting an application for PCAS, applicants need to ensure they meet the eligibility criteria. Applying when over the income and / or asset limit(s) will be cause for denial of benefits. The American Council on Aging offers a free Medicaid Eligibility Test to determine if one might meet Medicaid’s eligibility criteria. Take the Medicaid Eligibility Test.
As part of the application process, applicants will need to gather documentation for submission. Examples include copies of Social Security and Medicare cards, previous bank statements, proof of income, and copies of life insurance policies, property deeds, and pre-need burial contracts. Unfortunately, a common reason applications are delayed is required documentation is missing or not submitted in a timely manner.
Persons must be enrolled in New Hampshire’s Regular Medicaid program prior to applying for the Personal Care Attendant Services Program. Persons can apply for NH Medicaid online at NHEasy Gateway to Services or download an Application for Assistance (Form 800) and submit the completed application to one’s district office. For questions and / or application assistance, DHHS Customer Service Center can be reached at 1-844-ASK-DHHS or 1-844-275-3447.
Persons already enrolled in NH Medicaid can contact GSIL to put in a “Request for Services”. This will begin the process of determining eligibility for Personal Care Attendant Services. GSIL can be reached at 1-800-826-3700 or 603-228-9680.
Additional information about PCAS be found here. Persons can also contact GSIL at the numbers listed above for information .
The New Hampshire Department of Health and Human Services (DHHS) determines Medicaid eligibility. Functional eligibility for Personal Care Attendant Services is determined by the Center for Independent Living, Granite State Independent Living (GSIL).
Approval Process & Timing
The New Hampshire Medicaid application process can take up to 3 months, or even longer, from the beginning of the application process through the receipt of the determination letter indicating approval or denial. Generally, it takes one several weeks to complete the application and gather all of the supportive documentation. If the application is not properly completed, or required documentation is missing, the application process will be delayed. Based on federal law, Medicaid offices have up to 45 days to review and approve or deny one’s application (up to 90 days for disability applications). Despite the law, applications are sometimes delayed even further.