Working with Apple Community Health Services as a personal support provider

The division of labor

Two different provider types, two different enrollments, two different billings.

You deliver the service. Personal support, homemaker services, the aide in the house, the schedule, the supervision of that aide, the documentation of the visits.

The case management agency arranges, coordinates and monitors. It screens for waiver eligibility, coordinates the level-of-care assessment, builds the plan of care with the member, arranges the providers who will deliver each authorized service, and reviews the case on the schedule the waiver requires. Case Management §2038 requires the Lead Case Manager at the agency to be a Georgia-licensed registered nurse.

Neither role absorbs the other. A case management agency that started sending its own aides would be a different kind of provider, and a personal support agency that started authorizing its own service hours would be marking its own homework. The separation is the point.

Referring a client for case management

The common situations:

• A private-pay client whose funds are running down, who looks like they may meet a nursing-home level of care and Medicaid’s financial rules.
• A client whose Medicare home health episode is ending and whose ongoing need is non-skilled.
• A waiver-eligible client with no case manager, or one whose case management relationship has lapsed.
• A client whose needs have grown past what the current arrangement covers and who needs a plan of care rather than more hours bought ad hoc.

What to send is the same as any other referral: identifiers and Medicaid status, the functional picture you already hold from your own care notes, the home situation, and a reachable person with authority to consent. Your visit documentation is often better functional evidence than anything a hospital would send, because it describes the person in their own home over time. The documentation checklist sets out each item.

Referrals should come with the client’s agreement. You are disclosing their information; that is governed by your policy and HIPAA, not by ours.

What happens at authorization

Once eligibility is established and a plan of care is built, each service in the plan is authorized separately, and the member chooses the provider for each one. The case manager’s job at that point is to present the qualified providers serving the area as options and record the member’s choice. Being the agency that made the referral does not create a claim on the service hours.

That is not a courtesy. Georgia rules at §1834.13 prohibit soliciting the delivery of all of a member’s services through a single provider, and §1894 gives the member the right to choose their providers and to change them later. A referral arrangement that assumes the referring agency gets the work is the arrangement those rules exist to prevent.

Equally: no gift, gratuity, bonus, discount or payment passes in either direction for a referral, in any form. None is offered and none can be accepted.

Working the case once it is running

• Report change promptly. Function, hospitalizations, refused visits, a caregiver leaving the household, an unsafe home. The care plan is only as current as what the case manager is told.
• Stay inside the authorization. Hours delivered outside the authorized plan are not the case manager’s to fix retrospectively.
• Escalate on safety, do not wait for the review date.
• Keep the member’s choice open. If a member wants to change providers – yours or ours – that is their right, and neither agency should make it awkward.

Nothing here is an eligibility determination. Only the assessment and Medicaid’s own review decide whether a person qualifies for the waiver.