Tip for State-specific

Request the maximum clinically justified hours — it is easier to reduce than to increase later

Tip for State-specific

Ask about self-directed care options where you hire and manage your own attendant

Tip for State-specific

Keep documentation of any care gaps or unmet needs — this supports requests for additional hours

MedicaidmoderateDoctor signature required

Medicaid Personal Care Services Authorization

State-specific · State Medicaid Agencies

Authorization request for Medicaid-funded personal care services including bathing, dressing, meal preparation, and medication management in the home.

Form Details

Total fields: 35
Auto-fillable: 25 (71%)
Time without BeneFill: 30 minutes
Time with BeneFill: 8 minutes
Time saved: 22 minutes
Filled by: doctor
Frequency: annual
State-specific: Yes — form may vary by state

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Where to Submit This Form

📬

Your physician submits the authorization request to the state Medicaid agency or MCO

The requesting provider typically initiates this process.

📠

Fax to your state Medicaid agency or MCO authorization department

Fax number varies by state and plan.

🌐

Through the state Medicaid provider portal (provider-initiated)

Many states have electronic prior authorization systems for LTSS services.

Required Attachments

📎 Physician order for personal care services
📎 Completed functional assessment documenting ADL and IADL needs
📎 Person-centered service plan specifying hours and types of assistance needed
📎 Medical records supporting the need for personal care assistance
📎 Prior authorization form (state or MCO-specific)

Processing Time

Standard: 14-30 days. Expedited: 3-5 business days if delay could harm health. Reauthorizations are typically required every 6-12 months.

What Happens Next

The state or MCO will review the request and authorize a specific number of personal care hours per week. You may choose a home care agency or, in some states, a self-directed care model.

Tips for This Form

✓ Request the maximum clinically justified hours — it is easier to reduce than to increase later
✓ Ask about self-directed care options where you hire and manage your own attendant
✓ Keep documentation of any care gaps or unmet needs — this supports requests for additional hours
✓ Reauthorization is required periodically — mark the deadline on your calendar and start the process early

More Medicaid Forms

Medicaid Application

State-specific · State Medicaid Agencies / CMS via HealthCare.gov

Unified application for Medicaid, CHIP, and Marketplace coverage under ACA. Uses MAGI for financial eligibility. Available online, by mail, phone, or in person.

HealthCare.gov Marketplace Application

Federal Marketplace Application · CMS / Federal Marketplace

Federal marketplace application that also screens for Medicaid/CHIP eligibility and refers to state agencies when the applicant qualifies.

Emergency Medicaid Application

State-specific (e.g., Form 520) · State Medicaid Agencies

Application for Emergency Medical Assistance for individuals meeting all Medicaid requirements except citizenship/immigration status. Must have received emergency services.

Presumptive Eligibility Determination

State-specific PE form · State Medicaid Agencies / Qualified Entities

Temporary Medicaid coverage granted by qualified entities (hospitals, clinics) based on preliminary income assessment. Covers services until full application is processed.

Medicaid Renewal / Redetermination

State-specific (e.g., CA MC 210 RV) · State Medicaid Agencies

Annual renewal verifying continued Medicaid eligibility. Includes income, expenses, and household composition. Failure to complete results in disenrollment.

Medicaid Spend-Down Documentation

State-specific · State Medicaid Agencies

Documents medical expenses applied toward meeting the spend-down amount. Once the difference between income and the medically needy income level is met, Medicaid covers remaining expenses.

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Disclaimer: BeneFill™ provides form-filling assistance and informational guidance only. It is not affiliated with, endorsed by, or sponsored by the State Medicaid Agencies or any government agency. The information provided is for general informational purposes and does not constitute legal, medical, financial, or tax advice. Always verify form requirements and submission details directly with the issuing agency.