Office of Inspector General 
https://oig.hhs.gov 
 
The mission of the Office of Inspector General (OIG), as mandated by Public Law 95-452, as 
amended, is to protect the integrity of the Department of Health and Human Services (HHS) 
programs, as well as the health and welfare of beneficiaries served by those programs.  This 
statutory mission is carried out through a nationwide network of audits, investigations, and 
inspections conducted by the following operating components: 
Office of Audit Services 
The Office of Audit Services (OAS) provides auditing services for HHS, either by conducting 
audits with its own audit resources or by overseeing audit work done by others.  Audits examine 
the performance of HHS programs and/or its grantees and contractors in carrying out their 
respective responsibilities and are intended to provide independent assessments of HHS programs 
and operations.  These assessments help reduce waste, abuse, and mismanagement and promote 
economy and efficiency throughout HHS. 
Office of Evaluation and Inspections 
The Office of Evaluation and Inspections (OEI) conducts national evaluations to provide HHS, 
Congress, and the public with timely, useful, and reliable information on significant issues.  These 
evaluations focus on preventing fraud, waste, or abuse and promoting economy, efficiency, and 
effectiveness of departmental programs.  To promote impact, OEI reports also present practical 
recommendations for improving program operations.  
Office of Investigations 
The Office of Investigations (OI) conducts criminal, civil, and administrative investigations of 
fraud and misconduct related to HHS programs, operations, and beneficiaries.  With investigators 
working in all 50 States and the District of Columbia, OI utilizes its resources by actively 
coordinating with the Department of Justice and other Federal, State, and local law enforcement 
authorities.  The investigative efforts of OI often lead to criminal convictions, administrative 
sanctions, and/or civil monetary penalties. 
Office of Counsel to the Inspector General 
The Office of Counsel to the Inspector General (OCIG) provides general legal services to OIG, 
rendering advice and opinions on HHS programs and operations and providing all legal support 
for OIGs internal operations.  OCIG represents OIG in all civil and administrative fraud and 
abuse cases involving HHS programs, including False Claims Act, program exclusion, and civil 
monetary penalty cases.  In connection with these cases, OCIG also negotiates and monitors 
corporate integrity agreements.  OCIG renders advisory opinions, issues compliance program 
guidance, publishes fraud alerts, and provides other guidance to the health care industry 
concerning the anti-kickback statute and other OIG enforcement authorities.
 
   
 
 
The OIG Portfolio offers new recommendations to improve program vulnerabilities detected in 
prior audits, evaluations, and investigations.  The Portfolio synthesizes OIGs body of work in a 
program area and identifies trends in payment, compliance, oversight, or fraud vulnerabilities 
requiring priority attention and action to protect the integrity of Department of Health and 
Human Services (HHS) programs and the beneficiaries they serve.  
 
  EXECUTIVE SUMMARY 
 
The Office of Inspector Generals (OIG) body of work examining Medicaid personal care 
services (PCS) has found significant and persistent compliance, payment, and fraud 
vulnerabilities that demonstrate the need for Centers for Medicare & Medicaid Services (CMS) 
to take a more active role with States to combat these issues.  
 
In 2011, Medicaid costs for PCS totaled approximately $12.7 billion, a 35-percent increase since 
2005.  Several Federal court decisions and Department of Health and Human Services policy 
initiatives aimed at providing more home and community-based options to Medicaid 
beneficiaries contribute to the increase in PCS use.  As more and more State Medicaid programs 
explore home care options like PCS, it is critical that adequate safeguards exist to prevent fraud, 
waste, and abuse in PCS and other important home care benefits.  
 
This document summarizes OIGs PCS work and, on the basis of the analysis of this work in the 
aggregate, offers recommendations to improve the integrity of Medicaid PCS.   
SUMMARY OBSERVATIONS  
 
Improper Payments Linked to Lack of Compliance.  As of August 2012, OIG has produced 23 
audit and evaluation reports since 2006 focusing on PCS.  Although the objectives, 
methodologies, and scopes of these audits and evaluations differed, in many instances OIG found 
that PCS payments were improper because the services:  
 
  were not provided in compliance with State requirements,  
 
  were unsupported by documentation indicating they had been rendered, 
 
  were provided during periods in which the beneficiaries were in institutional stays 
reimbursed by Medicare or Medicaid, and/or  
 
  were provided by PCS attendants who did not meet State qualification requirements.  
 
Inadequate Controls To Ensure Appropriate Payment and Quality of Care. OIG work has 
demonstrated that existing program safeguards intended to ensure medical necessity, patient 
safety, and quality and prevent improper payments were often ineffective.  In one or more audits 
or evaluations, OIG found:  
 
  inadequate controls in the prior authorization processes (i.e., the processes to determine 
whether the beneficiaries qualify for PCS services before they are rendered);  
 
  lack of prepayment controls (e.g., electronic edits to deny claims for PCS services that 
overlap with institutional stays);  
 
  inconsistent standards for, and monitoring of, the qualifications of PCS attendants; and 
 
  problematic billing practices (e.g., claims that lack details regarding dates of service 
and/or the identity of the PCS attendants providing services).   
 
 
 
i 
  PCS Fraud Is a Growing Concern.  OIGs Office of Investigations and many State Medicaid 
Fraud Control Units report that the increasing volume of fraud involving PCS has become a top 
concern.  The most commonly reported schemes involve conspiracies between PCS attendants 
and Medicaid beneficiaries to submit claims for services that either were never provided or were 
not allowed under program rules.  Investigators have noted that self-directed Medicaid service 
models (i.e., those in which beneficiaries have decisionmaking authority over certain services 
and take direct responsibility for managing their services with the system of available supports), 
especially those that allow beneficiaries significant control over the selection and payment of 
PCS attendants, are particularly vulnerable to these fraud schemes.1    
 
RECOMMENDATIONS TO IMPROVE PROGRAM INTEGRITY   
 
On the basis of the body of OIGs PCS work, we recommend that CMS take the following 
actions: 
 
1.  More fully and effectively use authorities available under section 1102 and Title XIX of the 
Social Security Act to improve regulatory oversight and monitoring of Medicaid PCS 
programs.  Toward that end, CMS should promulgate regulations to: 
 
a.  Reduce significant variation in State PCS attendant qualification standards and the 
potential for beneficiary exposure to unqualified PCS attendants by establishing 
minimum Federal qualification standards applicable to all PCS reimbursed by 
Medicaid.   
 
b.  Improve CMSs and States ability to monitor billing and care quality by requiring 
States to (1) either enroll all PCS attendants as providers or require all PCS attendants 
to register with their State Medicaid agencies and assign each attendant a unique 
identifier and (2) require that PCS claims include the specific date(s) when services 
were performed and the identity of the rendering PCS attendants.   
 
c.  Reduce significant variation in States PCS laws and regulations by creating or 
expanding Federal requirements and issuing operational guidance for claims 
documentation, beneficiary assessments, plans of care, and supervision of attendants.   
 
2.  Issue guidance to States regarding adequate prepayment controls.  For example, CMS should 
identify a list of needed controls, including the necessary claims edits to prevent 
inappropriate PCS payments during periods when beneficiaries are receiving institutional 
care.  CMS should also offer design instructions to better ensure the operability of 
prepayment controls.  
 
3.  Consider whether additional controls are needed to ensure that PCS are allowed under 
program rules and are provided.   
 
4.  Take action to provide States with data suitable for identifying overpayments for PCS claims 
during periods when beneficiaries are receiving institutional care paid for by Medicare or 
Medicaid. While we understand that CMS makes Medicare data available to States, more 
could be done to ensure that Medicare data are compatible with States systems; that States 
have the capacity to store the data necessary to identify improper Medicaid payments; and 
 
ii  that States may crosswalk Medicare and Medicaid data to identify potential instances of 
fraud, waste, and abuse.    
 
5.  Address recommendations contained in prior OIG reports that remain unimplemented. (See 
page 13 for a list of some prior recommendations related to PCS that remain 
unimplemented.)   
iii 
  TABLE OF CONTENTS 
 
BACKGROUND ............................................................................................................................1 
   Personal Care Services (PCS), A Primer .............................................................................1 
 
SUMMARY OBSERVATIONS ...................................................................................................2 
 
IMPROPER PAYMENTS LINKED TO LACK OF COMPLIANCE WITH 
DOCUMENTATION, PLANS OF CARE, MEDICAL SUPERVISION, AND 
QUALIFICATION REQUIREMENTS .......................................................................................2 
Interviews With Medicaid Beneficiaries Reveal Quality-of-Care Concerns .......................3 
 
INADEQUATE CONTROLS TO ENSURE APPROPRIATE PAYMENT AND QUALITY 
OF CARE .....................................................................................................................................3 
   Inadequate Controls to Prevent PCS Payments During Institutional Care ..........................3 
 
Insufficient Qualification Safeguards ..................................................................................4 
 
Billing Policies That Impair Program Integrity Efforts .......................................................4 
 
Dates of Services Not Identified on Claims .............................................................4 
 
PCS Attendants Not Identified on Claims ...............................................................5 
 
PCS FRAUD IS A GROWING CONCERN ...............................................................................5 
Fraud Example: Owner of PCS Agency Sentenced for Defrauding Medicaid Out of More 
Than $650,000 .....................................................................................................................5 
 
RECOMMENDATIONS TO IMPROVE PROGRAM INTEGRITY .................................... 6 
 
AGENCY COMMENTS AND OFFICE OF INSPECTOR GENERAL RESPONSE ........... 8 
 
APPENDIX A  Personal Care Services  Related Authorities Under Title XIX of the 
Social Security Act .......................................................................................................................10 
 
APPENDIX B  List of Related OIG Reports ...........................................................................11 
 
APPENDIX C  List of Unimplemented Recommendations for Personal Care Services .....13 
 
APPENDIX D  Agency Comments ...........................................................................................14 
 
ENDNOTES..................................................................................................................................21 
 
  
 
 
 
iv 
   
 
BACKGROUND 
 
Personal care services (PCS) provide assistance to the elderly, people with disabilities, and 
individuals with chronic or temporary conditions so that they can remain in their homes and 
communities.  PCS are currently offered as either a State plan optional benefit or through various 
demonstrations and waivers2 in all 50 States.  (See Appendix A for related authorities.)  States 
that provide PCS through State plans 
must comply with the general Medicaid 
PERSONAL CARE SERVICES, A PRIMER 
program requirements outlined in 
 
section 1902 of the Social Security Act.  
What are PCS? PCS consist of nonmedical services 
States providing PCS through 
supporting activities of daily living, including 
demonstration or waiver authorities 
bathing, dressing, light housework, money 
must adhere to the terms of the 
management, meal preparation, and transportation.  
application approved by CMS.    PCS are provided to vulnerable care-dependent 
    persons, typically those who are elderly or infirm 
Recent data suggest rapid growth in  and/or have disabilities.  
PCS.  In 2011, Medicaid costs for PCS   
totaled approximately $12.7 billion, a  Who provides PCS? Typically, an attendant 
provides PCS. In many States, PCS attendants work 
35-percent increase since 2005.  
for personal care agencies, which are enrolled in the 
Additionally, the U.S. Department of 
Medicaid program and bill for services on the 
Labor, Bureau of Employment 
attendants behalf.  Some States require attendants to 
Statistics, in its Occupational Outlook 
register or enroll with the State, but most do not.  
Handbook, 2010-11 Edition, projected 
States may define specific qualification requirements 
that employment of personal and home 
for attendants, such as minimum age, education, and 
health aides will grow by 46 percent by  health status.   
2018, much faster than the average of   
10 percent for all occupations.  What are coverage rules for PCS? Medicaid 
  covers PCS for eligible individuals through 
A key factor in this increase was the  Medicaid State plan options and/or through 
Medicaid waiver and demonstration authorities 
United States Supreme Court decision 
approved by CMS. (See Appendix A for a list of 
in Olmstead v. L.C. 527 U.S. 581 
authorities.)  Medicare does not provide 
(1999), which held that unjustified 
reimbursement of PCS.   
institutionalization of people with 
 
disabilities is a violation of the 
Under Federal law, PCS must be provided in a home 
Americans With Disabilities Act.  The 
or another location specified by the State and must 
Department of Health and Human  follow a plan of care subject to approval and/or 
Services has promoted States efforts to  authorized by the State Medicaid agency. Although 
provide Medicaid beneficiaries who are  there are no Federal requirements for PCS 
elderly or have disabilities with the  attendants, States are required to develop 
choice of remaining in their homes and  qualifications or requirements for attendants to 
ensure quality of care.   
communities, as opposed to moving to 
nursing homes or other institutional 
care options.  For example, the Patient Protection and Affordable Care Act (ACA) of 2010 
removed barriers to providing home and community-based services by allowing additional State 
plan amendment options, increasing States timeframes to elect and renew PCS as a care option, 
and streamlining processes for accessing home and community-based services.  The ACA also 
1 
  provided additional funding for programs supporting home care goals, such as the Money 
Follows the Person demonstration and the Community First Choice Option programs.  
 
As of August 2012, the Office of Inspector General (OIG) has produced 23 audit and evaluation 
reports since 2006 on PCS, which consistently have found payment, compliance, and oversight 
vulnerabilities, as well as quality-of-care concerns.  (See Appendix B for a list of related PCS 
audit and evaluation reports and Appendix C for a list of prior OIG recommendations related to 
PCS that remain unimplemented by CMS and States.)  Federal investigators and State Medicaid 
Fraud Control Units (MFCUs) have also observed an increase in suspected PCS fraud.  What 
follows are summary observations based on vulnerabilities detected in OIG audits, evaluations, 
and investigations, as well as recommendations for corrective actions based on the body of 
OIGs PCS work.   
 
OIG work referenced throughout this document was conducted in accordance with the 
professional standards applicable to audits, evaluations, and investigations.  
SUMMARY OBSERVATIONS 
Improper Payments Linked to Lack of Compliance With Documentation, Plans 
of Care, Medical Supervision, and Qualification Requirements   
As of August 2012, OIG has completed seven statewide audits and one citywide audit of PCS 
payments.  Another statewide audit is in progress.  Since 2009, seven of the eight completed 
audits have identified over $582 million in questioned costs.  Table 1 lists the error rates,3 
questioned costs, and set-aside costs4 from each of the eight completed audits:  
Table 1: Error Rates, Questioned Costs, and Set-Aside Costs for PCS in Seven States and One 
City 
 
State  Error Rate5  Questioned Costs6  Set Aside Costs7 
(Percentage) 
Maryland8  0%  $0  $0 
West Virginia9  1.00%  $19,830  $0 
Nebraska10  2.31%  $168,652  $4,482,438 
New Jersey 11  40.35%  $145,405,192  $0 
New York12  31.78%  $100,335,472  $15,325,689 
New York City13  18.01%  $275,327,274  $0 
North Carolina14  16.31%  $41,734,368  $0 
Washington15  20.17%  $19,438,693  $30,323,597 
 
 
The seven audits that found overpayments noted several types of deficiencies:   
 
  Hours claimed in the billings were not supported by documentation.16 
 
  PCS services failed to meet State assessment and/or prior authorization requirements.17  
 
  PCS services did not meet State supervision requirements.18  
 
  PCS attendants did not meet State qualification and/or training requirements.19
 
2    Claims included periods during which beneficiaries received institutional care covered 
under Medicare or Medicaid.20 
 
These States often failed to provide oversight to prevent improper payments in several ways, 
including:  
 
  insufficient resources to adequately monitor their PCS programs, especially once they 
began to experience substantial growth;21 
 
  inadequate controls in the States prior authorization processes (i.e., the processes to 
determine whether beneficiaries qualify for services before they are rendered);22     
 
  ineffectiveness of accrediting organizations to which the States delegated authority to 
ensure compliance with applicable State regulations;23 
 
  failure to conduct monitoring site visits of PCS agencies that employed attendants, 
leaving the role of oversight largely to 
beneficiaries;24 and 
INTERVIEWS WITH 
 
  inadequate controls to prevent paying improper  MEDICAID BENEFICIARIES 
PCS claims, including instances when PCS were  REVEAL QUALITY-OF-CARE 
claimed while the beneficiaries received  CONCERNS 
institutional care.25   
  In interviews conducted in 
Separately, a 2010 OIG evaluation examining PCS in 10  connection with two OIG audits of 
States over a 1-year period found that 18 percent of paid  PCS in New York City and New 
York State, the majority of sampled 
claims for Medicaid PCS in a universe totaling $724 
Medicaid beneficiaries interviewed 
million were inappropriate because the required 
(40 of the 65 beneficiaries in New 
qualifications for PCS attendants were undocumented.26   
York City and 38 of the 55 in New 
The most often undocumented qualifications were age, 
York State) reported to OIG quality-
education, and the results of background checks.  
of-care problems with their PCS 
Although the insufficient documentation may be an 
attendants.  The most serious 
indicator that PCS attendants or agencies did not  allegations included physical abuse 
maintain or have ready access to documents containing  or threats of abuse, property theft, 
this information, it could signal that the sampled PCS  and patient abandonment.  One 
attendants did not meet State qualifications designed to  beneficiary reported that an 
ensure patient safety and high quality of care.      attendant abandoned her on two 
occasions  in the street and in the 
Inadequate Controls To Ensure Appropriate  subway  because the attendants 
shift had ended.   
Payment and Quality of Care 
 
 
Without proper control and oversight 
Inadequate Controls To Prevent PCS Payments During 
mechanisms, unqualified attendants 
Institutional Care. PCS are generally not eligible for 
could expose beneficiaries to 
Federal financial participation when provided to a 
substandard quality of care and 
beneficiary receiving services as an inpatient or a  injury.   
resident at a hospital, nursing home, or other 
institution.27  However, OIG work has documented many instances when PCS providers received 
payment during periods when the beneficiary purportedly received institutional care service. 
 
An audit examining paid PCS claims over a 30-month period in Nebraska identified 464 
instances in which PCS providers billed and were improperly paid for PCS during the 
3 
  beneficiaries inpatient hospital stays.28  A 2008 evaluation of PCS payments in the first quarter 
of 2006 found that the five States reviewed paid nearly $500,000 for PCS on dates when 
beneficiaries were institutionalized in Medicaid-funded facilities.29  This review cited problems
with the States claims payment systems, including unsuccessful prepayment edits, which could 
have contributed to the estimated $11 million in potentially improper payments over the 3-month 
period.30   
 
Numerous OIG and MFCU investigations have focused on potentially false PCS claims during 
periods of beneficiary institutionalization, resulting in convictions of PCS attendants and their 
employers.31 
 
Insufficient Qualification Safeguards.  To be eligible for Federal financial participation, PCS 
must be provided by a qualified individual.32  Although there are no Federal requirements that 
specify qualifications for PCS attendants, States are required to specify qualifications or 
requirements for PCS attendants to ensure quality of care.  A 2006 evaluation of State 
requirements for PCS attendants revealed 301 different sets of requirements nationwide.33  The 
most common requirements were background checks; training; supervision; minimum age; 
health status (e.g., that the attendant test negative for tuberculosis); and education (e.g., 
attainment of a high school diploma).  The report noted that the wide variation among States and 
within the same State may make it difficult to ensure compliance with requirements.  
Additionally, a 2010 evaluation of compliance with qualification requirements in 10 States found 
that PCS attendant qualifications were undocumented for 18 percent of Medicaid PCS claims.34  
Additional Federal regulations that set minimum qualifications could improve consistency 
among States and better ensure that beneficiaries receive PCS from qualified PCS attendants.  
 
Billing Policies That Impair Program Integrity Efforts.  OIG work on PCS has identified two 
distinct problems with State billing policies.  First, PCS claims often do not specify the dates 
when the services were actually provided, and second, PCS claims do not identify the attendant 
that provided the service(s).   
 
Dates of Services Not Identified on Claims.  The 2008 evaluation revealed that the claims data in 
three of five States reviewed could not be used to accurately identify overlapping claims.  These 
States allow PCS providers to submit claims through a process commonly referred to as span 
billing.  In general, span billing allows providers to submit one claim requesting payment for 
multiple instances of PCS provided over a range of dates (week or month), without specifying 
dates when the services were actually provided.  The inability to identify service dates on claims 
presents a significant oversight challenge because the State cannot determine whether, for 
example, PCS overlap with dates when the beneficiaries received institutional care services.35   
 
The problematic consequences of span billing were seen in an evaluation focusing on PCS 
claims for services in excess of 24 hours per day and between 16 and 24 hours per day.36  This 
review examined PCS claims in 5 States and identified 871 paid claims in 4 States that were for 
services provided in excess of 24 hours per day to a single beneficiary.  It also identified over 
2,000 other paid claims that totaled or nearly totaled 24 hours per day, a volume of services that 
could raise program integrity concerns.   
 
During ad hoc interviews with MFCU directors in two States that allow span billing, the 
directors reported that they have recommended to their Medicaid agencies that span billing be 
prohibited.  These MFCU directors reported that span billing prevents their investigators from 
obtaining necessary evidence to pursue fraud cases against PCS attendants and agencies.  In 
4  some PCS fraud cases, investigators rely on evidence that compares the dates of services listed 
on Medicaid claims to dates when the PCS attendants were engaged in conflicting activities (e.g., 
other job, travel).  When specific dates of service are not included on claims, fraud investigations 
could be significantly hindered.  Additional Federal regulations requiring that all States require 
the dates of services on claims would improve Federal and State program integrity efforts.   
 
PCS Attendants Not Identified on Claims.  Most States 
do not require PCS attendants to register with the State 
Medicaid programs and therefore do not assign PCS  FRAUD EXAMPLE 
attendants unique identifiers to be included on 
claims.37  As a result, conducting attendant-specific  OWNER OF PCS AGENCY 
data mining and analysis in such States is difficult.   SENTENCED FOR 
Further, in the absence of information identifying the  DEFRAUDING MEDICAID OUT 
attendants, States are challenged to implement edits  OF MORE THAN $650,000 
that would prevent payments or trigger prepayment    
reviews of claims associated with high-risk or  As a result of a joint investigation by 
excluded PCS attendants.38  Similarly, the absence of  Federal and State officials, John 
Alemoh Momoh, owner and operator 
the identity of the attendant on PCS claims forms 
of Hopecare Service, Inc., was 
creates significant challenges to law enforcement 
sentenced to 2 years of incarceration 
efforts to investigate potentially fraudulent claims.  
and ordered to pay $656,876 in 
For this reason, numerous MFCUs have recommended 
restitution to Medicaid.   
to their State Medicaid agencies that PCS attendants 
 
be assigned unique identifiers that would appear on 
Between May 2007 and March 2008, 
claims forms.39  If States registered or enrolled PCS  Momoh submitted claims that 
attendants and required attendant identifiers on claims,  inflated the number of PCS hours 
State and Federal program integrity staff could search  provided to Medicaid beneficiaries.  
for and follow up on questionable billing patterns  Momoh also submitted false claims 
(e.g., billings for more than 24 hours in a day or for  for services that were not rendered, 
were provided by an unqualified 
other impossible or improbable numbers of hours) and 
individual, and were not medically 
implement edits to prevent improper claims.   
necessary.   
PCS Fraud Is a Growing Concern 
 
OIG and the MFCUs have noted an increasing amount of fraud cases involving PCS.  As of 
2010, MFCUs had more open investigations involving PCS fraud than any other type of 
Medicaid service, with more than 1,000 investigations nationwide.  In a recent survey, MFCUs 
cited fraud occurring in home and community-based settings, consisting mostly of PCS fraud, as 
a top fraud concern affecting their States.40   
 
Cases investigated by OIGs Office of Investigations (OI) and discussions with multiple MFCUs 
indicate that the most common fraud schemes involve conspiracies between PCS attendants and 
beneficiaries.  In a growing number of instances, the beneficiaries are being charged as co-
conspirators because they accepted cash or other benefits in exchange for participating in the 
fraud.  These cases appear to be especially prevalent in States using CMS-approved home and 
community-based service waivers that allow relatives of beneficiaries to be their PCS 
attendants.41  In many of these cases, investigation reveals that the beneficiaries do not appear to 
have the medical conditions or physical limitations documented on their assessments and 
therefore are not eligible for PCS.42 
5   
Additionally, OI and the MFCUs are encountering a new fraud scenario in States with self-
directed Medicaid service models (i.e., those in which beneficiaries have decisionmaking 
authority over certain services and are directly responsible for managing their services with the 
system of available supports) and particularly in those States that send payment for PCS services 
directly to the beneficiaries instead of the attendants.43  Although State Medicaid programs in 
these States require beneficiaries to give the payments to the PCS attendants, cases in which 
beneficiaries submit false claims for services that were never provided are now being prosecuted.  
In such cases, the beneficiaries typically forge the PCS attendants names and then deposit the 
checks into their own bank accounts.44  In States allowing self-directed PCS models, additional 
controls may be necessary to ensure that services both are necessary and are provided.   
 
Fraud is often difficult to detect by reviewing documentation alone.  The majority of the 
overpayments identified in OIG audits are the consequence of missing documentation that 
services were performed, assessments were conducted, training and qualification requirements 
were met, and plans of care were completed.  In contrast, fraud is often proven by showing that 
the existing documentation of such activities by PCS attendants and providers is false (see the 
fraud example on the previous page).   
 
At present, most fraud cases involving PCS come to the attention of law enforcement only 
through referrals from individuals who know the persons committing the acts.  However, if the 
availability and quality of PCS data were improved, data could be analyzed to identify and 
follow up on aberrancies and questionable billing patterns.  For example, PCS attendants and 
agencies that commit fraud often bill for impossibly or improbably large volumes of services; for 
services that conflict with one another (e.g., a PCS attendant purports to provide many hours of 
services to multiple beneficiaries on the same dates); or for services that could not have been 
performed as claimed because of geographical distances between beneficiaries purportedly 
served by the same PCS attendant on the same day.  If claims contained more specific details, 
including the exact dates of service and the identity of the PCS attendants, such irregular billings 
could be more easily and systematically discovered through claims analysis by State program 
integrity units.  
RECOMMENDATIONS TO IMPROVE PROGRAM INTEGRITY 
 
On the basis of the body of OIGs PCS work, we recommend that CMS take the following 
actions: 
 
1.  More fully and effectively use authorities available under section 1102 and Title XIX of the 
Social Security Act to improve regulatory oversight and monitoring of Medicaid PCS 
programs.  Toward that end, CMS should promulgate regulations to: 
 
a.  Reduce significant variation in State PCS attendant qualification standards and the 
potential for beneficiary exposure to unqualified PCS attendants by establishing 
minimum Federal qualification standards applicable to all PCS reimbursed by 
Medicaid.  For example, CMS could establish minimum age and education standards 
and requirements for screening attendants (e.g., criminal background and Federal and 
6 
  State exclusion checks).  These standards could be informed by work currently being 
conducted by the CMS-funded National Direct Service Workforce Resource Center 
(the Resource Center), which plans to develop a set of core competencies for workers 
providing long-term services.  CMS could also consider the results of its National 
Background Check program, which has awarded selected States with funding to 
design a comprehensive national background check program for jobs involving direct 
patient care.  
 
b.  Improve CMSs and States ability to monitor billing and care quality by requiring 
States to (1) either enroll all PCS attendants as providers or require all PCS attendants 
to register with their State Medicaid agencies and assign each attendant a unique 
identifier and (2) require that PCS claims include the specific date(s) when services 
were performed and the identity of the rendering PCS attendants.   
 
c.  Reduce significant variation in States PCS laws and regulations by creating or 
expanding Federal requirements and issuing operational guidance for claims 
documentation, beneficiary assessments, plans of care, and supervision of attendants.   
 
2.  Issue guidance to States regarding adequate prepayment controls.  For example, CMS should 
identify a list of needed controls, including the necessary claims edits to prevent 
inappropriate PCS payments during periods when beneficiaries are receiving institutional 
care.  CMS should also offer design instructions to better ensure the operability of 
prepayment controls.  
 
3.  Consider whether additional controls are needed to ensure that PCS are allowed under 
program rules and are provided.  For example, as part of its State Plan and waiver application 
process, CMS could require States to identify specific safeguards to prevent the fraud 
schemes highlighted in this report.     
 
4.  Take action to provide States with data suitable for identifying overpayments for PCS claims 
during periods when beneficiaries are receiving institutional care paid for by Medicare or 
Medicaid.  While we understand that CMS makes Medicare data available to States, more 
could be done to ensure that Medicare data are compatible with States systems; that States 
have the capacity to store the data necessary to identify improper Medicaid payments; and 
that States may crosswalk Medicare and Medicaid data to identify potential instances of 
fraud, waste, and abuse.    
 
5.  Address recommendations contained in prior OIG reports that remain unimplemented.  (See 
Appendix C for a list of some prior recommendations related to PCS that remain 
unimplemented.)   
7 
   
AGENCY COMMENTS AND OFFICE OF INSPECTOR 
GENERAL RESPONSE 
 
We made five recommendations in the report.  CMS concurred with our fourth recommendation 
but did not indicate whether it concurred with our first, second, or third recommendations.  Our 
fifth recommendation related to addressing prior unimplemented OIG recommendations.  CMS 
indicated that it will incorporate those recommendations when developing action plans to address 
recommendations from this report.  CMS generally agreed that more needs to be done at the 
Federal and State level to ensure appropriate billing for provided PCS.   
 
More specifically, with regard to recommendation 1.a., CMS noted that in 2011 it funded the 
development of the Road Map of Core Competencies for the Direct Service Workforce; the direct 
service workforce will include PCS attendants.  CMS expects this project to produce a set of 
service worker competencies by 2014, which CMS will then encourage States to adopt for use in 
their PCS programs.  The agency also stated that it will continue to work with States on the 
National Background Check program. 
 
We support CMSs work to develop core competencies that include minimum standards that any 
PCS attendant must have in order to be considered qualified to render PCS.  However, on the 
basis of OIGs work documenting that States and local jurisdictions have developed over 300 
PCS attendant requirements in the absence of Federal qualification requirements, we remain 
concerned that States will not adopt any core competencies unless CMS requires them to do so. 
For that reason and because of the overpayments for unqualified PCS attendants identified in 
prior work, we continue to recommend that CMS establish minimum Federal qualification 
standards applicable to all Medicaid-reimbursed PCS.   
 
In relation to recommendation 1.b. (1), CMS stated that it will explore and identify the potential 
costs and benefits of States either enrolling all PCS attendants as providers or requiring that 
attendants register with their State Medicaid agencies.  In addition, CMS indicated that it would 
explore and identify improvements to claims documentation that facilitate accurate payments and 
the detection of fraud and abuse.  We reiterate that CMSs and States ability to monitor billing 
and care quality could be improved by assigning PCS attendants unique identifiers through either 
an enrollment or registration process and by requiring these identifiers, as well as the specific 
dates of service, on claims.  We continue to recommend that CMS promulgate related 
regulations.  
 
In relation to recommendation 1.c., CMS outlined regulations that are part of the Community 
First Choice (CFC) benefit that the agency reported would standardize requirements for both 
care plans and assessments.  CMS noted that the same requirements appear in its proposed 
regulations for home and community-based services provided under sections 1915(c) and 1915(i) 
of the Social Security Act.  We appreciate that in new programs, such as CFC, CMS is working 
to address some of the issues we have raised in this report.  We ask that in its final management 
decision, CMS provide further explanation as to how the regulations it referenced will serve to 
standardize States care plans and assessments.  We augmented our report to recommend that 
CMS issue guidance outlining expectations regarding how the regulations CMS referenced 
8 
  should be implemented to achieve standardization and improvements in claims documentation, 
beneficiary assessments, plans of care, and supervision of attendants.   
 
In relation to our second recommendation, CMS stated that it intends to issue guidance to remind 
States of their obligation to review their own data to identify payment and utilization aberrations.  
CMS also stated that it will begin using its own data sources to better identify claims outliers, 
review those findings regularly with States, provide technical assistance to States  on 
implementing those practices, share the findings of our report with States, and work with 
national long-term-care associations to improve program integrity in Medicaid PCS.  We would 
appreciate CMSs providing a timetable for implementation of each of these activities in its final 
management decision.   
 
In relation to our third recommendation, CMS stated that it plans to provide States with guidance 
on educating PCS providers on the program integrity issues identified in our report.  CMS 
indicated it will also consult with stakeholders and attempt to create and publish guidance for 
States about program integrity controls through various technical assistance vehicles.  We 
request that in its final management decision, CMS provide a timeline for development and 
completion of these activities. Furthermore, CMS identified several fraud protections it believes 
currently exist in its self-directed waiver service models.  While we agree that the existing 
protections CMS described are important, they have not succeeded in preventing the 
vulnerabilities found in our reviews, audits, and investigations.  We continue to recommend that 
CMS consider additional controls to ensure that PCS are allowed under program rules and are 
provided. 
 
CMS concurred with our fourth recommendation and indicated that it will work with the 
Medicare and Medicaid Coordination Office to identify additional data-sharing approaches with 
States for dually eligible beneficiaries to prevent overpayments for PCS claims.   
 
In response to our fifth recommendation, CMS stated that prior OIG recommendations that are 
contained in Appendix C appear to be largely encompassed within the first four recommendations 
in this report.  CMS therefore said that it will incorporate its response to the prior 
recommendations as part of its actions to address our first through fourth recommendations.  OIG 
continues to consider the prior recommendations as unimplemented and encourages CMS to take 
actions that address all recommendations in this report as well as our prior recommendations.   
OIG will consider whether specific actions taken by CMS address the PCS issues and 
recommendations identified in this report and the reports listed in Appendix C.   
We ask that in its final management decision, CMS more clearly indicate whether it concurs with 
our recommendations 1(a)-(c), 2, 3, and 5. 
9   
APPENDIX A Personal Care Services  Related 
Authorities Under Title XIX of the Social Security Act  
 
 
States can provide personal care services (PCS) to eligible Medicaid beneficiaries through State 
plan and waiver programs.  States that provide PCS through State plan programs must comply 
with the general Medicaid program requirements in section 1902 of the Social Security Act.  
States can also provide PCS through 1115 demonstration; 1915(a) and 1915(b) managed care 
and freedom of choice; 1915(c) home and community-based services waiver; 1915(j) self-
directed personal assistant services; 1915(k) community first choice programs; and 1915(i), 
which allows PCS under a State amendment option. 
 
10 
   
APPENDIX B - List of Related OIG Reports 
 
Report  Issue Date 
States Requirements for Medicaid-Funded Personal Care Service Attendants  December 2006  
(OEI-07-05-00250)  
 
Review of Personal Care Services Claimed by the Center for Living and  October 2007  
Workings, Inc. (A-01-06-00011) 
 
Payments Made in Error for Personal Care Services During Institutional Stays  August 2008  
(OEI-07-06-00620) 
 
Medicaid-Funded Personal Care Services in Excess of 24 Hours per Day   October 2008  
(OEI-07-06-00621) 
 
Partnership Review of Medicaid Claims Processed by Cerebral Palsy and Stavros  November 2008  
for Personal Care Attendant Services Provided to Beneficiaries during Inpatient 
Stays (A-01-08-00001) 
 
Review of Medicaid Personal Care Services Claims Made by Providers in New  June 2009  
York City (A-02-07-01054) 
 
Review of Medicaid Personal Care Service Claims Submitted by Independence  April 2010 
First, Inc. and Claimed by Wisconsin From July 1, 2006, Through June 30, 2008 
(A-05-09-00093) 
 
Review of Medicaid Personal Care Service Claims Submitted by Dane County  September 2010  
Department of Human Services and Claimed by Wisconsin From July 1, 2006, 
Through June 30, 2008 (A-05-10-00018) 
 
Review of Medicaid Personal Care Service Claims Submitted by Clarity Care,  October 2010  
Inc., and Claimed by Wisconsin From July 1, 2006, Through June 30, 2008  
(A-05-10-00019) 
 
Review of Medicaid Personal Care Services Claims Made by Providers in New  October 2010  
York State (A-02-08-01005) 
 
Review of Personal Care Services Provided by Tri-State Home Health and  November 2010  
Equipment Services, Inc., in the District of Columbia (A-03-08-00207) 
 
Inappropriate Claims for Medicaid Personal Care Services (OEI-07-08-00430)  December 2010  
 
Review of Federal Reimbursement Claimed by North Carolina for Medicaid  February 2011  
Personal Care Services Claims Submitted by Shipman Family Home Care, Inc. 
(A-04-09-04041) 
 
 
11  Review of New Mexico Medicaid Personal Care Services Provided by Ambercare  March 2011  
Home Health (A-06-09-00062) 
 
Review of Medicaid Personal Care Services Claimed by Washington State   June 2011  
(A-09-09-00030) 
 
Review of Medicaid Personal Care Services Claims Submitted by Providers in  June 2011  
North Carolina (A-04-10-04003) 
 
Nebraska Medicaid Payments for Personal Care Services (A-07-10-03152)    July 2011  
 
Review of Personal Care Services Claimed Under Marylands Medicaid State  November 2011 
Plan (A-03-11-00200) 
 
Review of Medicaid Personal Care Claims Submitted by Providers in New Jersey  December 2011 
(A-02-09-01002) 
 
Review of New Mexico Medicaid Personal Care Services Provided by Heritage  May 2012 
Home Healthcare (A-06-09-00063) 
 
Review of New Mexico Medicaid Personal Care Services Provided by Clovis  June 2012 
Homecare, Inc. (A-06-09-00117) 
 
Review of Louisiana Medicaid Personal Care Services Provided by American  June 2012 
Pride Caregivers, LLC (A-06-09-00107) 
 
West Virginia Complied With Certain Federal Requirements for Most of the  June 2012 
Personal Care Services Claimed for Its Aged and Disabled Waiver Program  
(A-03-11-00205) 
 
12   
APPENDIX C  List of Certain Unimplemented 
Recommendations for Personal Care Services*  
 
Recommendations To CMS 
 
1.  Work with States to reduce erroneous Medicaid payments for personal care services (PCS) 
provided during institutional stays (Payments Made in Error for Personal Care Services 
During Institutional Stays, OEI-07-06-00620) (CMS concurred.) 
 
2.  Enforce existing Federal Medicaid payment policies prohibiting Medicaid reimbursement for 
PCS provided over a range of dates if the range includes dates on which the beneficiary was 
institutionalized (Payments Made in Error for Personal Care Services During Institutional 
Stays, OEI-07-06-00620) (CMS did not concur.)  
 
3.  Work with States to ensure that agencies and attendants are aware of attendant qualification 
and documentation requirements and that Medicaid claims for PCS provided by attendants 
with undocumented qualifications are not paid (Inappropriate Claims for Medicaid Personal 
Care Services, OEI 07-08-00430) (CMS concurred.) 
 
Recommendations To Specific Medicaid State Agencies 
 
4.  Implement prepayment controls to monitor PCS claims for compliance with State 
requirements (Review of Personal Care Services Provided by Tri-State Home Health and 
Equipment Services, Inc., in the District of Columbia, A-03-08-00207) (The Department of 
Health Care Finance concurred.)   
 
5.  Provide more effective monitoring of PCS attendants compliance with qualification 
requirements (Review of Personal Care Services Provided by Tri-State Home Health and 
Equipment Services, Inc., in the District of Columbia, A-03-08-00207) (The Department of 
Health Care Finance concurred.) 
 
6.  Strengthen controls by developing policies and procedures for more substantive 
documentation and prepayment and postpayment claim review to ensure that PCS claims are 
reviewed and paid in accordance with Federal and State requirements (Nebraska Medicaid 
Payments for Personal Care Services, A-07-10-03152) (The Department of Health & Human 
Services concurred.) 
 
*This list does not include overpayment recovery recommendations included in some OIG reports. 
13   
APPENDIX D  Agency Comments 
 
 
 
   
14   
 
 
15   
 
16   
17   
18   
19   
20   
ENDNOTES  
                                                 
 
1 Additional information on self-directed Medicaid services is available at http://www.medicaid.gov/Medicaid-
CHIP-Program-Information/By-Topics/Delivery-Systems/Self-Directed-Services.html.  Accessed on April 24, 2012. 
 
2 Section 1115 waivers give States flexibility to design and improve the Medicaid and Childrens Health Insurance 
Program (CHIP) programs.  Waivers let States test new or existing ways to deliver and pay for program coverage. 
The Centers for Medicare & Medicaid Services (CMS) conducts and sponsors a number of innovative demonstration 
projects to test and measure the effect of potential program changes. Additional information on section 1115 waivers 
and demonstrations is available at http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-
Topics/Waivers/1115/Section-1115-Demonstration.html.  Accessed on August 15, 2012. 
 
3 We calculated the error rate for each review by dividing the point estimate for the estimated value of unallowable 
items by the value of the sampling frame.  These amounts can be found in the sampling methodology within the 
appendix of each report. 
 
4 The questioned costs and the set-aside costs are the lower limits of 90-percent confidence intervals.  These 
amounts can be found in the sampling methodology within the appendix of each report. 
 
5 We calculated the error rate for each review by dividing the point estimate for the estimated value of unallowable 
items by the value of the sampling frame.  These amounts can be found in the sampling methodology within the 
appendix of each report.    
 
6 ''Questioned cost'' means a cost that is questioned by OIG because of (1) an alleged violation of a provision of a 
law, regulation, contract, grant, cooperative agreement, or other agreement or document governing the expenditure 
of funds; (2) a finding that at the time of the audit, such cost is not supported by adequate documentation; or (3) a 
finding that the expenditure of funds for the intended purpose is unnecessary or unreasonable. 
 
7 Set-aside costs are generally costs that we believe are in error but the magnitude of which may not be statistically 
measurable or for which the criteria for determining the costs propriety were not clearly set forth by the 
administering agency. 
 
8 Review of Personal Care Services Claimed Under Marylands Medicaid State Plan (A-03-11-00200), November 
2011. 
 
9 West Virginia Complied With Certain Federal Requirements for Most of the Personal Care Services Claimed for 
Its Aged and Disabled Waiver Program (A-03-11-00205), June 2012. 
 
10 Nebraska Medicaid Payments for Personal Care Services (A-07-10-03152), July 2011. 
 
11 Review of Personal Care Claims Submitted by Providers in New Jersey (A-02-09-01002), December 2011. 
 
12 Review of Medicaid Personal Care Services Claims Made by Providers in New York State (A-02-08-01005), 
October 2010. 
 
13 Review of Medicaid Personal Care Services Claims Made by Providers in New York City (A-02-07-01054), June 
2009. 
 
14 Review of Medicaid Personal Care Services Claims Submitted by Providers in North Carolina (A-04-10-04003), 
June 2011. 
 
15 Review of Medicaid Personal Care Services Claimed by Washington State (A-09-09-00030), June 2011. 
 
16 Review of Medicaid Personal Care Services Claims Made by Providers in New York State (A-02-08-01005), 
October 2010;  Review of Medicaid Personal Care Services Claimed by Washington State (A-09-09-00030), June 
2011; Review of Medicaid Personal Care Services Claims Submitted by Providers in North Carolina (A-04-10-
04003), June 2011; Nebraska Medicaid Payments for Personal Care Services (A-07-10-03152), July 2011; Review 
of Personal Care Claims Submitted by Providers in New Jersey (A-02-09-01002), December 2011; and West 
Virginia Complied With Certain Federal Requirements for Most of the Personal Care Services Claimed for Its Aged 
and Disabled Waiver Program (A-03-11-00205), June 2012.  
21 
   
                                                                                                                                                             
 
 
17 Review of Medicaid Personal Care Services Claims Made by Providers in New York State (A-02-08-01005), 
October 2010;  Review of Medicaid Personal Care Services Claimed by Washington State (A-09-09-00030), June 
2011; Review of Medicaid Personal Care Services Claims Submitted by Providers in North Carolina (A-04-10-
04003), June 2011; Nebraska Medicaid Payments for Personal Care Services (A-07-10-03152), July 2011; and 
Review of Personal Care Claims Submitted by Providers in New Jersey (A-02-09-01002), December 2011. 
 
18 Review of Medicaid Personal Care Services Claims Made by Providers in New York City (A-02-07-01054), June 
2009; Review of Medicaid Personal Care Services Claims Made by Providers in New York State (A-02-08-01005), 
October 2010; Review of Medicaid Personal Care Services Claims Submitted by Providers in North Carolina (A-04-
10-04003), June 2011; and Review of Personal Care Claims Submitted by Providers in New Jersey (A-02-09-
01002), December 2011. 
 
19 Review of Medicaid Personal Care Services Claims Made by Providers in New York State (A-02-08-01005), 
October 2010; Review of Medicaid Personal Care Services Claimed by Washington State (A-09-09-00030), June 
2011; Review of Medicaid Personal Care Services Claims Submitted by Providers in North Carolina (A-04-10-
04003), June 2011; and Review of Personal Care Claims Submitted by Providers in New Jersey (A-02-09-01002), 
December 2011. 
 
20 Nebraska Medicaid Payments for Personal Care Services (A-07-10-03152), July 2011. 
 
21 Review of Medicaid Personal Care Services Claims Submitted by Providers in North Carolina (A-04-10-04003), 
June 2011. 
 
22 Review of Personal Care Claims Submitted by Providers in New Jersey (A-02-09-01002), December 2011. 
 
23 Ibid. 
 
24 Nebraska Medicaid Payments for Personal Care Services (A-07-10-03152), July 2011.  Failure to conduct onsite 
reviews of providers was also identified as a cause of payment of improper claims in New York State and New York 
City.  Review of Medicaid Personal Care Services Claims Made by Providers in New York City (A-02-07-01054), 
June 2009, and Review of Medicaid Personal Care Services Claims Made by Providers in New York State (A-02-08-
01005), October 2010.   
 
25 Review of Medicaid Personal Care Services Claimed by Washington State (A-09-09-00030), June 2011; Nebraska 
Medicaid Payments for Personal Care Services (A-07-10-03152), July 2011; and West Virginia Complied With 
Certain Federal Requirements for Most of the Personal Care Services Claimed for Its Aged and Disabled Waiver 
Program (A-03-11-00205), June 2012. 
 
26 Inappropriate Claims for Medicaid Personal Care Services (OEI-07-08-00430), December 2010. 
 
27 For State Plan PCS, see Social Security Act  1905(a)(24); 42 CFR  440.167; regarding waivers, see 42  
441.301(b)(1)(ii); 42 CFR  440.70(c). 
 
28 Nebraska Medicaid Payments for Personal Care Services (A-07-10-03152), July 2011. 
 
29 Payments Made in Error for Personal Care Services During Institutional Stays (OEI-07-06-00620), August 2008. 
 
30 Ibid. The review also identified a large number of overpayments for PCS during dates when the beneficiaries were 
institutionalized in Medicare-paid facilities.  The report recommended that CMS explore ways to ensure that State 
Medicaid programs have complete information on Medicare institutionalizations for dually eligible beneficiaries. 
 
31 A list of convictions may be found in OIGs compilation of State Enforcement Actions. Available at 
https://oig.hhs.gov/fraud/enforcement/state/index.asp.  Accessed on April 24, 2012. 
 
32 For State Plan PCS, see Social Security Act  1905(a)(24); 42 CFR  440.167; regarding waivers, see 42 CFR  
441.301(b)(1)(ii); 42 CFR  440.70(c). 
 
33 States Requirements for Medicaid-Funded Personal Care Service Attendants (OEI-07-05-00250), December 
2006.  The report noted that at the time of the review, there were 238 separate programs through which States were 
providing personal care services: 31 State plans and 207 Medicaid waivers. 
 
34 Inappropriate Claims for Medicaid Personal Care Services (OEI-07-08-00430), December 2010. 
22 
   
                                                                                                                                                             
 
 
35 For example, if a beneficiary was institutionalized from October 1 through October 7 and 10 hours of PCS were 
billed for the date range October 3 through October 9, the State cannot determine whether the PCS were provided 
between October 3 and October 6, when the beneficiary was institutionalized, or between October 7 and October 9, 
when the beneficiary was at home. 
 
36 Medicaid-Funded Personal Care Services in Excess of 24 Hours per Day (OEI-07-06-00621), October 2008. 
 
37 At least four States require enrollment of at least some of their Medicaid personal care attendants.  Minnesota 
enrolls all attendants providing both State plan and waiver PCS, regardless of whether the attendants are self-
employed or are employees of PCS agencies.  Iowa enrolls all attendants providing waiver PCS.  (Iowa does not 
have a State plan PCS benefit.)  For both State plan and waiver PCS, Ohio enrolls all PCS attendants who are not 
employees of PCS agencies.  Florida requires enrollment of attendants who are not employees of PCS agencies and 
are providing services under the State PCS plan. 
 
38 OIGs List of Excluded Individuals/Entities (LEIE) provides information to the health care industry, patients, and 
the public regarding individuals and entities currently excluded from participation in Medicare, Medicaid, and all 
other Federal health care programs. Individuals and entities who have been reinstated are removed from the LEIE. 
Additional information on excluded providers is available at https://oig.hhs.gov/faqs/exclusions-faq.asp.  Accessed 
on August 15, 2012. 
 
39 MFCUs in Ohio, Washington, New Mexico, and Louisiana have notified OIG that they have made such 
recommendations. 
 
40 Based on MFCU responses to the survey conducted through the US DHHS-OIG Public-Private information 
Sharing Project, released through a Freedom of Information Act request in September 2011.  
 
41 Section 1915(c) Home and Community-Based Services waivers authorize States to provide long-term care in 
home and community-based settings rather than institutional settings.  Additional information on these waivers is 
available at http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-
Topics/Waivers/Waivers.html?filterBy=1915(c)#waivers.  Accessed on June 20, 2012. 
 
42 Based on interviews with State officials and recommendations submitted to States by MFCUs in Missouri, 
Louisiana, Ohio, and Washington.   
 
43 Additional information on self-directed Medicaid services is available at http://www.medicaid.gov/Medicaid-
CHIP-Program-Information/By-Topics/Delivery-Systems/Self-Directed-Services.html.  Accessed on April 24, 2012.  
 
44 An example of beneficiary submission of false claims for PCS is described in, West Springfield Woman Pleads 
Guilty, Sentenced in Connection with Stealing Over $130,000 from Medicaid, May 3, 2011. Available at 
http://www.mass.gov/ago/news-and-updates/press-releases/2011/woman-pleads-guilty-sentenced-stealing-
130000.html.  Accessed on April 24, 2012. 
23