Family Member Employment Authorization for Same-Roof Caregivers

1.Policy Objective

This policy establishes Harbor Home Healthcare LLC’s (“Harbor”) requirements for screening, approving, documenting, and monitoring family member service arrangements under the CCC Plus Waiver, including same-roof family member caregiver situations. Harbor uses this policy to ensure that agency-directed personal care and agency-directed respite care are assigned, delivered, documented, and billed only when the arrangement is allowable under applicable DMAS requirements. This policy does not replace Harbor’s separate policies on personnel qualifications, RN supervision, service authorization, EVV, respite management, client records, or billing controls. (; ; ; ; ; )

Requirements

Harbor shall use a standardized decision process before assigning, scheduling, or billing for services provided by a family member, and shall maintain documentation sufficient to show that the arrangement is allowable, supported by the record, and not prohibited by CCC Plus Waiver payment restrictions.

1.1 Harbor shall not assign, bill, or seek Medicaid reimbursement for any waiver service furnished to a waiver individual by the waiver individual’s spouse. (; Ref: 5.1; Ref: 6.1)
1.2 Harbor shall not assign, bill, or seek Medicaid reimbursement for any waiver service furnished to a minor waiver individual by the minor’s natural, adoptive, step, or foster parent, or other legal guardian. (; Ref: 5.1; Ref: 6.1)
1.3 Harbor shall screen each proposed family member caregiver to identify the relationship to the waiver individual, whether the proposed caregiver lives under the same roof as the waiver individual, and whether the requested service is agency-directed personal care or agency-directed respite care. (; ; Ref: 5.1; Ref: 6.1)
1.4 Harbor shall not bill for agency-directed personal care or agency-directed respite care furnished by an other family member living under the same roof as the waiver individual unless objective written documentation explains why no other person or provider is available to render the service at the required times. (; Ref: 5.2; Ref: 6.2)
1.5 The RN Supervisor shall initially determine whether the objective written documentation supports the same-roof family member arrangement and shall document the determination fully in the waiver individual’s record before reimbursable services begin. (; Ref: 5.3; Ref: 6.2)
1.6 Harbor shall verify that any family member approved to be reimbursed for providing personal care or respite care meets the same qualifications as all other personal care aides before the family member provides reimbursable services. (; Ref: 5.4; Ref: 6.6)
1.7 When respite care is requested or anticipated, Harbor shall document the primary caregiver and whether the caregiver is paid or unpaid before requesting respite care service authorization. (; Ref: 5.5; Ref: 6.3)
1.8 Harbor shall not bill or seek Medicaid reimbursement for respite care services if the primary caregiver, as identified in the record, receives payment for providing personal care services to the waiver individual. (; Ref: 5.5; Ref: 6.3)
1.9 Harbor shall maintain business and professional records sufficient to document fully and accurately the nature, scope, and details of services provided, including records supporting any family member reimbursement decision. (; Ref: 6)
1.10 Harbor shall use DMAS-designated forms for required service documentation and shall not alter DMAS-designated forms without prior written approval from DMAS unless otherwise permitted. (; Ref: 6.7)

Family Member Service Restrictions Statement

The following statement summarizes Harbor’s approved family member service restriction standard.

Spouse prohibition: Harbor does not assign, bill, or seek Medicaid reimbursement for waiver services furnished by the waiver individual’s spouse. (; Ref: 5.1)
Minor parent/legal guardian prohibition: Harbor does not assign, bill, or seek Medicaid reimbursement for waiver services furnished to a minor waiver individual by the minor’s natural, adoptive, step, or foster parent, or other legal guardian. (; Ref: 5.1)
Same-roof other family member condition: Harbor may use an other family member living under the same roof for agency-directed personal care or agency-directed respite care only when objective written documentation supports why no other person or provider is available to render the service and the RN Supervisor documents the initial determination in the waiver individual’s record. (; Ref: 5.2; Ref: 5.3; Ref: 6.2)
Qualification parity: Any family member approved to provide reimbursable personal care or respite care must meet the same qualifications as all other personal care aides. (; Ref: 5.4; Ref: 6.6)
Respite billing restriction: Harbor does not bill respite care when the primary caregiver receives payment for providing personal care services to the waiver individual. (; Ref: 5.5; Ref: 6.3)

Definitions

The following definitions apply to this policy.

Family Member means a person related to the waiver individual by blood, adoption, step-relationship, marriage, in-law relationship, guardianship, or other family relationship relevant to the CCC Plus Waiver family member payment rules.
Same Roof means living under the same roof as the waiver individual. ()
Other Family Member means a family member who is not the waiver individual’s spouse and is not the natural, adoptive, step, or foster parent or other legal guardian of a minor waiver individual.
Agency-Directed Personal Care means non-skilled personal care services furnished through Harbor’s agency-directed model by a Harbor-employed or Harbor-assigned aide under Harbor’s scheduling, supervision, service documentation, and billing controls.
Agency-Directed Respite Care means non-skilled respite care furnished through Harbor’s agency-directed model to provide temporary relief to the primary caregiver when authorized, documented, and not prohibited by the paid-primary-caregiver restriction.
Objective Written Documentation means written, dated, and retrievable documentation explaining why no other person or provider is available to render the required service at the required times. ()
RN Supervisor Initial Determination means the nurse supervisor’s written decision that the same-roof documentation supports, or does not support, use of the same-roof other family member for reimbursable agency-directed personal care or respite care. ()
Primary Caregiver means the caregiver identified in the waiver individual’s record, including whether the caregiver is paid or unpaid, when respite care is requested or anticipated. ()
Qualification Parity means the requirement that a family member approved for reimbursement must meet the same qualifications as all other personal care aides. ()

Implementation Guidance

The following guidance explains how Harbor should apply this policy in a practical way.

A1 Harbor should treat the spouse prohibition and the minor parent/legal guardian prohibition as absolute billing stops. These situations should not move forward to the same-roof exception process because they are prohibited arrangements. (; Ref: 5.1)
A2 The same-roof process applies only to an other family member living under the same roof as the waiver individual. The record must show why no other person or provider is available at the required service times and must include the RN Supervisor’s documented initial determination. (; Ref: 5.2; Ref: 5.3; Ref: 6.2)
A3 “No other person or provider is available” should be supported by practical staffing evidence, such as dated staffing attempts, scheduling notes, open-shift outreach, declined shift responses, or other documentation showing that Harbor attempted to staff the required schedule with qualified non-family aides. (; ; Ref: 5.2; Ref: 6.5)
A4 Harbor’s internal same-roof packet is a supplemental compliance tool. It does not replace required DMAS forms, service authorization documents, EVV records, visit documentation, personnel records, or other billing-support records. (; ; Ref: 6.7)

2.Scope & Application

This section identifies who is expected to understand and apply Harbor Home Healthcare LLC’s (“Harbor”) family member service restriction and payment prohibition requirements. This policy applies across Harbor’s CCC Plus Waiver agency-directed personal care and agency-directed respite care operations whenever a family member is proposed, requested, hired, assigned, scheduled, or approved as a paid caregiver. (; ; ; )

Requirements

Harbor shall apply this policy before assigning, scheduling, authorizing, or billing for services furnished by a family member so that prohibited family member arrangements are stopped, same-roof arrangements are properly documented, qualification parity is verified, and respite billing restrictions are applied.

2.1 Harbor shall apply this policy to all CCC Plus Waiver agency-directed personal care and agency-directed respite care cases when a family member is proposed as the paid caregiver. (; ; Ref: 5.1; Ref: 6.1)
2.2 Harbor shall apply this policy to the Governing Body, Administrator or designee, RN Supervisor, intake and scheduling personnel, billing and compliance personnel, personnel file reviewer, and any family member aide involved in the service arrangement. (; Ref: 4; Ref: 6)
2.3 Harbor intake and scheduling personnel shall screen the proposed caregiver’s relationship to the waiver individual and same-roof status before the family member is assigned to provide reimbursable services. (; ; Ref: 5.1; Ref: 6.1)
2.4 Harbor shall apply the spouse prohibition and the minor parent/legal guardian prohibition regardless of whether the proposed caregiver lives with the waiver individual. (; Ref: 5.1; Ref: 6.1)
2.5 Harbor shall apply the same-roof documentation and RN Supervisor determination process when the proposed caregiver is an other family member living under the same roof as the waiver individual. (; Ref: 5.2; Ref: 5.3; Ref: 6.2)
2.6 Harbor shall apply qualification parity requirements to any family member approved to be reimbursed for providing personal care or respite care. (; Ref: 5.4; Ref: 6.6)
2.7 Harbor shall apply the primary caregiver and respite billing restriction whenever respite care is requested, anticipated, scheduled, or billed. (; Ref: 5.5; Ref: 6.3)
2.8 Harbor shall maintain required documentation in the waiver individual’s record and shall maintain personnel qualification evidence in the personnel file, using internal forms only as supplemental tools and not as replacements for required DMAS documentation. (; ; Ref: 6; Ref: 6.6; Ref: 6.7)

Scope Boundaries

The following scope boundaries explain when this policy applies and when a different Harbor policy or requirement controls.

Applies to agency-directed personal care: This policy applies when Harbor is responsible for assigning, supervising, documenting, and billing agency-directed personal care services under the CCC Plus Waiver. (; Ref: 5)
Applies to agency-directed respite care: This policy applies when Harbor is responsible for assigning, supervising, documenting, and billing agency-directed respite care under the CCC Plus Waiver. (; ; Ref: 5.5)
Applies to family member caregiver requests: This policy applies whether the family member is requested by the client, family, representative, referral source, or Harbor staffing process. (; Ref: 5.1)
Does not apply to consumer-directed services: Consumer-directed services are outside Harbor’s agency-directed employment, supervision, scheduling, and billing process, except when Harbor must distinguish agency-directed services from consumer-directed services during referral screening. ( Ref: 5.1)
Does not authorize skilled services: This policy does not authorize Harbor or a family member aide to provide private duty nursing, skilled nursing, therapy, or other skilled services outside Harbor’s approved scope. (; Ref: 3.9)
Does not replace other documentation policies: This policy does not replace Harbor’s policies on service authorization, EVV, RN supervision, respite tracking, personnel qualifications, personnel records, client records, or billing controls. (; ; Ref: 7)

Implementation Guidance

The following guidance explains how Harbor should apply this policy in a practical way.

A5 This policy should be used as an intake, staffing, supervision, and billing gate before a family member begins reimbursable service delivery. The purpose is to prevent Harbor from billing for a prohibited or unsupported family member arrangement. (; ; Ref: 5.1; Ref: 5.6)
A6 The same-roof process is not a general preference process. It applies only when an other family member lives under the same roof as the waiver individual and Harbor has objective written documentation explaining why no other person or provider is available to render the service at the required times. (; Ref: 5.2; Ref: 6.2)
A7 Harbor should keep the family member decision record separate from the full personnel file when possible. The waiver individual’s record should show the reimbursement decision and qualification parity verification, while the personnel file should hold the detailed employment and qualification documents. (; ; Ref: 6.6)
A8 When a situation changes, such as residence status, caregiver relationship, primary caregiver paid/unpaid status, staffing availability, service schedule, or authorization status, Harbor should reassess whether the family member arrangement remains allowable and supported by the record. (; ; Ref: 5.7)

3.Regulatory Basis

This section explains why Harbor Home Healthcare LLC (“Harbor”) maintains a family member service restriction and payment prohibition policy as part of its controlled CCC Plus Waiver compliance system. This is a Medicaid reimbursement and documentation control policy. The citations below support Harbor’s process for identifying prohibited family member arrangements, documenting same-roof other family member exceptions, verifying aide qualification parity, applying respite payment restrictions, using required DMAS documentation, and maintaining records sufficient to support service delivery and billing. They do not create a separate service authorization beyond the cited DMAS requirements. (; ; ; ; ; )

Requirements

Harbor shall use this policy to support the following CCC Plus Waiver regulatory expectations.

3.1 Harbor shall treat services furnished by the waiver individual’s spouse as nonreimbursable and shall not assign, bill, or seek Medicaid reimbursement for those services. (; Ref: 5.1; Ref: 6.1)
3.2 Harbor shall treat services furnished to a minor waiver individual by the minor’s natural, adoptive, step, or foster parent, or other legal guardian as nonreimbursable and shall not assign, bill, or seek Medicaid reimbursement for those services. (; Ref: 5.1; Ref: 6.1)
3.3 Harbor shall require objective written documentation before billing for agency-directed personal care or agency-directed respite care furnished by an other family member living under the same roof as the waiver individual. The documentation must explain why no other person or provider is available to render the service at the required times. (; Ref: 5.2; Ref: 6.2)
3.4 Harbor shall require the RN Supervisor to initially determine whether the same-roof objective written documentation supports the family member arrangement and to document the determination fully in the waiver individual’s record. (; Ref: 5.3; Ref: 6.2)
3.5 Harbor shall verify that any family member approved to be reimbursed for providing personal care or respite care meets the same qualifications as all other personal care aides. (; Ref: 5.4; Ref: 6.6)
3.6 Harbor shall document the primary caregiver and whether the caregiver is paid or unpaid before requesting respite care service authorization. (; Ref: 5.5; Ref: 6.3)
3.7 Harbor shall not bill or seek Medicaid reimbursement for respite care services if the primary caregiver, as identified in the record, receives payment for providing personal care services to the waiver individual. (; Ref: 5.5; Ref: 6.3)
3.8 Harbor shall use DMAS-designated forms for required service documentation and shall not alter DMAS-designated forms without prior written approval from DMAS unless otherwise permitted. (; Ref: 6.7)
3.9 Harbor shall maintain business and professional records sufficient to document fully and accurately the nature, scope, and details of services provided, including records supporting family member reimbursement decisions. (; Ref: 6)

Implementation Guidance

The following guidance explains the purpose of this section.

A9 This policy supports Medicaid reimbursement compliance but does not replace the specific Harbor policies that govern aide qualifications, RN supervision, service authorization, EVV, respite tracking, client records, personnel records, billing, or quality improvement. ( Ref: 7)
A9.1 The same-roof documentation pathway is limited to an other family member living under the same roof as the waiver individual. It does not override the spouse prohibition, the minor parent/legal guardian prohibition, the qualification parity requirement, or the respite payment restriction. (; ; ; ; Ref: 5)
A9.2 Harbor’s internal same-roof packet is a traceability tool. It helps show the reviewer what decision was made, who made it, what evidence was reviewed, and why the arrangement was allowable. It does not replace required DMAS forms, authorization records, EVV records, visit notes, personnel records, or billing-support documentation. (; ; Ref: 6.7)
A9.3 Detailed citation mapping and policy traceability are maintained in Section 8. ( Ref: 8)

4.Roles & Responsibilities

This section assigns responsibility for screening, approving, documenting, applying, and monitoring Harbor’s family member service restriction and payment prohibition requirements. Clear responsibility helps ensure prohibited family member arrangements are stopped before service delivery or billing, same-roof other family member arrangements are properly documented, qualification parity is verified, respite restrictions are applied, and the waiver individual’s record supports the reimbursement decision. (; ; ; ; )

4.1 Governing Body

The Governing Body provides oversight of Harbor’s controlled policy system and approves material policy changes that affect Harbor’s compliance structure.

4.1.1 The Governing Body shall approve this policy and any material revisions. (; Ref: 8)
4.1.2 The Governing Body shall review this policy as part of Harbor’s annual policy review process and approve revisions when needed. (; Ref: 8)
4.1.3 The Governing Body shall ensure Harbor maintains administrative oversight and documentation controls sufficient to support Medicaid reimbursement decisions and audit readiness. (; Ref: 6)

4.2 Administrator or Designee

The Administrator or designee is responsible for implementing this policy, maintaining the required process, and confirming that Harbor does not assign, schedule, or bill for prohibited or unsupported family member service arrangements.

4.2.1 The Administrator or designee shall implement this policy consistently for CCC Plus Waiver agency-directed personal care and agency-directed respite care. (; ; Ref: 5)
4.2.2 The Administrator or designee shall ensure applicable staff understand the spouse prohibition, the minor parent/legal guardian prohibition, the same-roof documentation requirement, the RN Supervisor determination requirement, the qualification parity requirement, and the respite payment restriction. (; ; ; ; Ref: 5)
4.2.3 The Administrator or designee shall ensure Harbor uses a standardized family member documentation process before a family member begins reimbursable service delivery. (; Ref: 5.6; Ref: 6.4)
4.2.4 The Administrator or designee shall confirm that the required documentation is complete before a same-roof other family member begins reimbursable services and before billing begins. (; ; Ref: 5.6; Ref: 6.4)
4.2.5 The Administrator or designee shall ensure Harbor’s internal same-roof packet does not replace, alter, or conflict with required DMAS-designated service documentation. (; Ref: 6.7)

4.3 RN Supervisor

The RN Supervisor is responsible for the required initial determination when an other family member living under the same roof is proposed to provide agency-directed personal care or agency-directed respite care.

4.3.1 The RN Supervisor shall review the objective written documentation for same-roof other family member requests involving agency-directed personal care or agency-directed respite care. (; Ref: 5.2; Ref: 6.2)
4.3.2 The RN Supervisor shall initially determine whether the documentation supports use of the same-roof other family member for reimbursable service delivery. (; Ref: 5.3; Ref: 6.2)
4.3.3 The RN Supervisor shall document the determination fully in the waiver individual’s record before reimbursable services begin. (; Ref: 5.3; Ref: 6.2)
4.3.4 The RN Supervisor shall ensure the determination identifies the service type, required schedule, documentation reviewed, approval or denial decision, rationale, RN name, RN signature, and date. (; ; Ref: 5.3; Ref: 6.2)
4.3.5 When respite care is requested or anticipated, the RN Supervisor or designated clinical reviewer shall ensure the primary caregiver and paid/unpaid status are documented in the waiver individual’s record before respite authorization is requested. (; Ref: 5.5; Ref: 6.3)

4.4 Intake and Scheduling Personnel

Intake and scheduling personnel are responsible for identifying family member arrangements early and preventing prohibited or unsupported assignments from moving forward.

4.4.1 Intake or scheduling personnel shall identify the proposed caregiver’s relationship to the waiver individual and whether the proposed caregiver lives under the same roof as the waiver individual. (; ; Ref: 5.1; Ref: 6.1)
4.4.2 Intake or scheduling personnel shall identify whether the requested service is agency-directed personal care, agency-directed respite care, or a service type outside the scope of this policy. ( Ref: 2; Ref: 5.1)
4.4.3 Intake or scheduling personnel shall flag spouse arrangements and minor parent/legal guardian arrangements as prohibited before scheduling or billing. (; Ref: 5.1; Ref: 6.1)
4.4.4 When a same-roof other family member is proposed, intake or scheduling personnel shall document reasonable staffing attempts and results for the required days and times before forwarding the record for RN Supervisor review. (; Ref: 5.2; Ref: 6.5)
4.4.5 Intake or scheduling personnel shall not place a same-roof other family member on a reimbursable schedule until the RN Supervisor determination, qualification parity verification, and administrative start-of-care gate are complete. (; ; ; Ref: 5.3; Ref: 5.4; Ref: 5.6)

4.5 Billing and Compliance Personnel

Billing and compliance personnel are responsible for verifying that family member service arrangements are supported before claims are submitted.

4.5.1 Billing or compliance personnel shall verify that required documentation is present before billing for services furnished by a same-roof other family member. (; ; Ref: 5.6; Ref: 6)
4.5.2 Billing or compliance personnel shall confirm that the family member arrangement has been approved under the applicable pathway before claims are submitted. ( Ref: 5.8; Ref: 6)
4.5.3 Billing or compliance personnel shall confirm the primary caregiver’s paid/unpaid status before respite care is billed. (; Ref: 5.5; Ref: 6.3)
4.5.4 Billing or compliance personnel shall not submit claims when required documentation is missing, incomplete, inconsistent, or shows that reimbursement is prohibited. (; ; ; ; Ref: 5; Ref: 6)

4.6 Personnel or HR File Reviewer

The personnel or HR file reviewer is responsible for verifying that any family member approved to provide reimbursable personal care or respite care meets the same qualifications as other Harbor personal care aides.

4.6.1 The personnel or HR file reviewer shall verify that the family member meets the same qualifications as all other personal care aides before independent reimbursable service delivery. (; Ref: 5.4; Ref: 6.6)
4.6.2 The personnel or HR file reviewer shall maintain qualification evidence in the personnel file according to Harbor’s personnel-file process. (; Ref: 6.6; Ref: 7)
4.6.3 The personnel or HR file reviewer shall provide a qualification parity attestation or personnel-file verification note for the waiver individual’s record without duplicating the full personnel file unless otherwise required. (; ; Ref: 6.6)

4.7 Family Member Aide

A family member aide is responsible for meeting Harbor’s qualification requirements, following Harbor’s service assignment and documentation rules, and reporting changes that may affect the family member reimbursement decision.

4.7.1 The family member aide shall meet the same qualification requirements as other Harbor personal care aides before providing reimbursable personal care or respite care. (; Ref: 5.4; Ref: 6.6)
4.7.2 The family member aide shall provide services only as authorized, scheduled, assigned, supervised, and documented by Harbor. (; ; Ref: 5; Ref: 6)
4.7.3 The family member aide shall complete required service documentation accurately, timely, and in the required format. (; ; Ref: 6.7)
4.7.4 The family member aide shall report changes in residence, relationship status, service schedule, primary caregiver status, or availability that may affect the same-roof determination or respite billing restriction. (; ; Ref: 5.7)

Implementation Guidance

The following guidance explains how Harbor may apply these responsibilities without adding unnecessary administrative steps.

A5 The same person may perform more than one administrative function, such as intake, scheduling, documentation review, or billing review, as long as the record shows each required decision point was completed. (; Ref: 6)
A5.1 Administrative approval does not replace the RN Supervisor’s required initial determination for same-roof other family member cases. The record must show the RN Supervisor reviewed the objective written documentation and made the initial determination. (; Ref: 5.3; Ref: 6.2)
A5.2 Staff performance, documentation errors, missed visits, EVV problems, or billing concerns should be handled under the applicable personnel, supervision, EVV, billing, complaint, incident, or quality improvement policy, not under this policy alone. ( Ref: 7)

5.Procedures

5. Procedures

Harbor shall use a standardized, step-by-step process to determine whether a family member may be assigned and reimbursed to provide agency-directed personal care or agency-directed respite care (non-skilled). For same-roof other family member cases, Harbor shall use one combined documentation packet to keep the process consistent, traceable, and audit-ready.

5.1 Relationship and Service-Type Screen

Harbor shall identify the waiver individual, proposed family member caregiver, relationship to the waiver individual, requested service type, and whether the proposed caregiver lives under the same roof as the waiver individual.
Harbor shall confirm whether the requested service is agency-directed personal care or agency-directed respite care (non-skilled).
If the proposed caregiver is the waiver individual’s spouse, Harbor shall stop the Medicaid reimbursement process, document the denial reason, and shall not assign, bill, or seek reimbursement for services furnished by the spouse. ()
If the waiver individual is a minor and the proposed caregiver is the minor’s natural, adoptive, step, or foster parent, or other legal guardian, Harbor shall stop the Medicaid reimbursement process, document the denial reason, and shall not assign, bill, or seek reimbursement for services furnished by that person. ()
If the proposed caregiver is an other family member who does not live under the same roof, Harbor shall document the relationship/residence status and proceed through standard hiring, qualification, scheduling, supervision, service documentation, and billing controls. (; ; )

5.2 Same-Roof Other Family Member Documentation

If the proposed caregiver is an other family member living under the same roof as the waiver individual, Harbor shall prepare objective written documentation before the family member provides reimbursable personal care or respite care services. ()

Required schedule: Harbor shall document the required days, times, and hours for the authorized service.
Staffing attempts: Harbor shall document reasonable attempts to staff the required schedule with qualified non-family aides using Harbor’s normal scheduling and recruitment process.
Examples of staffing evidence: Staffing evidence may include call notes, text messages, email outreach, open-shift notices, applicant outreach notes, scheduling notes, declined shift responses, no-response notes, or other dated staffing records.
Results: Harbor shall document the result of each reasonable staffing attempt, including whether coverage was unavailable, declined, conflicted with the required schedule, or otherwise did not result in feasible coverage.
Objective conclusion: Harbor shall document a brief dated conclusion explaining why no other person or provider is available to render the service at the required times. ()

5.3 RN Supervisor Initial Determination

The RN Supervisor shall review the objective written documentation for the same-roof other family member request.
The RN Supervisor shall initially determine whether the documentation supports use of the same-roof other family member for agency-directed personal care or agency-directed respite care (non-skilled). ()
The RN Supervisor shall document the determination fully in the waiver individual’s record. ()
The RN determination shall include, at minimum: waiver individual name, proposed caregiver name, relationship, same-roof status, service type, required schedule, documentation reviewed, approval or denial, brief rationale, RN name, RN signature, and date.
If the RN Supervisor denies the request, Harbor shall document the denial and continue appropriate non-family staffing efforts when services remain authorized and needed.
If the RN Supervisor approves the request, Harbor shall not allow reimbursable service delivery to begin until qualification parity is verified and the Administrator/Designee confirms the documentation packet is complete. (; )

5.4 Qualification Parity Verification

Before providing reimbursable services, the family member shall meet the same qualifications as all other personal care aides. ()
Harbor shall verify required onboarding, screenings, training, competency, and employment documentation through Harbor’s personnel file process.
The waiver individual’s record may contain a qualification parity attestation or reference showing that the family member’s personnel file was reviewed and verified.
Harbor shall not schedule the family member for independent reimbursable service delivery until qualification parity is verified. ()

5.5 Primary Caregiver and Respite Billing Gate

When respite care is requested or anticipated, Harbor shall document the primary caregiver and whether the caregiver is paid or unpaid in the waiver individual’s record before requesting respite care service authorization. ()
If the primary caregiver receives payment for providing personal care services to the waiver individual, Harbor shall not bill or seek reimbursement for respite care services provided by that primary caregiver. ()
If respite care is authorized and the primary caregiver is paid for personal care, Harbor shall staff respite with a different qualified caregiver or shall not bill respite for that period. ()
Billing/Compliance shall confirm the primary caregiver/respite billing gate before respite care is billed. (; )

5.6 Administrator Start-of-Care Gate

Before a same-roof other family member begins reimbursable services, the Administrator/Designee shall confirm that the Family Member Employment Authorization Packet is complete.
The packet shall include the relationship/prohibition screen, same-roof status, objective written documentation, RN Supervisor initial determination, qualification parity verification, primary caregiver/respite billing gate when applicable, and final administrative review. (; ; ; ; )
If any required element is missing or incomplete, Harbor shall not allow the family member to begin reimbursable service delivery until the missing element is completed.

5.7 Ongoing Monitoring and Reassessment

Harbor shall update the documentation when there is a material change in the service schedule, caregiver arrangement, staffing availability, primary caregiver status, residence status, or service authorization. ()
The RN Supervisor may confirm during routine supervisory review whether the same-roof family member arrangement remains supported by the current record.
If non-family staffing becomes available for the required schedule, Harbor shall reassess whether continued same-roof family member reimbursement remains supported by the documentation. ()
If the primary caregiver’s paid/unpaid status changes, Harbor shall reassess any respite authorization or billing risk before respite is scheduled or billed. ()

5.8 Decision Flow Summary

Step 1: Is the proposed caregiver the waiver individual’s spouse? If yes, do not assign or bill. ()
Step 2: Is the waiver individual a minor and the proposed caregiver the minor’s parent or legal guardian? If yes, do not assign or bill. ()
Step 3: Is the proposed caregiver an other family member living under the same roof? If yes, complete objective written documentation and obtain the RN Supervisor initial determination. ()
Step 4: Has the family member met the same qualifications as other personal care aides? If no, do not schedule for reimbursable service delivery. ()
Step 5: Is respite care requested or anticipated? If yes, document the primary caregiver and paid/unpaid status before requesting respite authorization or billing. ()
Step 6: Is the primary caregiver paid for personal care? If yes, do not bill respite care services for that primary caregiver. ()

Guidance and Explanatory Notes

A1 Harbor should avoid vague statements such as “no staff available” unless the record includes dated staffing attempts and results.
A2 Administrative approval is a final compliance gate and does not replace the RN Supervisor’s required initial determination for same-roof other family member cases. ()
A3 Harbor’s same-roof packet is supplemental and does not replace required DMAS service documentation, EVV records, authorization records, or visit documentation. (; )

6.Documentation Requirements

6. Documentation Requirements

Harbor shall maintain documentation in the waiver individual’s record sufficient to support the family member employment decision, service delivery, billing, and audit review. Documentation shall show why the arrangement is allowable, who made the required determination, what evidence was reviewed, and whether any billing restriction applies. (; ; )

6.1 Required Documentation for All Family Member Requests

Waiver individual name and identifying case information.
Proposed family member caregiver name and relationship to the waiver individual.
Requested service type: agency-directed personal care or agency-directed respite care (non-skilled).
Residence status showing whether the proposed family member lives under the same roof as the waiver individual. ()
Prohibition screen documenting whether the proposed caregiver is the waiver individual’s spouse or the parent/legal guardian of a minor waiver individual. ()
Qualification parity verification showing the family member meets the same qualifications as all other personal care aides before providing reimbursable services. ()
Required service authorization, service schedule, visit documentation, EVV records when applicable, and any required DMAS-designated service documentation. (; )

6.2 Required Documentation for Same-Roof Other Family Member Requests

When the proposed caregiver is an other family member living under the same roof as the waiver individual, Harbor shall maintain additional objective written documentation in the waiver individual’s record. ()

Required schedule: The days, times, and hours for which care is needed.
Staffing attempts: Documentation showing Harbor attempted to staff the required schedule with qualified non-family aides using Harbor’s normal recruitment and scheduling process.
Staffing results: The outcome of each staffing attempt, such as unavailable aide, declined shift, no response, schedule conflict, failed coverage attempt, or lack of feasible coverage.
Objective conclusion: A brief written statement explaining why no other person or provider is available to render the service at the required times. ()
RN Supervisor determination: The RN Supervisor’s initial determination approving or denying the same-roof other family member arrangement, documented fully in the waiver individual’s record. ()

6.3 Required Documentation for Respite Requests

When respite care is requested or anticipated, Harbor shall document the primary caregiver and whether the caregiver is paid or unpaid before requesting respite care service authorization. ()

Primary caregiver name.
Primary caregiver relationship to the waiver individual.
Whether the primary caregiver is paid or unpaid.
Whether the primary caregiver receives payment for providing personal care services to the waiver individual.
Billing gate outcome showing whether respite may be requested, scheduled, and billed. ()

6.4 Family Member Employment Authorization Packet

Harbor shall use Form 4.20-FM-A – Family Member Employment Authorization Packet as the combined internal documentation tool for family member employment requests. The packet is designed to reduce duplication while ensuring all required decision points are documented.

Documentation Area	Where Documented	Regulatory Anchor
Relationship and prohibition screen	Form 4.20-FM-A, Section A/C
Same-roof status	Form 4.20-FM-A, Section B
Objective written documentation	Form 4.20-FM-A, Section D and supporting attachments
RN Supervisor initial determination	Form 4.20-FM-A, Section E
Qualification parity verification	Form 4.20-FM-A, Section F and personnel file reference
Primary caregiver and respite billing gate	Form 4.20-FM-A, Section G
Administrator start-of-care gate	Form 4.20-FM-A, Section H

6.5 Supporting Evidence

Supporting evidence may be attached to the Family Member Employment Authorization Packet or referenced in the waiver individual’s record. Acceptable supporting evidence may include:

Call logs or notes showing outreach to available aides.
Text messages, emails, or scheduling communications showing staffing attempts and responses.
Open-shift notices or scheduling system notes.
Applicant outreach or recruitment notes.
Documented aide declines, no responses, schedule conflicts, or failed coverage attempts.
Care coordination notes relevant to the required days/times and staffing issue.

6.6 Personnel File and Client Record Separation

Qualification evidence for the family member aide shall be maintained in the personnel file according to Harbor’s personnel-file process.
The waiver individual’s record may include a qualification parity attestation or personnel-file verification note instead of duplicating the full personnel file. (; )
Client service documentation, RN determination, objective written documentation, primary caregiver documentation, and billing-support documentation shall be maintained in the waiver individual’s record. ()

6.7 DMAS Forms and Internal Forms

Harbor’s Family Member Employment Authorization Packet is an internal supplemental compliance tool.
The packet does not replace required DMAS-designated service documentation, service authorization records, EVV records, visit records, or other required billing-support documentation.
Harbor shall not alter DMAS-designated forms without prior written approval from DMAS. ()

Guidance and Explanatory Notes

A1 Documentation should be specific enough for a reviewer to understand the required schedule, what staffing alternatives were attempted, the results of those attempts, the RN Supervisor’s determination, and why the claim was reimbursable.
A2 Harbor should avoid vague statements such as “no staff available” unless the record includes dated staffing attempts and outcomes.
A3 The goal is not to create unnecessary paperwork; the goal is to make the reimbursement decision traceable to the regulation and supported by the record. (; )

8.References & Regulatory Citations

8. References & Regulatory Citations

This policy is based on the CCC Plus Waiver participation, reimbursement, documentation, and recordkeeping requirements applicable to family member reimbursement for agency-directed personal care and agency-directed respite care (non-skilled). Harbor shall use the citations below to support policy interpretation, staff training, documentation review, and audit preparation.

Citation	Requirement / Relevance to This Policy
	Establishes general requirements for home and community-based participating providers, including documentation, provider compliance, and records needed to support Medicaid participation.
	Requires use of DMAS-designated forms for service documentation and prohibits alteration of DMAS forms without prior written DMAS approval, unless otherwise permitted.
	Requires business and professional records sufficient to document fully and accurately the nature, scope, and details of services provided.
	Supports the requirement that services be connected to the waiver individual’s plan of care and authorized service needs.
	Establishes the family-member reimbursement prohibition for waiver services furnished by the waiver individual’s spouse or by the natural, adoptive, step, or foster parent or other legal guardian of a minor waiver individual.
	Establishes the same-roof other family member condition for personal care and respite care, including objective written documentation showing why no other person or provider is available and the nurse supervisor’s initial determination documented fully in the individual’s record.
	States that payment shall not be made for assistive technology, environmental modifications, transition services, or services facilitation furnished by other family members living under the same roof as the waiver individual. These services are outside the scope of this policy.
	States that payment shall not be made for private duty nursing services furnished by other family members, legal guardians, or other persons living under the same roof as the waiver individual. Private duty nursing is outside the scope of this policy.
	Requires family members approved to be reimbursed for providing personal care or respite care to meet the same qualifications as all other personal care aides, supporting Harbor’s qualification parity requirement.
	Requires documentation of the primary caregiver and paid/unpaid status before requesting respite care service authorization and prohibits payment for respite care if the primary caregiver receives payment for providing personal care services to the waiver individual.
DMAS CCC Plus Waiver Provider Manual	Provides operational guidance for CCC Plus Waiver service authorization, documentation, service delivery, and billing. Harbor shall follow the current DMAS manual and managed care organization requirements when applying this policy.

Policy Interpretation Rule

If there is any conflict between this policy and current DMAS regulation, DMAS guidance, service authorization requirements, or managed care organization requirements, Harbor shall follow the stricter or more current requirement and update this policy as needed.
This policy shall not be interpreted to permit billing for any family-member arrangement that is prohibited by , unsupported under , inconsistent with qualification parity under , or prohibited under the respite restriction in .
Harbor’s internal forms and checklists are supplemental compliance tools and shall not replace required DMAS-designated forms, service authorization records, EVV records, visit documentation, or other required Medicaid billing-support records. (; )

Review and Update

The Administrator shall review this policy when DMAS regulations, CCC Plus Waiver manual requirements, managed care organization requirements, or Harbor’s service model changes in a way that affects family-member reimbursement, same-roof documentation, respite billing, qualification parity, or service documentation.
Policy updates shall preserve traceability between Harbor’s operational process and the applicable regulatory citation.