How Do You Keep Caregiver Hours Inside a Medicaid Authorization?
Track units remaining, the end date and the service code for every client, and check them before each schedule change. Hours over the cap are unbillable.
By Caregiver Scheduling Team ·
Track three numbers for every Medicaid, waiver and VA client: units remaining in the current period, the authorization end date, and the service codes covered. Check them before every schedule change, not at billing time. Hours over the cap, or after the end date, usually cannot be billed to the payer. Under 42 CFR 447.15 you cannot bill the Medicaid client for them either.
What is a service authorization?
An authorization is the payer’s approval of a set number of units of a specific service for a specific date range. In Medicaid waiver programs it comes from the person-centered service plan. Federal rules require that plan to be written and approved by the Medicaid agency before services are furnished (42 CFR 441.301). A case manager or managed care organization then issues the authorization to you.
Most personal care authorizations are in 15-minute units, so 4 units equal 1 hour and 120 units a week is 30 hours. See Medicaid billing units for codes and rounding rules.
| Field | Example | Why it matters |
|---|---|---|
| Payer | State Medicaid waiver, MCO, VA community care | Rules and renewals differ |
| Service code | T1019 personal care | Billing a code that is not authorized is denied |
| Units authorized | 120 per week | The cap you schedule against |
| Period type | Weekly, monthly or total for the span | Monthly caps get used up early |
| Start and end dates | July 1 to December 31 | Visits after the end date are unbillable |
| Units used to date | 72 this week | Updated from verified visits, not the plan |
| Renewal requested | Date sent to case manager | Request 30 days before the end date |
Program rules differ by state and waiver. Our Medicaid waiver tool lists the programs and agencies by state.
Where do agencies go over?
Overruns almost never come from the planned schedule. They come from changes made during the week by someone who did not look at the balance.
| Cause | What happens | Fix |
|---|---|---|
| Call-out coverage | A replacement caregiver works a longer visit, or two caregivers overlap | Show units remaining when filling the open shift |
| Visits run long | A 2-hour visit becomes 2 hours 20 minutes, and EVV captures it | Set visit length to the authorized units and coach caregivers |
| Monthly caps used early | Extra visits in week one leave nothing for week four | Convert monthly caps to a weekly budget |
| Expired authorization | Visits continue while the renewal is pending | Request renewals 30 days out; flag end dates |
| Wrong code | Respite or homemaker hours billed as personal care | Store the code with the authorization |
Can you bill for hours over the authorization?
Usually not. Medicaid providers must accept the program’s payment as payment in full (42 CFR 447.15), so the client cannot be charged for the overage. The payer will deny units above the approved amount.
Suppose a client is authorized 120 units a week and the caregiver delivers 32 hours and 30 minutes, which is 130 units. Ten units are unbillable. At an example rate of $5.00 a unit, that is $50 of caregiver wages with no revenue.
Your options when it happens:
- Ask for a retroactive increase. Some programs allow it within a set window. Many do not.
- Private-pay agreement for extra hours. Some programs permit a separate voluntary agreement. Check your program rules first.
- Absorb it. Pay the caregiver, write off the units, and fix the process.
When a client’s needs grow, tell the case manager before adding hours. See EVV claim denials for the denial codes you see when units exceed the authorization.
How does EVV fit in?
EVV gives you actual units delivered, so you can compare them to the authorization before you bill. The 21st Century Cures Act required states to use EVV for Medicaid personal care services by January 1, 2020 (Medicaid.gov). Home health services followed on January 1, 2023. Count verified units, not scheduled ones, because that is what claims are matched against. See what is EVV.
What should the weekly routine look like?
Five checks every week:
- Monday: review units remaining for each client against the week’s scheduled visits. Fix any schedule that would exceed the cap before it runs.
- Before any schedule change: look at the balance, then approve.
- Thirty days before each end date: send the renewal request and log the date.
- Before billing: compare verified EVV units to authorized units per client per period.
- Monthly: report under-used authorizations too. Unused units get cut at renewal and can signal a staffing gap.
How Caregiver Scheduling handles this
On Growth and up, authorizations are stored per client with the payer, service code, units, period and end date. Scheduling a visit that would exceed a Medicaid or IHSS cap is blocked, and private-pay hours can go over with an override. Units remaining update from verified check-ins, so the balance you see on Monday is real, and end dates appear on the schedule before they arrive. $199/month for up to 10 caregivers or $299/month for up to 50, free for 30 days.
FAQ
What happens if I go over a Medicaid authorization? The extra units are usually denied, and you cannot bill the client for them. Ask for an increase before providing more care.
Can the client pay privately for extra hours? In some programs, yes, under a separate voluntary agreement. Check your state’s program rules before offering it.
How often should I check units remaining? Every Monday for the week ahead and before every schedule change.
When should I request a renewal? About 30 days before the end date.
This article is general information, not legal or billing advice. Check your state’s Medicaid program rules.