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Minnesota Department of Human Services Provider Manual
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Personal Care Assistance (PCA) Services

Revised: 09-26-2012

  • Overview
  • Eligible Providers
  • Eligible Recipients
  • Covered Services
  • Non-Covered Services
  • Authorization Requirements
  • Billing
  • Managed Care Recipients
  • Legal References
  • Overview

    Personal care assistance (PCA) services provide assistance and support for persons with disabilities, living independently in the community. This includes the elderly and others with special health care needs. PCA services are provided in the recipient’s home or in the community when normal life activities take him/her outside the home.

    Assessment for PCA Services

    PCA services are participant-centered. Recipients must have an assessment for PCA services by an assessor through a lead agency (a county, tribal government, or managed care organization). During the assessment, the assessor determines if:

  • • The recipient is able to direct his/her own care, or needs a responsible party (RP) to act on their behalf
  • • A need for PCA services exists; or if PCA services are the appropriate service to meet the recipient’s assessed needs

  • If PCA services are assessed to be appropriate, most MHCP recipients have flexible use of their PCA services, allowing them to use the assessed services how and when they want within a six-month period. The recipient/RP also chooses whether they want to receive either or both of the following:

  • • The PCA Choice option, which allows the recipient to decide which direct care staff will be providing the services
  • • The shared service option for PCA services, which allows the recipient to receive services from the same individual PCA, at the same time and in the same setting as another recipient receiving PCA services

  • Recipients/RPs must also select the MHCP-enrolled PCA provider agency they want to provide their PCA services. When the recipient selects the PCA Choice option, they must select an agency enrolled specifically to provider PCA Choice services.

    Supervision for PCA Services

    All recipients receiving PCA services are required to have qualified professional (QP) supervision services. The QP works for the PCA agency to provide oversight and evaluation of the individual personal care assistance service delivery, to ensure the recipient’s PCA service needs are met following the QP Services policy.

    The PCA agency is responsible for ensuring the QP:

  • • Meets the requirements in the QP criteria
  • • Develops the recipient care plan
  • Completes the minimum required QP visits. Review the Qualified Professional (QP) Activities & Timelines (PDF) for an at a glance view of the minimum required visits

    If a recipient needs more than 96 units of QP services before a services authorization ends, the PCA agencies may request additional units according to the QP supervision units increase policy.

    Eligible Providers

    MHCP enrolls and reimburses the following types of provider agencies to provide PCA services:

  • • Medicare-certified, Class A licensed home health agencies
  • • Personal care provider organizations (PCPOs)
  • • PCA Choice agencies

  • MHCP does not pay individual PCAs directly. MHCP does not require a PCPO or PCA Choice agency to have a license or certification to provide PCA services. However, PCA agencies with license/certifications must comply with the requirements of both the MHCP PCA program and whatever license/certification they hold.

    All agencies choosing to provide PCA services must meet MHCP PCA agency enrollment requirements described in more detail below.

    PCA Agency Enrollment

    Agencies enroll or maintain enrollment with MHCP to provide PCA services by:

  • • Following the PCA Provider Agency Enrollment Checklist
  • • Following annual review requirements
  • • Follow ongoing reporting requirements to report agency changes
  • • Maintaining the appropriate service credentials to provide PCA services
  • • Following PCA program requirements including but not limited to:
  • Provider enrollment requirements
  • Provider marketing PCA services
  • Provider owned or controlled housing
  • Provider policies and procedures
  • Provider time and activity documentation
  • Provider training requirements
  • Provider wage and benefit requirements

  • Verifying Credentials for Qualified Professionals (QPs)
    The QP works for and is reimbursed by the PCA provider agency. MHCP does not enroll the QP as an individual provider to identify on claims. PCA provider agencies are responsible for verifying the credentials of the QP (see Legal References) and keeping verification of those credentials in their agency files. Prior to having the QP provide services, the PCA agency must:

  • • Ensure the QP is not on the Office of Inspector General (OIG) exclusion list
  • • Initiate and receive confirmation that the QP has passed a background study or has a set aside from DHS Licensing
  • • Have the QP complete and submit the Qualified Professional (QP) Acknowledgment (DHS-4022C) form to MHCP Provider Enrollment
  • • Meet provider training requirements

  • Enrolling Individual PCAs
    MHCP is the official enumerator for enrolling and affiliating individual Minnesota’s PCA providers for the purpose of identifying the individual PCA who provides the services to recipients on both fee-for-service and managed care organization (MCOs) claims.

    PCA agencies must enroll individual PCAs with MHCP and affiliate individual PCAs with their agencies. MHCP assigns a Unique Minnesota Provider Identifier (UMPI, an NPI equivalent) to the individual PCA during their enrollment process. The PCA agency uses the UMPI on the claim, to report the individual as the person who rendered the services to the recipient. Prior to making the request, the PCA agency must ensure that each individual PCA they employ:

  • • Meets the personal care assistant criteria
  • • Successfully completes Individual PCA standardized training requirements
  • • Does not appear on the Office of Inspector (OIG) Exclusion list
  • • Successfully completes the background study using NETStudy through DHS Licensing

  • MHCP also ensures the individual PCA provider is not on the OIG Exclusion list and passes the background study with the agency, and shares this information with the MCOs, on a weekly basis.

    PCA provider agencies may not have or enforce any agreements, requirements or non-compete clause prohibiting, limiting or restricting an individual PCA from working with a recipient or different PCA provider agency after leaving a PCA provider agency, regardless of the date the agreement was signed.

    MHCP requires PCA agencies to comply with data and other information requests from the PCA Quality Assurance (QA) as written in the PCA QA policy.

    Eligible Recipients

    Recipients with eligibility for one of the following MHCP programs are entitled to an assessment for PCA services to determine eligibility for PCA services.

    AC

    Alternative Care Program

    EH

    Emergency

    IM

    Institution for Mental Disease

    KK

    MinnesotaCare Expanded

    LL

    MinnesotaCare Expanded

    MA

    Medical Assistance

    NM

    State-funded MA

    RM

    Refugee


    Recipients not eligible to receive PCA services are those eligible for one of the following programs:

    BB

    MinnesotaCare Plus One

    FF

    MinnesotaCare Basic Plus
    MinnesotaCare Basic Plus Two

    FP

    MFPP

    HH

    HIV/AIDS

    JJ

    MinnesotaCare Basic Plus
    MinnesotaCare Basic Plus Two

    QM

    Qualified Medicare Beneficiary

    Covered Services

    MHCP reimburses PCA covered services. MHCP may reimburse for assistance with self-administered medications or services outside of Minnesota when identified on the recipient’s Assessment, Service Plan and/or care plan documents.

    MHCP covers the travel time an individual PCA spends accompanying a recipient while that recipient is being transported to the destination where the individual PCA will assist the recipient in the community. PCA agency policies, procedures and agreements with recipients determine whether that agency allows an individual PCA employee to transport a recipient using their own or a recipient’s vehicle. PCA agencies must consult with their legal advisors/business consultants about the liabilities of transporting recipients.

    For example: A recipient receives PCA services and needs assistance eating. The recipient is meeting family at a local restaurant and the individual PCA will assist the recipient. MHCP will cover the time the individual PCA spends while the recipient is transported from their community setting to the restaurant (and back). If the individual PCA meets the recipient at the restaurant, MHCP will not cover the individual PCA’s travel time if the individual PCA meets the recipient at the restaurant.

    Non-Covered Services

  • MHCP does not reimburse for the following services provided by individual PCAs:
  • Identified non-covered PCA services
  • • Services not identified on the assessment and service plan or the recipient’s care plan documents
  • • Transportation for the sole purpose of transporting (see Covered Services above)
  • Authorization Requirements

    All PCA services require authorization. Refer to PCA Referral for Assessment and these bullets:

  • • All recipients will receive authorization for Qualified Professional Supervision services
  • • Lead agencies may authorize waiver recipients who are assessed to receive state plan PCA services to receive extended waiver PCA services. Lead agencies may also authorize fewer PCA services if the waiver recipient is able to get their needs met through other services authorized through a waiver program. Refer to the lead agency’s contract requirements to provide extended PCA services.
  • • The QP must contact the lead agency assessor when the recipient has a Change of Condition of Health Status to determine if there is a change in the recipient’s need for PCA services
  • Billing

    PCA agencies must follow general MHCP billing policies and guidelines in the Billing Policy section when submitting claims to MHCP. Refer to MHCP Billing Resources for methods of submitting claims to MHCP.

    Documentation Requirements

    PCA agencies must have all of the following documentation, prior to submitting a claim to MHCP for reimbursement of PCA or QP services:

  • • A copy of the recipient’s Assessment and Service Plan (DHS-3244) or Supplemental PCA Assessment and Service Plan (DHS-3428D) (for recipient’s receiving authorization for PCA services through a waiver)
  • • Service Authorization for PCA services
  • • PCA Time and Activity Documentation for all individual PCA providers delivering services to the recipient
  • • QP documentation supporting the QP visit being billed
  • • Shared Services agreements signed by all recipients sharing PCA services (if applicable)
  • • PCA Choice Agreement signed by the agency and recipient/RP (if applicable)

  • PCA agencies must have documentation supporting that the service has been provided for both individual PCA and QP services. MHCP requires PCA agencies to ensure that the individual PCA records all of the minimum required elements when completing the agency’s PCA Time and Activity Documentation process. PCA agencies determine the documentation methods used for recording the QP’s time and activity.

    PCA agencies must follow the direction of the Minnesota Department of Labor and Industry (DLI) when paying their individual PCA providers and QPs for services the PCA agency told them to provide,

    Submitting PCA Claims

    Submit claims for reimbursement of PCA services in the following manner:

  • • Use the (837P) Professional transaction
  • • Report the authorization number showing services were approved by MHCP for reimbursement
  • • Report the individual PCA who provided the PCA services as the rendering provider on the claim line
  • • Enter one line per date of service, per individual PCA or QP, per HCPCS code or HCPCS/modifier combination

  • For individual claims submission, follow the step-by-step instructions in the Completing a MN–ITS Interactive Professional (837P) claim for PCA Services (PDF). MHCP uses the following HCPCS codes and modifiers for reimbursement of PCA services.

    PCA Service

    HCPCS Code

    Modifier

    Authorization
    Required

    Service Unit

    1:1 PCA Services

    T1019

    Yes

    15 Minutes

    1:2 PCA Services

    T1019

    TT

    Yes

    15 Minutes

    1:3 PCA Services

    T1019

    HQ

    Yes

    15 Minutes

    Supervision of PCA Services

    T1019

    UA

    Yes

    15 Minutes

    Transitional Decrease in Units

    T1019

    U5

    Yes

    15 Minutes

    Temporary Increase in Units

    T1019

    U6

    Yes

    15 Minutes

    Extended PCA services (waiver services)

    T1019

    UC

    Yes

    15 Minutes

    Managed Care Recipients

    PCA agencies providing PCA services enrolled in a health plan must follow the Managed Care Organization’s rules and guidelines to enroll with, obtain authorizations or billing the health plan. Refer to the MCO PCA Resources for contact information and the health plan procedures.

    For recipients enrolled in the Special Needs Basic Care program, follow fee-for-service guidelines to obtain authorizations.

    Legal References

    MS 256B.0659 PCA Services
    MS 256B.0625, subdivision 19c Qualified Professional

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