PCA Relative Caregiver Payments


September 2, 2011 – MHCP Provider Update PCA-11-02R
Revised September 15, 2011

Effective for dates of service on and after October 1, 2011, the 2011 Minnesota Legislative Session, 1st Special Session, Chapter 9, article 7, section 10, requires MHCP to pay fee-for-service PCA service claims at 80% of the allowable rate when the individual PCA provider is related to the recipient in one of the following ways:

  • • Parent
  • • Sibling (sharing at least one biological/adoptive parent)
  • • Adult child
  • • Grandparent
  • • Grandchild

  • “Related” means the individual PCA is related to the recipient by blood or through a legal adoption process.

    This requirement does not apply to:

  • • Relationships through marriage (such as step-child/sibling or in-law relationships who meet all other Personal Care Assistant Criteria; spouses cannot be individual PCA providers)
  • • Legal guardians without a relationship above
  • • Qualified Professional (QP)

  • Review the Home Care Service Rate Limits Effective September 1, 2011 for PCA service rate information.

    Agency Responsibilities

    For each individual PCA provider and the recipient(s) for whom they provide services, MHCP requires all PCA agencies to identify, document and report individual PCA and recipient relationships for all fee-for-service PCA services, including the extended PCA services through the waiver or Alternative Care (AC) programs.

    Identify & Document Relationships

    Identify and document the relationship of each individual PCA provider with each recipient for whom they provide services:

  • • Complete the Individual PCA Relationship Acknowledgment form and keep in your agency files and the recipient health service record
  • • Identify the relationship on the agency’s PCA Time and Activity Documentation each pay period and keep in your agency files

  • Do not submit these forms but keep in your PCA agency files. Failure to maintain required documentation may result in a $500 fine to the PCA provider agency.

    Report Relationships

    MHCP is now requiring you to report the relationship between the individual PCA provider and the recipient to MHCP on fee-for-service PCA claims using only two modifiers. If your agency has already completed system programming for relationship modifiers previously announced and this change will cause a hardship for your agency, contact the MHCP Provider Call Center at (651) 431-2700 or 1-800-366-5411 to report this information.

    Use one of the two modifiers from the table below to report the relationship on the claim:

    Modifier

    Individual PCA Provider Relationship to Recipient

    U1

    Parent/Adoptive Parent, Sibling, Adult Child, Grandparent or Grandchild

    UD

    No Relationship/Not related as any of the above

    The public health nurse and the county/tribal case managers are not required to:

  • • Report relationship information on assessments or service authorizations (SA)
  • • Make changes to the rates on the SA because of relationship
  • Submit Claims

    Except for QP supervision (T1019 UA) claims, all other fee-for-service T1019 claim lines must also include at least one of the relationship modifiers from the table above on each claim line. All other HCPCS code and modifier combinations still apply to PCA claims. MHCP will cut back the payment rate during the claim processing.

    PCA & Caretaker Billing Examples

    For the following PCA service:

    Use combination below:

    1:1 PCA services provided by the grandmother of the recipient

    T1019 U1

    1:1 PCA services provided by the parent of an adult recipient

    T1019 U1

    1:1 Extended PCA services provided by the parent of an adult recipient

    T1019 UC U1

    1:2 PCA shared services provided by the adult child of the recipient

    T1019 TT U1

    1:1 PCA services provided by an individual PCA not related to the recipient

    T1019 UD

    1:1 PCA services provided by an individual PCA related to the recipient, but not one of the relationships specified in the table above (such as a cousin)

    T1019 UD

    Qualified Professional Supervision (relationship information not required)

    T1019 UA

    MHCP will deny PCA service claim lines with dates of service on and after 10/1/11 when you:

  • • Do not include at least one of the relationship modifiers on the claim line (except claim lines for QP supervision)
  • • Enter more than one of the relationship modifiers on the same claim line
  • • Include a relationship modifier to bill QP supervision
  • • Do not meet other PCA billing requirements
  • Review Billing information in the PCA section of the MHCP Provider Manual for other PCA billing requirements.

    Managed Care

    DHS is encouraging managed care organizations (MCOs) to use the same procedures described above, including requiring the same modifiers on claims. The rates paid by MCOs are determined by your contracts with the MCO. Contact the MCO with any questions about MCO effective dates for these changes and for rate information.

    Annual Review

    MHCP is updating the following agency enrollment forms to reflect the new relationship requirements (do not submit to MHCP):


    MHCP will collect these and other enrollment forms only at the time of the PCA agency’s next annual review. When it is time for your annual review, MHCP will place a letter of request in the PRVLTR folder in your MN–ITS mailbox.

    Additional Resources

  • • MHCP Provider Manual
  • • PCA Portal - PCA Relative Rates
  • • Individual PCA Criteria Policy
  • If you have questions about this information, call the MHCP Provider Call Center at (651) 431-2700 or 1-800-366-5411.

    Sign up to receive Provider Updates and other MHCP notices in your e-mail account.


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