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Minnesota Health Care Programs (MHCP) covers personal care assistance (PCA) services provided to children and youths with disabilities in the least restrictive environment, so the child or youth may attend school and receive a free appropriate public education (FAPE) just as other children and youths without disabilities.
For MHCP to reimburse for the federal share of the cost of school-based PCA services, the service must be identified in the child’s or youth’s Individualized Education Program (IEP) plan or Individualized Family Services Plan (IFSP).The service must be medically necessary and provided by a qualified personal care assistant who is trained and supervised by a qualified licensed health-related service professional (Minnesota Statutes, Chapter 148) or trained and supervised by a special education teacher with the core skills for licensure (Minnesota Administrative Rule, Chapter 8710.5000).
Note: In the remainder of this manual section, we will use IEP to mean both the IEP and the IFSP.
The procedures, tasks or activities that a personal care assistant performs must fall within the scope of practice or professional responsibilities of the qualified professional who is training and supervising the personal care assistant.
To be eligible to provide personal care assistance, the person must meet all of the following requirements:
To provide IEP PCA services, the personal care assistant must complete the following training activities:
PCA services and activities
Provide hands-on assistance with an ADL task
Remind or stand by and direct the completion of an ADL
Observe and Intervene or redirect
Identify and deescalate episodes of behavior
Perform delegated health related procedures and tasks
To be eligible for PCA services in school, the child or youth must be dependent and need assistance for one or more of the activities of daily living (ADL), or require intervention or redirection from another person for level 1 behaviors.
A child may not be found to be dependent in an activity of daily living if the child’s need for assistance is age appropriate.
Dependent in an ADL means the child requires cuing and stand-by supervision or hands-on assistance from a personal care assistant to begin and complete an activity of daily living.
Activities of daily living include health and hygiene needs that are part of daily living, as well as activities integral to the activity (for example, cleaning up spills, laundering soiled clothing, and cleaning up toileting accidents). ADLs include the following:
A child or youth qualifies as having the need for assistance from a personal care assistant through observation, redirection or intervention of a behavior episode if the episode is due to a medical or mental health condition and requires the immediate response of another person to prevent injury to self or others, or damage to property.
Behaviors may occur at different levels and in different situations. To qualify for PCA services, the display of a level 1 behavior must be current, and determined to be either daily or episodic and ongoing (for example, four times a week).
Level 1 behaviors are defined as:
Examples of level 1 behaviors
Physical injury to others
Destruction of property
Breaking windows, lamps or furniture
Using tools or objects to damage property
When determining the level of need for behavior intervention, address the following considerations:
If a current, but infrequent (less than four times per week or less than once daily) level 1 behavior is identified in the IEP plan that will require the immediate response of another person to intervene and redirect the physical aggression toward self or others or destruction of property, the IEP team will assign a personal care assistant to intervene or redirect the child or youth during that episode. Medical Assistance (MA) will pay for this response time. The time allowed is when the personal care assistant is fully engaged, working face-to-face or hands-on with the child or youth.
Once a child or youth qualifies for PCA services, he or she may also receive assistance from a personal care assistant for redirection or intervention during a behavioral episode, when the child or youth displays increased vulnerability due to cognitive deficits or socially inappropriate behaviors, and for other delegated health related procedures and tasks.
Determine how the lack of cognitive skill or vulnerability is affecting the child’s or youth’s behavior and what assistance must be provided to redirect or intervene during a behavioral episode.
For example: A child with Down Syndrome has qualified for PCA service for two ADLs: toileting and eating. Because the child qualifies for PCA services, the child or youth can receive PCA services because of his or her increased vulnerability due to cognitive deficits. The child has a history of elopement (wandering away) from the past school year and is currently displaying episodes of elopement when given the opportunity. In this case, it may be necessary to have a personal care assistant with the child during times such as recess, lunch, in the halls and going to the restroom. During these times, there is a reasonable expectation that the child may find the opportunity to elope and MA will cover PCA services during these periods.
However, once the child is in the classroom, a teacher or paraprofessional is watching over the room and a personal care assistant does not need to be available to observe the child in case the child may elope.
Other situations may require a personal care assistant to assist with ADLs and monitor a child for health related concerns for the full day at school. Such situations may be for a child or youth who is medically fragile and needs assistance with multiple ADLs, needs constant intervention or redirection of behaviors, or both. Documentation must clearly identify the child‘s or youth’s specific medical needs, why constant continuous care is needed throughout the school day, and how the services provided relate to the child’s or youth’s medical needs. MHCP does not pay to have a PCA sit with a child or youth to watch for a behavior that occurs infrequently or to keep the child on task with his or her educational activities or assignments.
The increased vulnerability due to cognitive deficits or socially inappropriate behavior of a child and youth who is verbally aggressive or resistive to care must relate back to:
If the child or youth is not staying on task with the lesson plan, listening to the teacher, or is speaking out of turn, making comments out loud, grabbing for other children’s property or generally disrupting the class, it is the responsibility of the school to have the teacher, teaching assistant or paraprofessional assigned to the classroom or to that child or youth to keep the child or youth on task for his or her educational needs and classroom behavior protocol. Classroom support of this type is not an MA covered PCA service.
Health-related procedures and tasks may be delegated or assigned by a licensed health care professional under state law to be performed by a person providing PCA services.
Document delegation of health-related procedures and tasks and training in the PCA plan of care for the child or youth and in the file of the person providing the PCA services. These PCA services include, but are not limited to the following:
MHCP does not cover the following:
To be eligible for Medicaid payment, state and federal regulations require schools to maintain fiscal records that support the nature and extent of health related service they provide to children and youths eligible for services under the Individuals with Disability Education Act (IDEA).
The school must maintain required documentation listed in this section and have it readily available. It is the responsibility of the school to determine where the documentation is maintained and available.
Documentation may be web-based, electronic or paper records.
The activity record must correspond to the current PCA plan of care and be reviewed by the QP. Documentation for PCA services must include the following:
To be considered a recent time study, review the time study annually and update it at least every two years, unless the needs of the child change requiring a change to the child’s plan of care before then.
PCA time studies should be:
Once the 10-day study is complete, schools must calculate the average daily time for each task, and the total daily time for all PCA services.
Effective July 1, 2018, MHCP will allow schools to use the “average times” documented in a recent time study when billing for PCA services.
If the child leaves school early on any given day, reduce the average daily time for that task by the percent of services not provided
If the child is absent from school, enter “absent” in the activity field and report 0 for time. Do not bill MA.
Bill MA 1 unit using procedure code T1018 with modifier U6, TM.
For annual data reporting, document the total amount of time identified and documented in the PCA Activities Checklist.
The qualifications for a person providing supervision of a personal care assistant who is providing PCA services are based on the service provided, and the license, certification, scope of practice, professional responsibilities and professional experience of the supervisor.
For example, ADLs such as positioning, transfers or toileting may be taught and supervised by a physical therapist or professional nurse. These ADLs may not be taught or supervised by a speech pathologist, audiologist, school psychologist, social worker or certain special education teacher, because it is not within the scope of practice of those professionals.
Responding to level 1 behaviors is the scope of practice of school personnel such as, but not limited to, school social workers, school psychologists and some special education teachers.
A QP may be any of the following:
A QP must supervise anyone providing personal care assistance through use of direct training, observation, return demonstrations and consultation with school staff, the child or youth, and the parent or guardian of the child or youth.
The QP trains and supervises the person providing PCA services and evaluates the effectiveness of the services. The QP must do the following:
A PCA care plan is a written description of each of the medically necessary PCA services a child will need during the school day with specific instruction of how the services should be provided. The plan of care must be developed by a QP working within their scope of practice. A QP is also responsible for the training and supervision of the person who will be providing the service to the child. Review the information about People Eligible to Provide PCA Services in the Eligible Providers subsection.
The PCA plan of care must be completed within the first week of starting the personal care assistance. Update it when there is a change in the child’s need for PCA services. Review the plan of care annually.
The plan of care may be embedded within the child’s IEP or IFSP or may be provided as a separate document. The IEP or IFSP must have a statement indicating the IEP or IFSP is serving as the PCA plan of care or that the plan of care will be maintained as a separate document. In either situation the PCA plan of care must be specific to the needs of the child and include enough detail to describe how each service should be provided.
A copy of the most current PCA plan of care or the child’s IEP or IFSP must be immediately available to the person who is providing the PCA services.
Components of a PCA plan of Care must include:
A statement that the school will provide assistance for eating and toileting does not identify why the child needs the service, or provide enough information to justify the medical need or how the person providing the PCA care should provide the service. Instead, be specific.
The child has a traumatic brain injury. Because of the brain injury the child has tremors and an unsteady gait. The child will need assistance with mobility, eating lunch and toileting.
The child has an unsteady gait and falls frequently.
Tremors interfere with dexterity an ability to grasp or hold items.
As needed (see time study).
The QP must complete an initial evaluation of the personal care assistant through direct observation of the personal care assistant’s work within the first 14 days (or sooner as determined by the QP) of starting to provide regularly scheduled services to the child or youth.
After the initial evaluation, subsequent visits do not require direct observation of each person providing PCA services unless determined by the QP based on the needs of the child or youth and the personal care assistant’s ability to meet those needs.
The QP must complete periodic evaluations as follows:
Sign, date and indicate the supervision visit on the PCA Activity Checklist when a periodic evaluation and supervision visit is conducted during the period identified on the activity checklist.
Conduct evaluations more often if:
At the initial and each periodic supervisory visit, the QP must evaluate whether the PCA services:
The QP evaluation must include review and documentation of the following:
At the conclusion of the evaluation, the QP must document the above and the following:
Refer to the Covered and Noncovered Services section of this Provider Manual for an overview of noncovered services that apply to all IEP services.
Review the Record Keeping and Documentation section for an overview of the basic IEP record keeping, documentation of services time and encounter reporting requirements.
Submit claims using the 837P Professional claim type. Refer to the MN–ITS IEP User Guide for step-by-step instructions for direct data entry claims. Batch billers submitting X12 837P claims may review the MHCP 5010/D.0 Compliance webpage and the AUC Minnesota Uniform Companion Guide for transaction guideline.
MHCP is the payer of last resort for all other liable parties except school districts. Bill MHCP for covered IEP services (except transportation and PCA services) only after receiving payment or a denial of coverage from all other liable health care plans.
IEP PCA services are not covered by private health care plans; therefore, it is not necessary to obtain a denial of coverage for these services before billing MHCP.
Retain copies of all correspondence with private health plans regarding determinations for IEP services coverage, including phone conversations for five years.
Billing for PCA services:
Review the Billing and Authorization Requirements section for general billing requirements.
Minnesota Statutes 256B.0625, subd. 26 Covered Services – Special Education
Minnesota Statutes 256B.0625, subd.19 (c) Covered Services – Personal Care Assistance Services
Minnesota Statutes 256B.0659 Personal Care Assistance Program
Minnesota Statutes Chapter 148 – Public Health Occupations
Minnesota Administrative Rule, Chapter 8710 – Teacher and Other School Professional Licensing (see 8710.5000 – 6300)
Minnesota Statutes 125A.08 (c. 1-3) IEP Programs, Paraprofessionals
Minnesota Statutes 125A.21 Third Party Payment
Minnesota Statutes 125A.74 Medical Assistance Payments to School Districts