Personal Care Assistance (PCA) Services

Revised: January 13, 2026

· Overview

· Eligible Providers

· Eligible Members

· Covered Services

· Noncovered Services

· Authorization Requirements

· Billing

· Managed Care Members

· Legal References

Overview

Personal care assistance (PCA) services provide assistance and support for people with disabilities who are living independently in the community. This includes the elderly and others with special health care needs. PCA services are provided in the Minnesota Health Care Programs (MHCP) member’s home or in the community when normal life activities take them outside the home.

Community First Services and Supports (CFSS) has replaced PCA and the Consumer Support Grant (CSG) effective Oct. 1, 2024. PCA and CSG will be phased out as members transition to CFSS.

Assessment for PCA Services

Members must have an assessment for PCA/CFSS services by an assessor through a lead agency (a county, Tribal government or managed care organization). During the assessment, the assessor determines if:

· The member is able to direct their own care, or needs a responsible party (RP) to act on their behalf.

· The member meets the PCA/CFSS eligibility criteria.

If the assessor determines PCA services are appropriate, most MHCP members have flexible use of their PCA/CFSS services. This means members can use the assessed services how and when they want within a six-month period. The member or RP also chooses whether they want to receive either or both of the following:

· The PCA Choice option, which allows the member to assume some employer tasks, such as recruiting, hiring, training, scheduling and supervising workers. If the member cannot or chooses not to use PCA Choice, they use traditional PCA.

· The shared service option for PCA/CFSS services, which allows the member to receive PCA services from the same individual PCA at the same time and in the same setting as up to two other members receiving PCA services.

Members or responsible parties must also select the MHCP-enrolled PCA provider agency they want to provide their PCA services. The member must select a PCA provider agency enrolled to provide the option they select (PCA Choice or traditional PCA.). Members on the Minnesota Restricted Recipient Program are prohibited from using the PCA Choice option and flexible-use options.

Supervision for PCA Services

All members receiving PCA services are required to have a qualified professional (QP) supervising the services. The QP works for the PCA agency to provide oversight and evaluation of the individual PCA service delivery to ensure the member’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.

· Works with the member to develops the member care plan.

· Completes the minimum required QP visits within the timelines of the QP services policy.

If additional QP units are needed, the PCA agency may request additional services according to the QP authorization policy.

Eligible Providers

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

· Medicare-certified, comprehensive licensed home health agency

· 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 licenses or certifications must comply with the requirements of both the PCA program and the licenses or certifications they hold.

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

PCA Agency Enrollment

Agencies must do the following to enroll or maintain enrollment with MHCP to provide PCA services:

· Follow PCA provider agency enrollment requirements.

· Revalidate enrollment records once every three years.

· Follow PCA/CFSS provider agency policy requirements including, but not limited to:

· Provider marketing for PCA/CFSS services

· Provider-owned or provider-controlled housing

· Provider agency policies and procedures

· Provider time and activity documentation

· Provider training requirements

· Provider wage and benefit requirements

Note: Effective Oct. 1, 2024, agencies are unable to enroll to be a PCA agency. New providers wanting to provide personal care services need to enroll using the Community First Services and Supports (CFSS) Agency Enrollment Criteria and forms.

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 (refer to 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) Exclusions Database.

· Initiate and receive confirmation that the QP has passed a background study or has a set aside from Minnesota Department of Human Services (DHS) Licensing.

· Have the QP complete and submit the QP Acknowledgment (DHS-4022C) (PDF) form to MHCP.

· Meet provider training requirements.

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

· Meets the PCA/CFSS worker criteria.

· Successfully completes individual PCA/CFSS standardized training requirements.

· Does not appear on the Office of Inspector (OIG) Exclusions Database.

· Successfully completes the background study 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 managed care organizations (MCOs) weekly.

PCA provider agencies cannot have or enforce any agreements, requirements or noncompete clause prohibiting, limiting or restricting an individual PCA from working with a member 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 process as written in the PCA Quality Assurance policy.

Eligible Members

MHCP members with eligibility for one of the following MHCP programs are entitled to an assessment for PCA services to determine eligibility for PCA/CFSS services:

AC	Alternative Care Program
EH	Emergency Medical Assistance with an approved Care Plan Certification
KK	MinnesotaCare State funded coverage for children through the end of the month they turn 19 years old.
LL	MinnesotaCare State and federally funded coverage for children through the end of the month they turn 19 years old
MA	Medical Assistance (MA)
NM	State-funded MA
RM	Refugee

Covered Services

MHCP reimburses PCA/CFSS covered services. MHCP may reimburse for services outside of Minnesota when identified on the member’s assessment, service plan or care plan documents.

MHCP covers PCA driving time when the need for driving is documented in the member’s care plan. This means a PCA provider agency may be reimbursed for time a PCA worker spends driving an adult member into the community, including to medical appointments. Refer to Requirements for Driving in the PCA/CFSS covered services section of the CFSS Manual.

Noncovered Services

· MHCP does not reimburse for the following services provided by individual PCAs:

· Services without authorization

· Identified noncovered PCA/CFSS services

· Services not identified on the assessment and service plan or the member’s care plan documents

Authorization Requirements

All PCA services require authorization. Refer to Assessment for PCA/CFSS services and the following information:

· All members will receive authorization for QP supervision services.

· Lead agencies may authorize waiver members who are assessed to receive state plan PCA services to also receive extended waiver PCA/CFSS services. Lead agencies may also authorize fewer PCA services if the waiver member 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 when the member has a change of condition or health status to determine if there is a change in the member’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 the following documentation before submitting a claim to MHCP for reimbursement of PCA or QP services:

· A copy of either the member’s CFSS Assessment (DHS-6893A) (PDF) or the MnCHOICES PCA Provider Report, or a similar document.

· Service authorization for PCA services

· PCA time and activity documentation for all individual PCA providers delivering services to the member. Refer to Electronic Visit Verification webpage for more information.

· QP documentation supporting the QP visit being billed

· Written agreement signed by the agency and member or responsible party, in addition including the PCA Program Responsible Party/CFSS Participant Representative Agreement (DHS-6893F) (PDF)

· Home Care Shared Services Agreement (HCN, PCA or CFSS) (DHS-6893E) (PDF) signed by all members sharing PCA services (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 ensure that the individual PCA records all required components when completing the agency’s PCA/CFSS provider time and activity documentation process.

PCA agencies may use electronic visit verification (EVV) or the DHS template PCA Time and Activity Documentation (DHS-4691) (PDF) to document time and activities. PCA agencies determine the documentation methods used for recording time and activities for individual PCAs and QPs.

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. PCA agencies must comply with the terms of the Service Employee’s International Union Healthcare Minnesota and Iowa collective bargaining agreement for workers serving members using PCA Choice. Refer to the Personal Care Assistance (PCA) Choice and financial management services (FMS) provider information webpage for more information.

Tiered Rates and Wage Floors

Tiered reimbursement rates for all PCA agencies
Reimbursement rates for PCA services provided by a direct support worker will be increased based on the experience level of the specific worker providing those services. PCA provider agencies must use the increase in the reimbursement rate for wages and wage-related costs for the direct support worker.

Tiered minimum wages, or wage floors for PCA Choice
The hours of PCA services a direct support worker has provided since July 1, 2017, determines the minimum wage floor for direct support workers in the PCA Choice model. Direct support workers in PCA Choice must be paid at least the appropriate minimum wage on the tiered wage schedule starting Jan. 1, 2025.

For additional information, see PCA and CFSS tiered rates and wage floors webpage.

PCA provider agencies can view which tier direct support workers are in by logging into MN–ITS and downloading the Tiered Wage PCA/CFSS list. Find instructions for how to access the list in MN–ITS in the MN–ITS User Manual in the Provider Lists section.

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.

· Submit your Usual and Customary charge.

· 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 and modifier combination.

· Enter U2 modifier on PCA claim when service is being provided by a parent of a minor or spouse.

· For PCA complex claims, follow the previous procedures as well as the billing grid in this section.

· If a member is eligible for the enhanced rate, the lead agency authorizes PCA services at the enhanced rate. Bill DHS using the TG modifier and the enhanced rate for all members eligible for the enhanced rate. If the PCA worker who delivered the services completed qualifying trainings, DHS reimburses the PCA agency at the enhanced rate. If the PCA worker did not complete the qualifying trainings, DHS will pay the claim at the regular PCA base rate. Refer to PCA, CFSS, and CSG enhanced rate/budget for qualified trainings. Providers can verify that a worker is qualified for the enhanced rate by reviewing the steps under Personal Care Assistance (PCA) Providers A – Z section on Provider Lists webpage.

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

PCA Service	HCPCS Code	Modifier	Modifier	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
1:1 PCA Complex	T1019	TG			Yes	15 minutes
1:2 PCA Complex	T1019	TG	TT		Yes	15 minutes
1:3 PCA Complex	T1019	TG	HQ		Yes	15 minutes
Supervision of PCA Services	T1019	UA			Yes	15 minutes
Notice of Reduction, 1:1	T1019	U5			Yes	15 minutes
Notice of Reduction, 1:2	T1019	U5	TT		Yes	15 minutes
Notice of Reduction, 1:3	T1019	U5	HQ		Yes	15 minutes
Notice of Reduction PCA Complex 1:1	T1019	TG	U5		Yes	15 minutes
Notice of Reduction PCA Complex 1:2	T1019	TG	TT	U5	Yes	15 minutes
Notice of Reduction PCA Complex 1:3	T1019	TG	HQ	U5	Yes	15 minutes
Temporary Increase in Units, 1:1	T1019	U6			Yes	15 minutes
Temporary Increase in Units, 1:2	T1019	U6	TT		Yes	15 minutes
Temporary Increase in Units, 1:3	T1019	U6	HQ		Yes	15 minutes
Temporary Increase in Units PCA Complex 1:1	T1019	TG	U6		Yes	15 minutes
Temporary Increase in Units PCA Complex 1:2	T1019	TG	TT	U6	Yes	15 minutes
Temporary Increase in Units PCA Complex 1:3	T1019	TG	HQ	U6	Yes	15 minutes
Extended PCA Services (waiver services), 1:1	T1019	UC			Yes	15 minutes
Extended PCA Services (waiver services), 1:2	T1019	UC	TT		Yes	15 minutes
Extended PCA Services (waiver services), 1:3	T1019	UC	HQ		Yes	15 minutes
Extended PCA Complex (waiver services), 1:1	T1019	TG	UC		Yes	15 minutes
Extended PCA Complex (waiver services), 1:2	T1019	TG	UC	TT	Yes	15 minutes
Extended PCA Complex (waiver services), 1:1	T1019	TG	UC	HQ	Yes	15 minutes
PCA Services (provided by a parent of a minor or spouse)	T1019	U2			Yes	15 minutes

Managed Care Members

PCA provider agencies providing PCA services to eligible participants aged 65 and over, who are enrolled in a health plan, must follow the managed care organizations (MCO) rules and guidelines to enroll with, obtain authorizations if necessary, and bill the health plan. This includes:

· Minnesota Senior Health Options (MSHO)

· Minnesota Senior Care Plus (MSC+) health plan

Refer to the MCO contacts for MHCP providers webpage for contact information and the health plan procedures.

PCA provider agencies providing PCA services to eligible participants aged 64 and younger are carved out of MCO coverage and are covered through fee-for-service Minnesota Health Care Programs. PCA providers must follow fee-for-service guidelines to obtain authorization and bill to MHCP directly. This includes:

· Special Needs Basic Care (SNBC)

· Medical Assistance for Families and Children (also referred to as a Prepaid Medical Assistance Program [PMAP])

Legal References

Minnesota Statutes, 256B.04, subdivision 21 (Provider enrollment)
Minnesota Statutes, 256B.0659 (PCA Program)
Minnesota Statutes, 256B.0625, subdivision 19c (Personal care-qualified professional)
Minnesota Statutes, Sec. 62A.61 (Usual and Customary Charge)