Enhanced rate or budget for PCA and CSG: A higher reimbursement rate or budget for work that is both:

Enhanced budget for CDCS: See CDCS – Enhanced budget process.

This page provides counties/tribal nations with program- and/or service-specific information about implementing the enhanced rate or budget for people at initial assessment or reassessment.

Effective Jan. 1, 2022, this information applies to people at initial assessment or reassessment who are eligible for at least 10 hours of state plan PCA per day and receive:

For information about consumer directed community supports (CDCS) enhanced budgets, see CDCS – Enhanced budget process.

MCOs

Counties/tribal nations and provider agencies working with a person who receives PCA or CDCS through a managed care organization (MCO) must check with the MCO about how it manages the enhanced rate or budget.

Tracking training

Counties/tribal nations are not responsible for tracking whether a worker has completed the qualifying trainings. A company contracted with DHS tracks this information and shares it with the worker and DHS.

MMIS programming

In MMIS, the enhanced rate and budget is called “PCA complex.” To implement the enhanced rate or budget effective Jan. 1, 2022, counties/tribal nations must complete the following fields in MMIS:

Specific instructions for MMIS and implementation timelines vary depending on the program. For more information, see the sections below.

At initial assessment or reassessment, the county/tribal nation will inform the person if they are eligible for the enhanced rate.

MMIS instructions

The county/tribal nation must enter a valid value in the PCA complex field. If the county/tribal nation enters a PCA service agreement and does not have a valid value in the PCA complex field, the county/tribal nation will receive an edit to resolve.

If the person is eligible

To authorize the enhanced rate in MMIS for an eligible person, the county/tribal nation must do all of the following:

1. Enter a Y indicator in the PCA complex field on the ALT4 screen of the long-term care (LTC) screening document (not applicable if county/tribal nation is not entering a screening document)

2. Enter a Y indicator in the PCA complex field on the ASA2 screen in the service agreement

3. Enter the T1019 TG modifier code on the PCA line items on the ASA3 screen on the service agreement using the new state-set enhanced rate.

If the person is not eligible

If the person is not eligible for the enhanced rate, the county/tribal nation must do all of the following:

1. Enter an N indicator in the PCA complex field on the ALT4 screen of the LTC screening document (not applicable if county/tribal nation is not entering a screening document)

2. Enter an N indicator in the PCA complex field on the ASA2 screen on the service agreement.

At initial assessment or reassessment, the county/tribal nation will inform the person if they are eligible for the enhanced budget and confirm if the person has a worker who has completed the qualifying trainings.

MMIS instructions

The county/tribal nation must enter a valid value in the PCA complex field. If the county/tribal nation enters a CSG service agreement and does not have a valid value in the PCA complex field, the county/tribal nation will receive an edit to resolve.

If the person is eligible

To authorize the enhanced budget for an eligible person who has already identified a qualifying worker, the county/tribal nation must do all of the following:

1. Enter a Y indicator in the PCA complex field on the ASA2 screen on the service agreement

2. Enter the regular budget amount on the T2025 line item on the ASA3 screen on the service agreement

3. Enter a note on the service agreement to document that the county/tribal nation has submitted DHS-4292 to request the enhanced budget because the person has a qualifying worker (for more information, see the next step)

4. Complete PCA Request Fax Form, DHS-4292 (PDF) to request an enhanced budget. On DHS-4292, the county/tribal nation should:

If the person is eligible but has not yet identified a qualifying worker, the county/tribal nation must:

1. Enter a Y indicator in the PCA complex field on the ASA2 screen

2. Enter the regular CSG budget.

If the person and FMS provider identify a qualifying worker during the approved service agreement span, the person and FMS provider can initiate the process of requesting the enhanced budget. For information about this process, see PCA Manual – Provider agency/FMS provider requirements for enhanced rate or budget.

If the person is not eligible

If the person is not eligible for the enhanced budget, the county/tribal nation must enter an N indicator in the PCA complex field on the ASA2 screen on the service agreement

At initial assessment or reassessment, the county/tribal nation will inform the person if they are eligible for the enhanced rate.

MMIS instructions

The county/tribal nation must enter a valid value in the PCA complex field on both the long-term care (LTC) screening document and the service agreement. If the county/tribal nation changes or enters a service agreement and does not have a valid values in the PCA complex fields, the county/tribal nation will receive an edit to resolve.

If the person is eligible

To authorize the enhanced rate in MMIS for an eligible person, the county/tribal nation must do all of the following:

1. Enter a Y indicator in the PCA complex field on the ALT4 screen of the LTC screening document to correspond with field 100a on the LTC Screening Document, DHS-3427

2. Enter a Y indicator in the PCA complex field on the ASA2 screen in the service agreement

3. Enter the T1019 TG modifier code on the PCA line items on the ASA3 screen on the service agreement using the new state-set enhanced rate.

If the person is not eligible

If the person is not eligible for the enhanced rate, the county/tribal nation must do all of the following:

1. Enter an N indicator in the PCA complex field on the ALT4 screen of the LTC screening document

2. Enter an N indicator in the PCA complex field on the ASA2 screen on the service agreement.

Extended PCA hours do not count toward eligibility for the enhanced rate. At initial assessment or reassessment, if a person is eligible for 10 or more hours of state plan PCA and has a qualifying worker, the enhanced rate also applies to the person’s extended PCA rate.

The county/tribal nation must inform the person if they are eligible for the enhanced rate at initial assessment or reassessment.

MMIS instructions

The county/tribal nation must enter a valid value in the PCA complex field.

If the person is eligible

To authorize the enhanced rate in MMIS for an eligible person, the county/tribal nation must do all of the following:

1. Enter a Y indicator in the PCA complex field on the ALT4 screen of the long-term care (LTC) screening document (not applicable if county/tribal nation is not entering a screening document)

2. Enter a Y indicator in the PCA complex field on the ASA2 screen in the service agreement

3. Enter the T1019 UC TG modifier code on the extended PCA line item on the ASA3 screen on the service agreement using the new state-set enhanced rate.

If the person is not eligible

If the person is not eligible for the enhanced rate, the county/tribal nation must do all of the following:

1. Enter an N indicator in the PCA complex field on the ALT4 screen of the LTC screening document (not applicable if county/tribal nation is not entering a screening document)

2. Enter an N indicator in the PCA complex field on the ASA2 screen on the service agreement.

If an existing service agreement needs to be modified to include enhanced rate/budget information, the PCA provider agency/FMS provider must take additional steps. For more information, see PCA Manual – Provider agency/FMS provider requirements for enhanced rate and budget – Modifying service agreements.