IEP Personal Care Assistance (PCA) Services
Overview
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. It is necessary for MHCP and schools to follow FAPE.
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 PCA who is trained and supervised by a qualified licensed health-related service professional (Minnesota Statutes, chapter 148 – Public Health Occupations) or trained and supervised by a special education teacher with the core skills for licensure (Minnesota Rules, 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 PCA performs must fall within the scope of practice or professional responsibilities of the qualified professional (QP) who is training and supervising the personal care assistant.
Eligible Providers
People Eligible to Provide PCA Services
To be eligible to provide PCA services, the person must meet all of the following requirements:
Required PCA Training
To provide IEP PCA services, the personal care assistant must complete the following training activities:
Note: Not all paraprofessional work or assistance is health related. Paraprofessionals that meet the requirements to provide PCA services must be able to identify the difference between health-related services and educational services.
Scope of PCA Services
PCA services and activities
Service | Activity |
Assist | Provide hands-on assistance with an activity of daily living (ADL) |
Cue | Remind or stand by and direct the completion of an ADL |
Observe and Intervene or redirect | Identify and de-escalate episodes of behavior |
Monitor | Perform delegated health-related procedures and tasks |
Eligible Members
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.
Covered Services
Activities of Daily Living (ADLs)
A child or youth that is qualified for ADL services means the child requires cuing and stand-by supervision or hands-on assistance from a PCA 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:
Level 1 Behaviors
A child or youth qualifies for PCA assistance for Level 1 behaviors if they demonstrate one or more of the following list of behaviors that are 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
Self-injurious | Physical injury to others | Destruction of property |
Hitting | Hitting | Breaking windows, lamps or furniture |
Biting oneself | Biting | Tearing clothes |
Head banging | Pinching | Setting fires |
Burning oneself | Scratching | Using tools or objects to damage property |
Self-poking or stabbing | Kicking | |
Ingesting foreign substances | ||
Pulling out hair | ||
Suicide threats |
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 redirect the physical aggression, the IEP team will assign a PCA to intervene. Medical Assistance (MA) will pay for this response time. The time allowed is when the PCA 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 PCA 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.
The IEP team and the QP need to 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 wandering away from the past school year and is currently displaying episodes of wandering when given the opportunity. In this case, it may be necessary to have a PCA 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 wander 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 PCA does not need to be available to observe the child in case the child may wander.
Other situations may require a PCA 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.
Other Health-Related Procedures and Tasks
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:
Noncovered Services
MHCP does not cover the following:
Documentation
To be eligible for Medicaid MHCP 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).
Review the documentation requirements provided in the Record Keeping and Documentation section of the IEP Services manual.
The school must maintain required documentation listed in this section and have it readily available for periodic submission to MHCP or the Minnesota Department of Education for interim rates. It is the responsibility of the school to determine where the documentation is maintained and that it is readily available.
Documentation may be web-based, electronic or paper records.
PCA Time Studies
A PCA time study is a report that documents the average daily time per day it takes to perform each daily task based on a 10 day time study. A PCA time study is completed by the PCA. To be considered a recent time study, the QP or supervisor must review the time study with the school annually and update it at least every two years, unless the child’s care plan needs to be updated sooner.
PCA time studies should be:
After 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.
PCA Plan of Care
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 PCA services. 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 may be provided as a separate document. In either situation, the PCA plan of care must be specific to the location of where the special education is being provided and to the needs of the child that includes 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 must be immediately available to the person who is providing the PCA services.
Required Components
Components of a PCA plan of care must include:
Example of a Detailed Plan of Care
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.
Example:
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.
Mobility:
The child has an unsteady gait and falls frequently.
Eating:
Tremors interfere with dexterity an ability to grasp or hold items.
Toileting:
As needed.
Note: This is only an example to show the level of specific details needed in a PCA plan of care. Schools may follow their own school policy for format (template or form created by the school, bulleted list, and so forth). Follow school policy for documentation and location of the plan of care (in the IEP, IFSP or in a separate document).
Activities Checklist
The IEP Services Personal Care Assistance Activities Checklist (DHS-4122C) (PDF) allows for two options. Schools may report:
Follow the prompts on the PCA checklist to complete this form.
Supervision
QP Qualifications
The qualifications for a person providing supervision of a PCA are based on the service provided, 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:
QP Duties
A QP must supervise anyone providing PCA services 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:
PCA Evaluations and Supervision Visits
Initial Evaluation
The QP must complete an initial evaluation of the PCA through direct observation of the PCA’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.
Periodic Evaluations
The QP must complete periodic evaluations as follows:
The QP must 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:
Documentation of Supervision Visit
At the initial and each periodic supervision 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.
Billing
Submit claims using the 837P Professional claim type. Refer to the IEP section of the MN–ITS User Manual 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 guidelines.
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
Use place of service 12 (home) when the child is learning from home and the medically necessary health-related IEP PCA services are identified in the child’s IEP.
Review the IEP Billing and Authorization Requirements section for general billing requirements
Legal References
Minnesota Statutes, 256B.0625, subdivision 26 (Covered Services – Special education services)
Minnesota Statutes, 256B.0625, subdivision 19(c) (Covered Services – Personal care)
Minnesota Statutes, 256B.0659 (Personal Care Assistance Program)
Minnesota Statutes, chapter 148 (Public Health Occupations)
Minnesota Rules, chapter 8710 (Teacher and Other School Professional Licensing) (see 8710.5000 – 6300)
Minnesota Statutes, 125A.08(c)(1-3) (Individual Education Programs – paraprofessionals)
Minnesota Statutes, 125A.21 (Third-Party Payment)
Minnesota Statutes, 125A.74 (Medical Assistance Payments to School Districts)
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