Revised: November 12, 2024
Understanding the Minnesota Personal Care Assistance (PCA) Program
The Minnesota Personal Care Assistance (PCA) program is designed to provide crucial support and assistance to individuals with disabilities who are striving for independent living within their communities. This vital program extends its benefits to a wide range of individuals, including the elderly and those with complex healthcare needs. PCA services are delivered within the comfort of the recipient’s home and also extend into the community, ensuring support is available when individuals engage in daily life activities outside their residence.
It’s important to note that the landscape of Minnesota’s disability support services is evolving. The Community First Services and Supports (CFSS) program is set to replace both PCA and the Consumer Support Grant (CSG) programs in the future. The Minnesota Department of Human Services (DHS) initiated the implementation of CFSS on October 1, 2024, marking a significant shift in how these services are delivered.
Navigating the Assessment Process for PCA Services
At the heart of the Minnesota PCA program is a person-centered approach. To access these services, individuals must undergo a PCA assessment. This assessment is conducted by a qualified assessor from a lead agency, which could be a county, tribal government, or a managed care organization. The assessment process is critical in determining several key factors:
- Self-Direction of Care: The assessor evaluates whether the individual can manage and direct their own care. If not, they will determine if a responsible party (RP) is needed to act on their behalf. A responsible party plays a crucial role in overseeing and making decisions related to the PCA services.
- PCA Eligibility Criteria: The assessment rigorously checks if the individual meets the specific eligibility requirements for PCA services as defined by the Minnesota Department of Human Services. Meeting these criteria is essential for program enrollment.
If the assessment concludes that PCA services are appropriate for the individual, most Minnesota Health Care Programs (MHCP) members gain flexible use of their PCA services. This flexibility empowers members to utilize their assessed services in a way that best suits their needs and schedules within a six-month authorization period. Furthermore, the member or their responsible party has the autonomy to choose between, or combine, the following options:
- PCA Choice Option: This option grants the member greater control by allowing them to take on certain employer responsibilities. These responsibilities include recruiting, hiring, training, scheduling, and supervising their PCA workers. This option is ideal for those who wish to be actively involved in managing their care. For individuals who prefer not to, or are unable to, assume these employer tasks, traditional PCA services are available.
- Shared Service Option: The shared service option introduces the possibility of receiving PCA services concurrently with up to two other PCA recipients. This means that members can receive care from the same PCA worker, at the same time, and in the same setting. This can be a beneficial option in certain living situations or for individuals with similar care needs.
In addition to these choices, members or responsible parties are required to select an MHCP-enrolled PCA provider agency that will coordinate and deliver their PCA services. It is crucial to choose an agency that is enrolled to offer the specific service option selected (PCA Choice or traditional PCA). It is important to note that members participating in the Minnesota Restricted Recipient Program are not eligible for the PCA Choice option or the flexible-use options.
The Role of Supervision in PCA Services
To ensure quality and appropriate care, all recipients of Minnesota PCA services are required to have their services supervised by a qualified professional (QP). These QPs are employed by PCA agencies and play a vital role in overseeing and evaluating the delivery of PCA services. Their primary responsibility is to ensure that the member’s needs are being met in accordance with the QP services policy.
PCA agencies bear the responsibility for ensuring that their QPs:
- Meet QP Criteria: QPs must fulfill specific requirements outlined in the QP criteria. These criteria ensure that QPs have the necessary qualifications and expertise to supervise PCA services effectively.
- Develop Member Care Plans: QPs work collaboratively with the member to create a comprehensive care plan. This care plan serves as a roadmap for service delivery, outlining the member’s specific needs and how PCA services will address them.
- Conduct Required QP Visits: QPs are required to conduct a minimum number of visits within specific timelines as stipulated in the QP services policy. These visits are crucial for ongoing monitoring and evaluation of the PCA services being provided.
In situations where additional QP supervision units are deemed necessary, PCA agencies have the option to request these additional services, adhering to the QP authorization policy.
Who Can Provide Minnesota PCA Services? Eligible Providers
The Minnesota Health Care Programs (MHCP) enrolls and provides reimbursement to specific types of provider agencies that are authorized to deliver PCA services. These eligible provider types include:
- Medicare-certified, comprehensive licensed home health agencies: These agencies are already recognized for meeting federal healthcare standards and can offer PCA services as part of their broader home health offerings.
- Personal care provider organizations (PCPOs): PCPOs are organizations specifically focused on providing personal care services, including PCA, and are enrolled with MHCP.
- PCA Choice agencies: These agencies are specialized in administering the PCA Choice option, providing the necessary support and administrative framework for members who choose to self-direct their care.
It’s important to understand that MHCP does not directly reimburse individual PCAs. Instead, payments are made to the enrolled provider agencies. Interestingly, MHCP does not mandate that PCPOs or PCA Choice agencies possess a specific license or certification to provide PCA services. However, agencies that do hold licenses or certifications are obligated to comply with the requirements of both the MHCP PCA program and the standards associated with their licenses or certifications.
All agencies that choose to offer Minnesota PCA services must meet the MHCP PCA agency enrollment requirements, which are detailed further below.
PCA Agency Enrollment and Requirements
For agencies seeking to enroll or maintain their enrollment with MHCP as PCA service providers, several crucial steps and ongoing requirements must be met:
- PCA Provider Agency Enrollment Requirements: Agencies must diligently follow all PCA provider agency enrollment requirements set forth by MHCP. This includes submitting the necessary documentation and adhering to the application process.
- Revalidation of Enrollment: To ensure ongoing compliance and eligibility, enrolled agencies are required to revalidate their enrollment records every three years. This process confirms that the agency continues to meet program standards.
- Compliance with PCA Provider Agency Policy: Agencies are bound to adhere to a comprehensive set of PCA provider agency policy requirements. These policies cover various aspects of service provision and agency operations, including but not limited to:
- Provider marketing for PCA services: Guidelines on how agencies can ethically and accurately market their PCA services.
- Provider-owned or provider-controlled housing: Regulations regarding situations where the provider agency also owns or controls the housing of PCA recipients.
- Provider agency policies and procedures: Requirements for agencies to establish and maintain clear policies and procedures governing their operations and service delivery.
- Provider time and activity documentation: Specific guidelines on how agencies must document the time and activities of their PCA workers to ensure accurate billing and accountability.
- Provider training requirements: Mandates for agencies to ensure that their PCA workers and Qualified Professionals receive adequate and standardized training to provide high-quality care.
- Provider wage and benefit requirements: Regulations concerning the wages and benefits that PCA agencies must provide to their workers, ensuring fair labor practices.
Verifying Credentials for Qualified Professionals (QPs)
Qualified Professionals (QPs) are integral to the Minnesota PCA program, and their credentials must be rigorously verified. While QPs are employed and reimbursed by PCA provider agencies, MHCP does not enroll them as individual providers for claim identification purposes. The responsibility for verifying QP credentials rests firmly with the PCA provider agencies. Agencies must ensure this verification process is completed and documented in their agency files, referencing the Legal References section for specific statutory requirements.
Prior to allowing a QP to provide services, the PCA agency must take the following critical steps:
- OIG Exclusions Database Check: Agencies must ensure that the QP is not listed on the Office of Inspector General (OIG) Exclusions Database. This database lists individuals and entities excluded from participation in federal healthcare programs due to fraud or abuse.
- Background Study Confirmation: Agencies must initiate and receive confirmation that the QP has successfully passed a background study or has been granted a set aside by Minnesota Department of Human Services (DHS) Licensing. This background study is a crucial safeguard to protect PCA recipients.
- QP Acknowledgment Form Submission: The QP must complete and submit the QP Acknowledgment (DHS-4022C) (PDF) form to MHCP. This form serves as a formal acknowledgment of the QP’s understanding of their roles and responsibilities within the PCA program.
- Provider Training Requirements Compliance: Agencies must ensure that the QP meets all relevant provider training requirements to ensure they are adequately prepared to supervise PCA services.
Enrolling Individual PCAs
PCA agencies are also responsible for enrolling individual PCAs with MHCP and formally affiliating these PCAs with their agency. During the enrollment process, MHCP assigns a Unique Minnesota Provider Identifier (UMPI) to each individual PCA. This UMPI is essential for claim submissions, as the PCA agency must use it to identify the individual PCA who rendered services to the member.
Before initiating the enrollment request for individual PCAs, PCA agencies must verify that each PCA they employ:
- Meets PCA Worker Criteria: The individual must meet the specific PCA worker criteria established by MHCP. These criteria outline the qualifications and characteristics expected of PCA workers.
- Completes Standardized Training: PCAs must successfully complete individual PCA standardized training requirements. This training ensures that PCAs possess the fundamental skills and knowledge to provide safe and effective personal care assistance.
- OIG Exclusions Database Clearance: Similar to QPs, individual PCAs must also not appear on the Office of Inspector (OIG) Exclusions Database.
- Background Study Clearance: Individual PCAs are required to successfully complete a background study through DHS Licensing.
MHCP also independently verifies that each individual PCA provider is not on the OIG Exclusion list and has passed the background study. This information is then shared with managed care organizations (MCOs) on a weekly basis to maintain program integrity.
To protect the rights and mobility of PCA workers, MHCP prohibits PCA provider agencies from having or enforcing any agreements, requirements, or noncompete clauses that would prevent, limit, or restrict an individual PCA from working with a member or another PCA provider agency after leaving their employment, regardless of when such agreements were signed.
Furthermore, MHCP mandates that PCA agencies comply with data and information requests stemming from the PCA quality assurance process, as detailed in the PCA Quality Assurance policy. This ensures ongoing monitoring and improvement of service quality within the Minnesota Personal Care Assistance Program.
Who is Eligible for Minnesota PCA Services? Eligible Members
Eligibility for the Minnesota Personal Care Assistance program is linked to enrollment in specific Minnesota Health Care Programs (MHCP). MHCP members who are eligible for one of the following programs are entitled to undergo an assessment to determine their eligibility for PCA services:
| Program Code | Program Name |
|---|---|
| AC | Alternative Care Program |
| EH | Emergency Medical Assistance |
| KK | MinnesotaCare for children under 19 and pregnant people |
| LL | MinnesotaCare for children under 19 and pregnant people |
| MA | Medical Assistance (MA) |
| NM | State-funded MA |
| RM | Refugee |
However, individuals enrolled in the following programs are not eligible to receive PCA services:
| Program Code | Program Name |
|---|---|
| BB | MinnesotaCare for parents, caretakers, and adults without children |
| FF | MinnesotaCare for parents, caretakers, and adults without children |
| FP | Minnesota Family Planning Program (MFPP) |
| HH | HIV/AIDS |
| JJ | MinnesotaCare for parents, caretakers, and adults without children |
| QM | Qualified Medicare Beneficiary |
What Services are Covered Under the PCA Program? Covered Services
The Minnesota PCA program offers reimbursement for a range of PCA covered services that are essential for supporting individuals with disabilities. In certain situations, MHCP may also provide reimbursement for services delivered outside of Minnesota. This coverage extension is applicable when such out-of-state services are clearly documented in the member’s assessment, service plan, or care plan documents. This ensures that necessary support is available even when members travel or temporarily reside outside of Minnesota.
One notable covered service is PCA driving time. MHCP recognizes the importance of community integration and covers the time a PCA worker spends driving an adult member for community engagement, including transportation to medical appointments. The necessity for driving must be explicitly documented within the member’s care plan. Detailed requirements for driving services are available in the PCA covered services section of the PCA Manual. This coverage ensures that transportation barriers are minimized for PCA recipients, enabling them to access essential services and participate more fully in community life.
Services Not Covered by the PCA Program: Noncovered Services
While the Minnesota PCA program is comprehensive, it’s important to be aware of services that are not covered. MHCP does not provide reimbursement for the following services provided by individual PCAs:
- Services without authorization: Any PCA services delivered without proper authorization from the relevant lead agency or MHCP will not be reimbursed. Obtaining necessary authorization prior to service delivery is crucial.
- Identified noncovered PCA services: There are specific services that are explicitly defined as noncovered within the PCA program guidelines. Providers and recipients should familiarize themselves with this list to ensure appropriate service delivery and billing practices.
- Services not identified in care plans: Services that are not specifically outlined in the member’s assessment and service plan or the member’s care plan documents are considered noncovered. The care plan serves as a blueprint for authorized services, and adherence to this plan is essential for reimbursement.
Understanding these noncovered services is vital for both PCA agencies and recipients to avoid billing errors and ensure that services provided align with program coverage guidelines.
Understanding Authorization Requirements for PCA Services
Authorization is a fundamental requirement for all Minnesota PCA services. To navigate the authorization process effectively, it’s essential to refer to the Assessment for PCA services information and the following key points:
- Automatic QP Supervision Authorization: All PCA recipients will automatically receive authorization for Qualified Professional (QP) supervision services. This ensures that the necessary oversight and care planning are in place for every member.
- Extended Waiver PCA Services: For waiver program members who are assessed as eligible for state plan PCA services, lead agencies have the authority to authorize extended waiver PCA services. However, lead agencies also retain the discretion to authorize fewer PCA services if the waiver member’s needs can be adequately met through other services authorized within their waiver program. The specific contract requirements of the lead agency will govern the provision of extended PCA services.
- QP Responsibility for Condition Changes: It is the responsibility of the Qualified Professional (QP) to promptly contact the lead agency whenever there is a change in the member’s condition or health status. This communication is crucial to determine if the change necessitates an adjustment in the member’s PCA service needs. (Refer to PCA Provider Agency Responsibilities in the PCA Manual for further details).
Adhering to these authorization requirements is paramount for ensuring that Minnesota PCA services are appropriately approved and reimbursed, and that members receive the necessary level of care based on their assessed needs.
Billing Procedures for Minnesota PCA Services
PCA agencies are required to adhere to the general MHCP billing policies and guidelines outlined in the Billing Policy section when submitting claims to MHCP for Minnesota PCA services. For comprehensive guidance on claim submission methods and resources, agencies should consult the MHCP billing resources webpage.
Essential Documentation Requirements for Billing
Before submitting any claim to MHCP for reimbursement of PCA or QP services, PCA agencies must ensure they have the following documentation readily available:
- Assessment and Service Plan: Agencies must possess either a copy of the member’s PCA Assessment and Service Plan (DHS-3244) (PDF), or the CFSS Assessment (DHS-6893A) (PDF) for members receiving PCA services through a waiver, or the MnCHOICES PCA Provider Report. This documentation confirms the assessed needs and authorized services.
- Service Authorization: Valid service authorization for the PCA services being billed is mandatory. This authorization verifies that the services have been approved by the appropriate authority.
- PCA Time and Activity Documentation: Detailed PCA time and activity documentation for each individual PCA who delivered services to the member is essential. Agencies should also refer to the Electronic Visit Verification webpage for information on electronic documentation requirements.
- QP Documentation: Supporting documentation for the QP visit being billed is required. This documentation should substantiate the QP services rendered.
- Written Agreement: A written agreement, signed by both the agency and the member or responsible party, must be in place. This agreement outlines the terms and conditions of service provision.
- Shared Services Agreement (if applicable): If PCA services are being shared, a Home Care Shared Services Agreement (HCN, PCA or CFSS) (DHS-6893E) (PDF), signed by all members participating in the shared service arrangement, is required.
PCA agencies are obligated to maintain documentation verifying that services have been provided for both individual PCA and QP services. MHCP mandates that PCA agencies ensure individual PCAs record all minimum required elements when completing the agency’s PCA time and activity documentation process. The specific methods for documenting QP time and activity are determined by the PCA agencies themselves.
Agencies must also adhere to the directives of the Minnesota Department of Labor and Industry (DLI) concerning payment practices for individual PCA providers and QPs for services they are instructed to provide. Furthermore, 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 under the PCA Choice option. Additional information can be found on the Personal Care Assistance (PCA) Choice and financial management services (FMS) provider information webpage. These regulations ensure fair labor practices and compliance with union agreements where applicable.
Submitting PCA Claims to MHCP
Claims for reimbursement of Minnesota PCA services must be submitted in the following manner:
- Transaction Type: Utilize the (837P) Professional transaction for claim submissions.
- Authorization Number Reporting: Report the authorization number that confirms MHCP approval for reimbursement of the services.
- Rendering Provider Identification: The individual PCA who provided the services must be identified as the rendering provider on the claim line. This ensures accurate tracking of service delivery.
- Line-Item Reporting: Submit one line per date of service, per individual PCA or QP, and per HCPCS code or HCPCS and modifier combination. This detailed line-item approach ensures clarity and accuracy in billing.
- U2 Modifier for Parent/Spouse Providers: When services are provided by a parent of a minor or a spouse, append the U2 modifier to the PCA claim. This modifier indicates the relationship of the PCA provider to the recipient.
- Complex Claim Procedures: For PCA complex claims, follow the procedures outlined above, along with the specific billing grid provided in this section.
- TG Modifier for Enhanced Rate Eligibility: If a member is eligible for the enhanced rate, the lead agency will authorize PCA services at this rate. Bill DHS using the TG modifier and the enhanced rate for all members who qualify. Reimbursement at the enhanced rate is contingent on the PCA worker completing qualifying trainings. If the worker has completed the required trainings, the agency will be reimbursed at the enhanced rate; otherwise, the claim will be paid at the regular PCA rate. Refer to PCA and CSG enhanced rate/budget for details on qualified trainings. Providers can verify worker eligibility for the enhanced rate by following the steps outlined under the Personal Care Assistance (PCA) Providers A – Z section on the Provider Lists webpage.
For detailed, step-by-step instructions on individual claim submission, consult the Completing a MN–ITS Interactive Professional (837P) claim for PCA Services guide. MHCP utilizes 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 |
Minnesota PCA Services for Managed Care Members
PCA agencies that provide Minnesota PCA services to eligible members aged 65 and over who are enrolled in a health plan must adhere to the specific rules and guidelines established by the managed care organization (MCO). This includes enrollment procedures with the health plan, authorization protocols, and billing requirements. Agencies should consult the MCO information for PCA agencies webpage for contact information and detailed health plan-specific procedures.
For members enrolled in the Special Needs BasicCare program and the Families and Children program, the authorization process follows the standard fee-for-service guidelines. This distinction is important for agencies to ensure they are following the correct procedures based on the member’s specific managed care program.
Legal and Statutory References for the Minnesota PCA Program
For comprehensive legal and statutory information related to the Minnesota Personal Care Assistance Program, please refer to the following Minnesota Statutes:
- Minnesota Statutes, 256B.04, subdivision 21 (Provider enrollment)
- Minnesota Statutes, 256B.0659 (PCA Program)
- Minnesota Statutes, 256B.0625, subdivision 19c (Personal care-qualified professional)
These statutory references provide the legal framework and detailed regulations governing the Minnesota Personal Care Assistance Program.
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