Personal Care Assistance (PCA) Services

Effective October 1, 2024, PrimeWest Health members transition from Personal Care Assistance (PCA) services to Community First Services and Supports (CFSS) at their yearly reassessment. Members not previously enrolled in PCA services are enrolled directly in CFSS.

The guidance in this section is directly related to PCA services. Review the Community First Services and Supports (CFSS) section of the PrimeWest Health Provider Manual for more information on CFSS.

Effective January 1, 2019, PrimeWest Health is only responsible for payment for PCA services for PrimeWest Senior Health Complete (HMO SNP) and Minnesota Senior Care Plus (MSC+) members. Minnesota Department of Human Services (DHS) fee-for-service (FFS) authorizes and pays for PCA services for Families and Children, MinnesotaCare, and Special Needs BasicCare (SNBC) members.

PCA services are provided to assist and support people with disabilities living independently in the community. This includes the elderly and others with special health care needs. PCA services are provided in the member’s home or in the community when normal life activities take him/her outside the home.

PCA services may only be provided when the following conditions are met:

A MnCHOICES assessment has established the need for PCA services
PrimeWest Health has authorized the services*
The services are documented in the member’s PCA care plan
The services are provided by a PCA under the direction of a qualified professional (QP)

*The requirement for Service Authorization from PrimeWest Health is waived for MSC+ and PrimeWest Senior Health Complete (HMO SNP) members if the PCA agency is a contracted provider. If the PCA assessment determines the need for PCA services, the member’s county case manager includes the PCA services on the member’s care plan/service plan. All PCA services by non-contracted PCA agencies require Service Authorization.

Eligible Providers

PrimeWest Health-enrolled agencies that employ individual PCAs include the following:

PCPOs
PCA Choice providers/fiscal intermediaries
Medicare-certified, Comprehensive licensed home care agencies

PrimeWest Health requires enrollment by both the agencies that employ individual PCAs and each individual PCA. PrimeWest Health reimburses the agency, not the individual PCA, for services performed. MHCP does not require licensure or certification of PCPOs or PCA Choice agencies to provide PCA services; however, PCA agencies with licenses or certifications must comply with the requirements of both the MHCP PCA program and those of the licenses or certifications they hold.

Minnesota Health Care Programs (MHCP) Revalidation of Enrollment

Providers who are currently enrolled with MHCP must revalidate their enrollment record(s) at least once every five years. Revalidation occurs when MHCP notifies providers to complete and update all enrollment documents to continue participation with MHCP. Providers can expect to receive an initial revalidation notice as early as three-and-a-half years after the most recent revalidation or enrollment date.

If a provider’s enrollment with MHCP ends, the provider must immediately notify the county or counties where their MHCP recipients live. The provider informs the county that the provider can no longer be reimbursed for services as an MHCP provider, and that the county should take actions to ensure the safety of the recipients (Minnesota Stat. sec. 626.557). Terminated personal care assistance (PCA) provider agencies, including all named individuals on the current enrollment disclosure form, and known or discovered affiliates of the PCA provider agency, are not eligible to enroll as a PCA agency for two years following the termination (Minnesota Stat. sec. 256B.0659, subd. 23).

General Personal Care Assistant (PCA) Provider Requirements

All PrimeWest Health-contracted PCA providers must comply with the following responsibilities:

Enroll with PrimeWest Health
Follow the requirements outlined in Requirements All Providers Must Meet
Confirm that all employed PCAs are enrolled with PrimeWest Health as individual PCAs
Fully identify all parties with an ownership/controlling interest of 5 percent or more
Fully identify all management officials
Comply with background study requirements as specified in MN Stat. Chap. 245C
Comply with general Medical Assistance (Medicaid) coverage requirements
Comply with Workers’ Compensation
Comply with PCA program policy
Verify member eligibility on a monthly basis
Keep documentations of individual PCA time and activity between one PCA and one member using PCA Time and Activity Documentation (DHS-4691)
Maintain fidelity/dishonesty bond and liability insurance
Notify PrimeWest Health of cancellation/lapse of general liability insurance
Maintain documentation of services provided per MN Rules part 9505.2175
Owners of housing must follow the State requirements listed in MN Stat. sec. 256B.0659, subd. 3

Additional Requirements

Maintain documentation of compliance with PCA training (MN Rules part 9505.0335)
1. Complete mandatory training requirements for all owners, managing employees, QPs, and billing personnel
Use Generally Accepted Accounting Principles (GAAP)
Develop and maintain agency policies and procedures for the following:
1. Prevention, control, and investigation of infections and communicable diseases
2. Hiring of employees
3. Training, including a listing of all trainings and classes the agency requires of its individual PCAs
4. Employee misconduct
5. Service deliveries
6. Employee and consumer safety, including notification and resolution of consumer grievances
7. Member-directed supervision activities
8. Others as appropriate
Notify PrimeWest Health Provider Enrollment when PCA employees are hired/terminated
Apply for criminal background checks for each PCA at time of employment
Verify each PCA does not appear on the Office of Inspector General (OIG) exclusion list
Verify to ensure each PCA is not on the MHCP Enrolled Provider Excluded Provider Lists as an excluded individual provider
When appropriate, coordinate services with a Medicare-certified home health agency to meet member’s needs
Maintain an individualized PCA care plan in each member file
Provide services in a manner consistent with member’s independent living ability
Manage shared care
Manage/monitor Flexible Use and Standard Use
Document identity of responsible party if member cannot direct own care
Notify PrimeWest Health when the responsible party changes
Demonstrate knowledge of, sensitivity to, and experience with the following:
1. Special needs
2. Communication needs
3. Independent living needs
Document all activities provided to each member by initialing and completing the DHS-approved timecard (PCA Time and Activity Documentation [DHS-4691]) or approved alternate form
Ensure the services initialed on the PCA time card:
1. Meet the member’s needs for health and safety
2. Are reflected in the member’s PCA care plan
3. Reasonably account for the amount of time billed for PCA services
Ensure PCA services provided are reflected in the member’s care plan
Request reassessments 60 days before end of current Service Agreement using correct form (Referral for Reassessment for PCA/CFSS Services [DHS‑6893B]). Request for reassessment should be sent to the county Public Health agency
Manage Flexible Use-approved units/hours
Document each PCA’s completed training
QP provides training and supervision
QP develops PCA care plan
QP provides supervision as follows (MN Stat. sec. 256B.0659, subds. 13-14):
1. The QP shall evaluate the PCA within the first 14 days of starting to provide regularly scheduled services for a member, or sooner as determined by the QP, except for the PCA Choice option under MN Stat. sec. 256B.0659, subd. 19 (a) (4). For the initial evaluation, the QP shall evaluate the personal care assistance services for a member through direct observation of a PCA’s work. The QP may conduct additional training and evaluation visits, based upon the needs of the member and the PCA’s ability to meet those needs. Subsequent visits to evaluate the personal care assistance services provided to a member do not require direct observation of each PCA’s work and shall occur:
  1. At least every 90 days thereafter for the first year of a member’s services;
  2. Every 120 days after the first year of a member’s service or whenever needed for response to a member’s request for increased supervision of the personal care assistance staff; and
  3. After the first 180 days of a member’s service, supervisory visits may alternate between unscheduled phone or Internet technology and in-person visits, unless the in-person visits are needed according to the care plan.
2. Communication with the member is a part of the evaluation process of the personal care assistance staff
3. At each supervisory visit, the QP shall evaluate personal care assistance services including the following information:
  1. Satisfaction level of the member with personal care assistance services;
  2. Review of the month-to-month plan for use of personal care assistance services;
  3. Review of documentation of personal care assistance services provided;
  4. Whether the personal care assistance services are meeting the goals of the service as stated in the personal care assistance care plan and service plan;
  5. A written record of the results of the evaluation and actions taken to correct any deficiencies in the work of a PCA; and
  6. Revision of the personal care assistance care plan as necessary in consultation with the member or responsible party, to meet the needs of the member.
4. The QP shall complete the required documentation in the agency member and employee files and the member’s home, including the following documentation (on agency templates):
  1. The personal care assistance care plan based on the service plan and individualized needs of the member;
  2. A month-to-month plan for use of personal care assistance services;
  3. Changes in need of the member requiring a change to the level of service and the personal care assistance care plan;
  4. Evaluation results of supervision visits and identified issues with personal care assistance staff with actions taken;
  5. All communication with the member and personal care assistance staff; and
  6. Hands-on training or individualized training for the care of the member.
5. The services that are not eligible for payment as QP services include:
  1. Direct professional nursing tasks that could be assessed and authorized as skilled nursing tasks;
  2. Agency administrative activities;
  3. Training other than the individualized training required to provide care for a member; and
  4. Any other activity that is not described in this section.
Ensure the health-related functions performed by the PCA are under the supervision of a QP or the direction of a physician
Possess the capacity to enter into a legally binding contract

Additional Requirements for PCPOs

Maintain a scheduling system
Notify the county PHN or county case manager of changes in needs or health status of the member
Maintain quality assurance mechanisms
Demonstrate a training and supervision system for PCAs
Recruit and hire staff per agency policy and PCA criteria
Provide required basic training (e.g., blood-born pathogen, etc.)
Ensure a QP is employed to supervise PCA services
Possess the capacity to enter into a legally binding contract

Additional Requirements for Personal Care Assistant (PCA) Choice Agency/Fiscal Intermediary

The PCA Choice provider (fiscal intermediary) must ensure the following:

A written agreement exists between the member/responsible party, PCA Choice Agency, PCA, and QP. This agreement must include the following:
1. Duties of the member, PCA, QP, and PCA Choice provider
2. Salary and benefits for the PCA and QP
3. Administrative fee paid to the PCA Choice provider and services included with fee, including background studies
4. Response procedures for billing/payment complaints
The member/responsible party, not the provider, recruits and hires a PCA and a QP
Fiscal support services provided for the member include the following:
1. Medical Assistance (Medicaid) billing
2. Federal and State tax withholding
3. Payroll for PCA and QP
4. Workers’ compensation
5. Liability insurance

If the member/responsible party requests the PCA Choice Option during the current Service Agreement period and the last assessment was a “service update,” a new face-to-face assessment is required. All subsequent assessments must be face-to-face if the member continues to receive services through the PCA Choice Option. An annual face-to-face assessment is completed by the county PHN.

Reimbursement for PCA service is paid at the Medical Assistance (Medicaid) rate to the PCA Choice provider. Reimbursement not designated as a provider administrative fee must pay PCA and QP salaries and benefits.

Eligible Members

Members of the following programs are eligible for PCA services:

Members age 65 and over who have Medical Assistance (Medicaid)
Members of Waiver Service Programs

Members must meet all of the following criteria:

Need PCA services to live in the community
Have a stable medical condition
Be able to identify his/her needs or have a responsible party
Be able to direct and evaluate PCA task accomplishment or have a responsible party providing this support
Be able to provide for his/her health and safety or have a responsible part that is able to do so
Live in his/her own home that is not a hospital, NF, ICF, health facility licensed by MDH, or foster care setting licensed for more than four residents
Have a service plan developed with the county PHN/county case manager that specifies the PCA services needed
Have a PCA assessment and service plan from PrimeWest Health (Personal Care Assistance [PCA] Assessment and Service Plan [DHS-6893A])
1. In addition, PCA services may only be provided when determined medically necessary through the assessment process

Ventilator-Dependent Members

A ventilator-dependent member is a member receiving mechanical ventilation for life support at least six hours per day and is ventilator-dependent for at least 30 consecutive days.

The provider is responsible for training the PCA responsible for working with a ventilator-dependent member. All training and supervision must be documented and on file in the PCA’s employment record. If offering personal care services to a ventilator-dependent member, the provider must demonstrate the ability to do the following:

Train the individual PCA
Supervise the PCA in ventilator operation and maintenance
Supervise the member/responsible party in ventilator operation and maintenance

Requirements for a Responsible Party

The PCA program requires members receiving PCA services be able to direct their own care or have a responsible party that is able to do so. The responsible party must:

Be 18 years or over
Be able to provide necessary support to assist member with remaining in the community
Not be the PCA
Be identified and present at the time of all assessments
Be listed on the Service Agreement and PCA Service Plan

The responsible party cannot be the:

PCA
QP
PCA agency staff
County case manager/supervisor, unless specified in a court order
Foster care license holder, unless there is a face-to-face visit provided by county case management every six months to do the following:
1. Monitor the member’s health and safety
2. Ensure goals of the care plan are met

The responsible party is required to do the following:

Be accessible (any mode that allows for direct communication) to the person and PCA when services are provided, as determined by the responsible party and the provider. For example, the PCA calls the responsible party when services are being provided.
Monitor PCA services at least once per week
Determine if the member’s health and safety are assured with current support service
Actively participate in the planning and direction of PCA services
Report suspected member abuse/neglect to the local county human service agency
Attend all PCA or long-term care (LTC) assessments
Complete required forms, including signing timesheets
Provide written documentation to request a change in provider
Develop the care plan with the QP
Make choices for the person such as type of PCA provider, supervision, hiring, training of staff, and scheduling

Responsible parties who are parents of minors or guardians of minors or incapacitated people may delegate responsibility as necessary according to the following guidelines:

Delegation must be for a period of at least 24 hours but not more than six months total time during a one-year period
1. The one-year period begins at the start of the current member’s Service Agreement
2. All or part of the responsibilities may be delegated
The delegate must reside with the member while serving as the responsible party unless the care plan or Individual Community Support Plan (ICSP) identifies competent supervision and monitoring to ensure the member’s health and safety through one of the following:
1. Case management (targeted or other types)
2. Home and Community Based Waivers
3. Home care
The person who is the delegated responsible party must meet criteria and assume responsibilities determined by the person’s responsible party

Assessments

An assessment is the review and evaluation of a member’s need for home care services and includes the following:

Documentation of the health status of a person
Determination of need for PCA services
Information about options available to a person in the PCA program
Identification of appropriate services including PCA and QP
Coordination of services and referrals to appropriate payers and community resources
Completion of required reports and additional documentation as necessary to substantiate services
Authorization recommended
Evaluation of service effectiveness

Eligible members or their representative, with consent of the member, may request an initial PCA assessment at any time.

Subsequent assessments are conducted annually, or when there is a significant change in the member’s condition.

Assessments are completed:

By county PHN/certified PHN under contract with the county
By the county case manager when an LTCC assessment is conducted for the purposes of determining a member’s eligibility for HCBS, including PCA services, per MN Stat. sec. 256B.0659, subd.3a.

An assessment must be completed:

Before services begin
When there is a change in the member’s need for service
Annually thereafter

For additional information about waiver services, refer to the appropriate chapters in this manual or call the Provider Contact Center at 1-866-431-0802 (toll free). An assessment must be completed any time PCA services are requested.

New Assessment Criteria

PHN PCA assessors will use the following assessment criteria to determine the need for PCA services and the amount of time given.

To receive PCA services, the member must have one of the following:

Dependency in at least one ADL
Level 1 behavior (physical aggression toward self, others or destruction of property requiring the immediate response of another person)

PCA services are not based on minutes per task. Time is based on the assessment criteria. The member’s home care rating will determine the base amount of time. Additional time is added to this base amount if the member also has any of the following:

Critical ADL dependency, such as eating, transfers, mobility, and toileting
Complex health-related needs, such as tube feeding, wounds, and bowel programs
Behavioral needs

Reassessment Outcomes

The reassessment determines the need and amount of time for PCA services. The number of hours may increase, decrease, or stay the same. Some reassessments may result in PCA services being stopped.
Members who no longer meet the criteria to access PCA services or receive a reduction in time will receive a 10-day notice of these changes (this change to a 10-day notice went into effect September 1, 2012). This includes reductions to the maximum consumer support grant (CSG) grant amount.
All members who receive PCA services will receive and be limited to 96 units (15 minutes per unit) of QP supervision per year.

Covered Services

PCA services are an individual, one-to-one based service (with the exception of shared care) to meet the member’s needs to maintain independence in the community.

Delivery models that provide this are eligible for reimbursement by PrimeWest Health if they meet all policy and program requirements.

Covered services are determined by the PCA assessment and may include the following:

ADLs
IADLs, when the PCA assessment determines the need (IADLs are not covered for members under age 18)
Health-related functions that can be delegated or assigned under State law by licensed health care professionals to be performed by a PCA (must be under the direction of a QP or physician)
Redirections and intervention for behavior including observation and monitoring

Combination PCA Hospice and Other Home Care Services

PCA combinations are services that include a PCA and one or more of the following options:

HHA
SNV
Home Care Nursing (HCN)

Home care services must be medically necessary and cost effective. The home care rating determines the maximum dollar amount that can be authorized for all home care services. Review the following decision trees for more information.

PrimeWest Health coordinates any combination of PCA with other home care services through its utilization review team and the county PHNs as needed.

Standard or Flexible Use Service Option

All PrimeWest Health PCA service hours/units are authorized in two date spans, with the total months covered up to one year (12 months). At the time of the PCA assessment, the county PHN or a waiver case manager and the member/responsible party must discuss and determine the appropriate option.

Standard Use Option: date spans reflect the daily average allocation
Flexible Use Service Option: hours/units may vary from month-to-month (no more than 75 percent of the total service plan/authorization may be allocated in any six-month date span)

The DHS DSPM has the Flexible Use Service Option policies available in a table format.

PHNs and county case managers can review Flexible Use – Personal Care Assistance: Flexible use of PCA services for more detailed policy descriptions.

The member/responsible party must carefully select the number of units within each six-month period.

The QP must develop and document a month-to-month plan with the member/responsible party on projected use of PCA hours.

PCA providers must do the following:

Monitor Flexible Use hours for correct billing, according to the plan/Service Authorization
Notify both the PHN and member/responsible party in advance and in writing when the number of units is likely to go over the authorized number of units for the month. Unused PCA units are not transferable. After the PCA units are assigned to a six-month period on the Service Agreement, they cannot be transferred from one six-month period to another.

Revocation of Flexible Use Services

When the Flexible Use Service Option hours exceed the authorized number of units for a period of two out of three months, PrimeWest Health may notify the PHN, the member/responsible party, and the provider in writing that the Flexible Use Service Option will be revoked (denied) beginning the following month. Denials may be Appealed by the member/responsible party. The provider may not Appeal a denied PCA Choice request. Denial, revocation, or suspension to use PCA Choice will not affect the member’s authorized level of service.

PrimeWest Health may revoke or deny the Flexible Use Service Option at any time if a member:

Requests not to participate in the Flexible Use Service Option
Misuses his/her PCA service hours/units
Exceeds the average monthly service plan/authorization for two months
Is placed on the Minnesota Restricted Recipient Program (MRRP)

PCA Choice

Members may choose the PCA Choice Option, also known as a fiscal intermediary. This allows the member more flexibility, choice, control, and responsibility for his/her service needs. The PCA Choice provider may provide technical guidance in employment matters, bills for services, and pays the PCA and QP based on actual hours of services provided. These activities must be completed in accordance with all applicable Federal and State laws including withholding unemployment insurance, Workers’ Compensation, liability insurance, and any other benefits. See the General Personal Care Assistant (PCA) Provider Requirements section.

Denial of PCA Choice

PrimeWest Health may deny, revoke, or suspend authorization to use PCA Choice if the county PHN, county case manager, QP or PrimeWest Health determines that:

The use of this option jeopardizes the member’s health and safety
The parties fail to comply with the written agreement
Abusive or fraudulent billing for PCA services has occurred
The member is placed on the MRRP

Choice of Supervision

PCA services are provided under the supervision of either:

A QP if requested by the member at assessment; or
The member/responsible party along with the member’s physician

Health-related functions performed by the PCA are required to be under the supervision of a QP or the direction of a physician.

The QP may conduct the required supervision remotely for a member with chronic health conditions or a severely compromised immune system when the following criteria are met:

The member requests a determination from their primary health care provider.
The primary health care provider determines remote supervision is appropriate.
The primary health care provider documents their determination of need for remote supervision.
The PCA provider agency retains copies of the primary health care provider’s documents with all copies of the member’s care plan.

The QP must still conduct the initial visit in-person or complete the PCA care plan in person.

This change does not affect the policy for remote QP visits for other people using PCA services.

For more information, refer to the PCA qualified professional (QP) services section of the DHS Provider Manual.

Provision of PCA Services Outside of Minnesota

PrimeWest Health requires Service Authorization for out-of-network PCA services.

Authorization Requirements

All PCA and QP supervision services require Service Authorization. Effective January 1, 2019, PrimeWest Health is only responsible for payment for PCA services for PrimeWest Senior Health Complete (HMO SNP) and Minnesota Senior Care Plus (MSC+) members. Minnesota Department of Human Services (DHS) fee-for-service (FFS) authorizes and pays for PCA services for Families and Children, MinnesotaCare, and Special Needs BasicCare (SNBC) members It is the responsibility of the PCA organization to have a current Service plan/Authorization in place before providing services.

Providers should review the PCA Service Changes section in the DHS Provider Manual for information about Service Authorization/agreements for clients who have gone from fee-for-service (FFS) to PrimeWest Health, or vice versa.

The MnCHOICES assessment is used by PrimeWest Health to determine the amount of services to add to the service agreement.

PrimeWest Health adds PCA services to the PrimeWest Health service agreement for six-month blocks of time as noted on the service plan completed by the assessor.

PW_11-19_576
Updated_03/16/2026

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