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HealthPartners

Coverage criteria policies

Personal care assistant (PCA) - Minnesota Health Care Programs

These services may or may not be covered by your HealthPartners plan. Please see your plan documents for your specific coverage information. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage.

Administrative Process

Prior authorization is required for Personal Care Assistant (PCA) Services.

The prior authorization process requires an initial PCA assessment of the recipient’s need for PCA services. Assessments are then done annually and when there is a significant change in medical condition.

An enrollee, a person with the authority to act on behalf of the enrollee, or a health care professional can request an initial assessment when there have been no PCA services provided or there has been a break in PCA services.

Coverage

PCA Services are generally covered as per the indications listed below and per your plan documents.

PCA services include those provided through PCA shared care services as well as traditional and choice models.

Indications that are covered

Authorized PCA hours may be used flexibly within the approved authorization start and end dates.

  1. PCA services provided must meet all of the following criteria:
    1. Be the appropriate level of care based on recipient’s current PCA assessment
    2. Be included in the PCA Care Plan and provided under the direction and supervision of a Qualified Professional; and
    3. Be provided by a PCA through a HealthPartners contracted PCA agency; and
    4. Be under the supervision of a qualified professional
  2. The member must:
    1. Live in his/her own home and need PCA Services to live in the community; and
    2. Be in a stable medical condition and not have acute care needs that require inpatient hospitalization; and
    3. Have needs that can be met in their home by a PCA; and
    4. Have a current PCA Assessment that specifies the personal care services needed.

Indications that are not covered

The following services are not covered:

  1. Personal care service that is not supervised by a qualified professional;
  2. Services that are over and above the capped rate per DHS – Please see related content at right for link to PCA Decision Tree
  3. Services provided by a person who is:
    1. Paid legal guardian of an adult, or
    2. Legal guardian of a minor, or
    3. Parent or stepparent of a minor child member, or
    4. Spouse of a recipient ,or
    5. A recipient of PCA services, or
    6. Licensed foster provider
    7. Responsible party of a recipient.
  4. Services that are provided in a licensed hospital, nursing facility, intermediate care facility, health facility licensed by MDH, or a foster care setting that is licensed where there are more than four residents;
  5. Services that are the responsibility of a residential or program license-holder under the terms of the service agreement and administrative rules;
  6. PCA services provider without authorization:
  7. Injections of fluid and medication into veins, muscles or skin or any administration of sterile procedures
  8. Services that are not covered PCA Services per MHCP guidelines;

Definitions

Personal Care Assistant (PCA) - An employee of a home health care agency that has passed the criminal background check, and has a current provider ID number. He/she is employed to provide custodial services outlined in a written care plan and under the direction of a Qualified Professional. The PCA cannot be the member’s responsible party.

PCA Agency – Health care agency that works with the health plan and member to provide PCA services that are safe and competent. The agency ensures that records are kept to show that services are being provided and submits requests for re-assessments annually.

Medically Necessary or Medical Necessity- a health service that is consistent with the recipient's diagnosis or condition and is recognized as the prevailing standard or current practice.

Products

This information is for most, but not all, HealthPartners plans. Please read your plan documents to see if your plan has limits or will not cover some items. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage. These coverage criteria may not apply to Medicare Products if Medicare requires different coverage. For more information regarding Medicare coverage criteria or for a copy of a Medicare coverage policy contact Member Services at 952-883-7979 or 1-800-233-9645.

Portions of the contents of these coverage criteria relating to Minnesota Public Programs medical coverage criteria are taken directly from the Minnesota Health Care Programs Provider Manual at: http://www.dhs.state.mn.us/main/idcplg?IdcService=GET_DYNAMIC_CONVERSION&RevisionSelectionMethod=LatestReleased&dDocName=dhs16_146076

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Policy activity

  • 12/28/2004 - Date of origin
  • 09/15/2017 - Effective date
Review date
  • 09/2018
Revision date
  • 02/01/2016

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