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					                             Description and Purpose:
                             Guidelines for Flexible Use Option of State plan PCA service hours/units

       Briefcase             Where Found:
  Resource Document          DSPM: PCA Chapter – Flexible Use Option



Background
The 2005 legislature made changes to the PCA Flexible Use Option. Implementation of the
changes to this program is reflected below.

Definitions

   Flexible Use or Flexible Use Option: Planned use of authorized PCA service
   hours/units in a flexible schedule to more effectively meet the needs of the person.

   Standard PCA: Limited use of PCA service hours/units to a monthly basis: Daily and
   weekly usage of PCA service hours/units should be close to the daily average
   allocation. Hours do not transfer from month-to-month.

   Extended PCA: PCA services covered under a waiver program that exceed the
   amount, duration, frequency and scope of comparable State plan PCA services.
   Extended PCA services may be used for temporary increases in consumer needs.

   Date Span for Service Agreement Line Item: Length of time between the start and
   end dates of the service for a line item. PCA service date span cannot exceed six
   months.

   PCA Short-Term Service Agreements: A Service Agreement for a consumer who’s
   PCA need is anticipated to be less than twelve months or the need for PCA services is
   temporary.

I. Check Eligibility for the Flexible Use Option
   Prior to conducting a PCA assessment, check to see if the person is eligible for the Flexible
   Use Option. Restrictions of the Flexible Use Option do not affect a recipient’s total amount of
   authorized PCA service hours/units. A consumer or responsible party has the right to appeal
   any restriction of flexible use.

   There are four types of eligibility restrictions for flexible use:

   1. Minnesota Restricted Recipient Program (MRRP)
      MRRP coordinates health care for recipients who have used MA services at a frequency
      or amount that is not medically necessary and/or who have used health services that

                    Minnesota Department of Human Services - Disability Services Division
                                                     1
                        Description and Purpose:
                        Guidelines for Flexible Use Option of State plan PCA service hours/units

     Briefcase          Where Found:
Resource Document       DSPM: PCA Chapter – Flexible Use Option



   resulted in unnecessary costs to the state. Persons on the MRRP must obtain services
   from a Medicare-certified home health agency and are ineligible for the following:
      • Consumer Directed Community Supports (CDCS)
      • Consumer Support Grant (CSG)
      • PCA Choice
      • PCA Flexible Use Option

   Use one of these two methods to identify consumers who are on MRRP:
      Call the MHCP Automated Inquiry Service (aka EVS) at 651-282-5354 or toll-free at 1-
      800-657-3613:
         • Press 1 for recipient information
         • Have your 9-digit MHCP provider number available

      Go to the MMIS Recipient RPCR screen and look at the Primary Care Utilization
      Review (PCUR) begin and end date fields:
         • Restricted recipient if PCUR date span is present
         • Not restricted if PCUR date span is blank

2. DHS Restricted Flexible Use
   DHS may deny or revoke flexible use of PCA service hours/units when consumers have a
   history of using their PCA service hours/units too quickly. DHS will notify the consumer
   or responsible party, provider and county about the restriction.

   Check the MMIS Recipient Comments (ARCP) screen of the last Service Agreement for:
     • DHS comments on the denial or revocation
     • Date of eligibility for Flexible Use Option (Comments should include both the date
         of denial and future date of eligibility)

3. County Restricted Flexible Use
   When the PHN or case manager has concerns about a consumer’s health and safety or
   past overuse of PCA service hours/units, they may decide to restrict the flexible use of
   PCA service hours/units.




                Minnesota Department of Human Services - Disability Services Division
                                                 2
                           Description and Purpose:
                           Guidelines for Flexible Use Option of State plan PCA service hours/units

       Briefcase           Where Found:
  Resource Document        DSPM: PCA Chapter – Flexible Use Option



      To restrict the Flexible Use Option:

      1. Complete the PCA Flexible Use Agreement, Addendum to the MA Home Care
         Service Plan (DHS-3244A): The consumer or responsible party may choose to sign
         either the Flexible Use or Standard Use of PCA service hours/units on the agreement.
      2. Check County Restricted.
      3. Document the reasons for denying flexible use on the agreement. Attach additional
         pages or documentation, if necessary. Keep a copy in the county files.
      4. Add a comment on the MMIS Recipient Comments screen (ARCP) of the Service
         Agreement to explain the denial of flexible use.

      To check if the county has denied flexible use in the past, for Service Agreements starting
      after April 15 2006, look in the consumer’s file or check the MMIS ARCP screen for
      county comments.

   4. Consumer Declines Flexible Use
      If the person declines the Flexible Use Option, follow the instructions on the PCA
      Flexible Use Agreement.

II. Plan for Flexible Use
    Prior to the PCA assessment, make information on the Flexible Use Option available to a
    consumer or responsible party. DSD designed the Flexible Use Option Consumer Toolkit to
    help consumers and providers manage use of PCA service hours/units. A link to the toolkit
    is available through the DSPM under PCA Forms.

   DHS recommends that when possible, mail the Flexible Use Option Consumer Toolkit at
   least seven days prior to a PCA assessment. The toolkit includes:

      a. PCA Flexbook: Works like a check book to help consumers or providers track their
         use of PCA service hours/units.
      b. PCA Budgeting Tool: Budgets the use of PCA service hours/units on a month-to-
         month basis, and compares the number of PCA service hours/units budgeted to the
         number of PCA service hours/units used.
      c. Frequently Asked Questions: Answers questions about the Flexible Use Option for
         PCA services from a consumer perspective.



                   Minnesota Department of Human Services - Disability Services Division
                                                    3
                        Description and Purpose:
                        Guidelines for Flexible Use Option of State plan PCA service hours/units

     Briefcase          Where Found:
Resource Document       DSPM: PCA Chapter – Flexible Use Option



1. Complete the MA Health Status Assessment for PCA Services (DHS-3244) or LTC
   Screening Document – LTCC, CADI, CAC, AC, EW, TBI (DHS-3427).
2. Discuss the Flexible Use Option with the consumer or responsible party. If the number of
   PCA service hours/units is not known at the time of the PCA assessment, complete the
   agreement based on a percentage of PCA service hours/units.

   Considerations and limitations to dividing PCA service hours/units:
     a. Total PCA authorization for the two date spans equals the total number
         of PCA service hours/units authorized for the service plan year.
     b. Health and safety needs must be met through the duration of the 12-
         month Service Agreement.
     c. When planning how to allocate PCA service hours/units, consider
         summer vacations or planned hospitalizations when more or fewer PCA
         service hours/units may be needed.
     d. No more than 75% of the total authorization may be allocated in any six-
         month date span.

             For example: If a person has 4,000 PCA service hours/units in a twelve-
             month period, the maximum amount of PCA service hours/units that can be
             allocated in one six-month date span is 3,000 units.

3. Fill out and obtain signatures on the PCA Flexible Use Agreement to substantiate the
   decision made by the consumer or responsible party on how PCA service hours/units
   will be divided for the entire length of the Service Agreement.

   If the consumer requests additional time to consider how to divide their PCA
   service hours/units, they have up to 14 days to return the signed agreement to
   the county before the county assigns them to standard PCA services.
       a. Check “County Restricted” and document the reason on the MMIS
           ARCP screen. The person will be eligible for the Flexible Use Option on
           the next Service Agreement.
       b. At the discretion of the county, the 14 day time period may be extended.

4. Provide a signed copy of the agreement to the consumer or responsible party and the
   provider with the total number of hours included.
5. Authorize flexible use in two six-month date spans based on how the consumer plans to
   use allocated PCA services hours/units to meet needs.
                Minnesota Department of Human Services - Disability Services Division
                                                 4
                            Description and Purpose:
                            Guidelines for Flexible Use Option of State plan PCA service hours/units

       Briefcase            Where Found:
  Resource Document         DSPM: PCA Chapter – Flexible Use Option



   6. Enter the Service Agreement into MMIS: Remember that once the Service Agreement is
      entered into MMIS, the PCA service hours/units cannot be transferred from one date
      span to another.

   The PCA Flexible Use Agreement is required prior to the start of flexible or standard PCA
   services. The agreement can be:
      a. Completed by either a public health nurse or a case manager
      b. Completed with either the number of hours or as a percentage of the authorization

III. Service Agreement Procedures
     Counties now enter Service Agreements directly into MMIS for PCA services. In most
     instances, PCA agreements are entered based on a twelve-month period using two six-
     month date spans.

   1. Enter a frequency code 5 to indicate Flexible Use Option or code 1 to indicate standard
      PCA services.
   2. Enter two line items using the PCA HCPC code T1019 (15-minute units):
         a. Line items cannot be longer than six calendar months.
         b. If the Service Agreement starts in the middle of the month, the first six-
             month date span will be shorter. The second six-month date span will
             always be six calendar months.

         Example: If a Service Agreement starts on January 15, enter the first date span from
         January 15 to June 30; second date span from July 1 to December 31.

   3. Enter other related services such as qualified professional supervision for PCA services
      using one line item for the duration of the Service Agreement.
   4. If a consumer does not use all of their PCA service hours/units by the end of a six-month
      date span, do not carry the remaining PCA service hours/units over to the next six-month
      date span or Service Agreement.

IV. Manage PCA service changes (Not waiver programs)

   A. Change in condition of 45 days or less
      Use the PCA Request Fax Form (DHS-4292) to request a temporary increase in PCA
      service hours/units. DHS will enter the increase as a separate line item using PCA HCPC
      code T1019 U6.
                   Minnesota Department of Human Services - Disability Services Division
                                                    5
                        Description and Purpose:
                        Guidelines for Flexible Use Option of State plan PCA service hours/units

     Briefcase          Where Found:
Resource Document       DSPM: PCA Chapter – Flexible Use Option



B. Change in condition longer than 45 days
   1. A new face-to-face PCA assessment is required. Use the PCA Request Fax Form to
      submit new assessment information to DHS.
   2. DHS will prorate the PCA service hours/units based on the amount of the increase
      and the amount of PCA service hours/units already used under the flexible use plan if
      the same home care rating applies.
         • If the consumer has exhausted the previously authorized amount of PCA
            service hours/units, only the approved increase in PCA service hours/units will
            be added to the Service Agreement.
         • If there is a change in the home care rating, DHS will prorate PCA service
            hours/units as appropriate for the new Service Agreement.

   3. Prior to the end of the existing Service Agreement, the PHN may either conduct a
      second face-to-face assessment or submit a Home Care Service Update (DHS 3244B) if
      the person’s condition is unchanged.

      Note: The PCA provider is required to obtain a new Physician Statement of Need
      before they bill DHS for any increase in PCA service hours/units.

C. PCA Short-Term Service Agreements
A Service Agreement for a consumer who’s PCA need is anticipated to be less than
twelve months or the need for PCA services is temporary.

      Six calendar months or less: Authorize services using one line item for the duration of
      the Service Agreement.

      Longer than 6 months but shorter than a year: Use two date spans: The second date
      span will be 6 calendar months.

   Note: The PCA Flexible Use Agreement is required for short-term Service Agreements.

D. Behavior Documentation
   If documentation of Level I behavior(s) is not available at the time of the PCA
   assessment:

   1. Enter assessment data into MMIS without authorizing time for Level I Behavior.

                Minnesota Department of Human Services - Disability Services Division
                                                 6
                       Description and Purpose:
                       Guidelines for Flexible Use Option of State plan PCA service hours/units

     Briefcase         Where Found:
Resource Document      DSPM: PCA Chapter – Flexible Use Option



   2. Note in the MMIS AHC3 screen that the documentation for Level I behavior is
      pending.
   3. Once Level I behavior documentation is received, submit PCA Request Fax Form
      (DHS-4292) to DHS with the date that the Level 1 documentation was received.
   4. DHS will prorate additional PCA service hours/units for the remaining days in the
      Service Agreement based on the flexible use allocation or percentage of PCA service
      hours/units within the appropriate date spans.
   5. If the additional PCA service hours/units are to be split differently than what was
      agreed to on the original flexible use agreement, a new flexible use agreement must
      be included with the PCA Request Fax Form.

   Note: Only the additional units for the Level 1 behavior can be allocated under the new
   flexible use agreement. The original PCA service hours/units authorized cannot be
   transferred between date spans.

E. Interruption of PCA Service
   If a consumer terminates PCA services and reapplies within the same 12-month
   authorization period, the original date spans apply.

   If there is no change in condition:
   PHN may do a face-to-face assessment or Service Update at their discretion.

   1. Submit the PCA Request Fax Form (DHS-4292) to reinstate the PCA services.
   2. DHS will prorate services for the remainder of the Service Agreement based on the
      earlier date spans and PCA service hours/units used.

   If there has been a change in condition:
   A new face-to-face assessment must be completed dependent upon the consumer’s
   needs, the amount of time lapsed from the last assessment and the PHN’s decision.

   1. Submit a PCA Request Fax Form (DHS-4292) with the new PCA information.
   2. DHS authorizes additional PCA time based on the previous amount of PCA
      service hours/units used, the date spans from the Service Agreement and the
      amount of units authorized under the change in condition.




               Minnesota Department of Human Services - Disability Services Division
                                                7
                          Description and Purpose:
                          Guidelines for Flexible Use Option of State plan PCA service hours/units

       Briefcase          Where Found:
  Resource Document       DSPM: PCA Chapter – Flexible Use Option



V. Manage PCA Service Changes through Waiver Programs

  A. Change in Condition
     Waivers may use a combination of State plan PCA services and extended PCA services
     through waiver programs to meet an individual’s needs.

     1. Use Extended PCA HCPC code T1019 UC. Extended PCA services:
           • Require that the consumer have State plan PCA services on the Service
              Agreement
           • May be entered or adjusted for any length of time per Service Agreement
           • Are billed after State plan PCA services (for more information see Chapter 24
              of the MHCP Provider Manual)
           • May not be authorized for misuse of State plan PCA services

     2. Enter extended PCA as one line item for the duration of the increased need for
        services or until the end of the Service Agreement.

     Note: At the next Service Agreement, maximize MA State plan PCA service hours/units
     before authorizing extended PCA service hours/units through the waiver.

        Example: A person receives six hours of PCA services daily. During the last month of
        an existing Service Agreement, the person has a change of condition and needs two
        additional PCA service hours/units a day. On the next Service Agreement, authorize
        eight hours of PCA service hours/units daily under MA State plan PCA and no
        Extended PCA.

  B. Starting State plan PCA After an Existing Waiver Service Agreement is in Place
     If State plan PCA services start after a waiver Service Agreement is in place, the case
     manager has the option of beginning a new Service Agreement, or prorating PCA service
     hours/units according to the original service plan year. Line items for State plan PCA in
     existing Service Agreements may not exceed six calendar months.
        Example 1: If a waiver Service Agreement goes from January through December and
        State plan PCA services start in April: Enter the first line item for PCA service
        hours/units from April through June (three months) and the second line item from July
        through December (six months).


                  Minnesota Department of Human Services - Disability Services Division
                                                   8
                           Description and Purpose:
                           Guidelines for Flexible Use Option of State plan PCA service hours/units

       Briefcase           Where Found:
  Resource Document        DSPM: PCA Chapter – Flexible Use Option



          Example 2: If a waiver Service Agreement goes from January through December and
          State plan PCA services start in August: Enter one line item for PCA service
          hours/units from August through December (five months).
   C. Interruption of PCA Services for Waiver Recipients
   For waiver recipients who receive PCA services, follow current guidelines for reopening to a
   waiver.

VI. Manage PCA Service Changes through the Alternative Care Program
    1. Enter PCA service hours/units for recipients who are on the Alternative Care Program
       in two line items using the six-month date spans and PCA HCPC code T1019 or
       T1020.
    2. If there is a change in condition, enter changes in PCA service hours/units on the
       existing Service Agreement for the appropriate six-month date span and force edit 891
       to accept the changes.

VII. Monitor Overuse of PCA Service Hours/Units
   Monitoring of PCA services is the responsibility of the following:
     • Consumer or responsible party
     • Provider
     • Case manager (for recipients receiving PCA services through a waiver or the
         Alternative Care Program)

   DHS will provide written notice to the consumer or responsible party, provider, PHN and
   the case manager (if any) when a recipient’s PCA services are likely to be exhausted prior to
   the end of a six-month date span per MMIS automated letters.

   DHS will request documentation from the provider regarding the individual’s month to
   month plan. After reviewing documentation, DHS may, at its discretion, revoke or deny
   flexible use.




                   Minnesota Department of Human Services - Disability Services Division
                                                    9

				
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