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PCA is defined as follows in the waiver approved by CMS:

One or more persons assisting an elder with tasks that the individual would typically do for him/herself in the absence of a disability. Such tasks may be performed at home or in the community. The client has employer authority and is responsible for direction of the PCA’s activities. Such services may include physical or verbal assistance to the consumer in accomplishing any Activity of Daily Living (ADL), and Instrumental Activities of Daily Living (IADL). ADL’s include bathing, dressing, toileting, transferring, and feeding. IADLs include meal preparation, shopping, housekeeping, laundry and cueing/reminders for self medication administration. Transportation costs associated with the provision of personal care outside of the client's home are billed separately and are not included in the scope of personal care.

Subject to the limitations in the next paragraph, members of the individual’s family may act as the PCA as long as they meet the training requirements specified by the Department. The client’s spouse, the client’s conservator/legal guardian, or a relative of the client’s conservator/legal guardian may not serve as the PCA. If a family member who resides with a waiver client is approved to be paid as a PCA, the plan of care that is developed must address only those needs that are not currently being met by the family member. Examples of needs that could be assessed as being already met by the family member residing with the waiver client are household activities including but not limited to services such as meal preparation, laundry, shopping and housekeeping. 

PCA services are intended to supplement, not supplant, existing informal, voluntary supports.

Limitations of PCA service as specified in the waiver are as follows:

Overnight and per diem PCA services are subject to approval by Alternate Care Unit Utilization Review staff. PCA services must cost effective on an individual basis when compared with Home Health Aide, Homemaker and Companion services. Recipients of PCA services are not eligible to receive Homemaker, Chore or Companion services. Edits have been created in the MMIS to deny any Homemaker, Chore or Companion claims for PCA service recipients. Personal Care may not be provided to clients receiving Assisted Living Services because all PCA functions are provided by the Assisted Living Service provider. The benefit plan for Assisted Living service recipients excludes personal care to prevent duplicative billing. PCA services may not be billed under any circumstances when the client is in either a hospital or nursing home.

The PCA service is not to substitute for any in-kind or informal support services that the applicant or client is receiving. The development of the plan of care is based on the client’s unmet needs. A relative or any other type of caregiver already providing the services on an in kind basis WILL NOT be eligible to be paid as a PCA for the client for those services. 

All formal, informal and family supports must be explored and documented in the record at the time of the initial assessment and at each subsequent visit. It is not the purpose of the PCA to displace services that have been and are reasonably expected to be provided free of charge by family members and relatives, and may reasonably be expected in the future. A personal care services plan may not be developed which substitutes the paid services of a personal care assistant for voluntary services provided by family members. If a family member or other provider has been providing care and claims that the care was compensated and not in-kind, they must produce verification of the compensation before they can be considered to be a paid PCA.

In situations where a client resides with a family member who is paid as a PCA under this service there will be no reimbursement to that family member for usual household functions that benefit others in the household including, but not limited to, housekeeping, shopping, laundry and meal preparation and transportation. 

In order for the care manager to recommend a family member to be a PCA for an applicant or active client, he or she must document the reasons why the provision of services by a family member is in the best interests of the client and provide to the Department the facts that support the recommendation utilizing a 1547.