Care coordination resources

Medica DUAL Solution® (HMO D-DNP) (MSHO)

Manuals, policies + processes

Guidelines

Assessments

  • Supplemental Waiver Personal Care Assistance (PCA) Assessment and Service Plan (PDF)
  • Assessment Schedule Policy
    • Care Coordinators will NOT complete a PCA Reassessment for members that are new to Medica with a current PCA authorization (i.e. from another health plan or fee for service) unless member has had a change in condition, a change in services or supports, or per member request.
    • PCA Reassessments can be done up to 60 days before the end of the authorization period.
    • Reassessments can be done early only for change of condition or supports.
    • PCA reassessment cannot be completed early due to using up units before the end of the authorization period.
    • PCA Assessment must be completed if denying PCA services and submitted with the Denial Termination Reduction (DTR) Form.
    • For members on other waivers managed by the county (i.e.: CADI), Medica will accept the MnCHOICES Assessment completed by the county waiver case manager.

Authorizations

Keep in mind:

  • Complete Referral Request Form (RRF) is to be submitted to Medica.
    • Include the PCA Assessment with the RRF when there is an increase of 8 or more units from the previous assessment.
    • Must use an in network provider.
  • Services can start as early as the date of the assessment (initial assessment) if there is a provider already in place.
  • Authorizations cannot extend beyond one year.
  • Authorization dates should line up with Elderly Waiver (EW) waiver span or HRA reassessment dates.
  • Medica will honor PCA Assessments and authorizations when member newly enrolls with Medica. The Care Coordinator (CC) can use the Flexible PCA Verification Form to determine number of units left in the authorization.
  • Medica/Care Coordinator will authorize an Out of Network (OON) PCA provider with Medica for up to 120 days from the date of enrollment with Medica. Indicate this on the RRF in the comment section.
  • OON PCA provider requests other than for newly enrolled members cannot be authorized by the Care Coordinator and requires a utilization management review.
  • 45 day temp auths should be used for temporary changes in condition.
    • To determine hours, must review PCA assessment to determine what has changed on the assessment and approve the increase of units based on the PCA assessment. Changes must be documented in the member’s record.
    • A DTR is not done to reduce back to the previous level of services.
    • Temp auth cannot exceed 45 days, if increased need beyond 45 days, another PCA assessment must be completed.
  • To reduce or terminate a PCA authorization a DTR form must be completed and include the PCA Assessment. An RRF will not be accepted.

Resources

Templates, tools, and additional resources

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