Pediatric Complex Care Assistant Services

A child may qualify for Medicaid PCCA services if they:

• Are under 21 years old
• Have a medical condition that qualifies as pediatric complex care
• Are enrolled in Montana Medicaid
• Have a physician-ordered plan of care
• Have a licensed caregiver such as a parent, relative, guardian, or foster parent who is willing to deliver the care

Emergency Planning and Backup Care

• Develop a backup plan for care
• Implement the plan when needed
• Notify the provider agency anytime the plan is activated

Oversight of Services

• Review and approve all service delivery records
• Sign and date records to confirm the child’s care plan is being followed

Legal and Medical Accountability

• Accept responsibility for all care-related decisions and medical services provided

Licensing Requirements

• Obtain certification from a licensed healthcare provider
• Complete licensing before starting services
• Renew the license annually

Daily Decision-Making

• Make informed decisions about everyday care activities
• Understand the impact of those decisions
• Take full responsibility for those decisions

With a Montana PCCA license and a physician’s authorization, family caregivers can deliver medically complex care at home, including:

• Medication administration
• Tracheostomy care (suctioning, routine care, and emergencies)
• Enteral feeding and therapy
• Airway clearance (oral suction, device setup/cleaning)
• Support for oxygen, ventilators, CPAP, BIPAP, and more

PCCA services are an added state plan Medicaid benefit designed to integrate within a broader care plan. They complement other Medicaid services such as private-duty nursing (PDN) and personal care services (PCS), but are not a standalone program or covered under a Medicaid waiver.

PCCA services are not intended to:

• Replace or fully substitute for PDN
• Supplant health maintenance activities available through Community First-Choice Services (CFCS), PCS, or Home Health Services
• Cover certified nurse aide (CNA) tasks (Note: some tasks such as bowel, bladder, or wound care may be eligible under PCCA if tied to medical complexity, but are more often covered through other Medicaid programs like self-directed CFCS)

PCCA services DO NOT cover autism and/or other neurodivergent conditions or behavioral health issues

To get licensed, you must:

1. Apply for a PCCA license and pay a $25 annual licensing fee
2. Provide the DLI Attestation form to your child's physician, so you can get trained and certified as a PCCA
3. Once your physician certifies you and completes the Physician's Attestation, you must return the physician-signed form to DLI.
4. DLI reviews your materials and issues your license.

Once licensed by the Department of Labor and Industry (DLI), your next step is finding employment with a Montana Medicaid-enrolled PCCA service provider agency. These agencies coordinate your work schedule, training, and Medicaid billing while ensuring your license stays active and compliant.

To begin employment, you must:

• Provide a copy of your current PCCA license to your hiring agency.
• Be enrolled as a rendering provider with Medicaid through the agency (if required).
• Complete agency-specific onboarding like Electronic Visit Verification (EVV) training, timesheet protocols, and other policies.

The hiring agency also initiates the prior authorization (PA) process to approve PCCA services for the member under your care.

Important guidelines:

• Medicaid dos not reimburse overtime hours for caregivers
• Authorized services hours (units) must be used within each pay period. They cannot be banked or carried over.
• While there are no time-of-day restrictions, services must not exceed 24 hours or 96 units in a single day.

Your schedule will be based on the member's care plan, PA approval, and the provider agency's staffing frameworks.

[ Link to PCCA-approved service provider agencies coming soon. ]

• PCCA FAQ Sheet
• PCCA Marketing Post Card

To Qualify as a PCCA service provider:

Providers must meet the following criteria:

• Be in good standing with Montana Medicaid

  • Enrolled as a PCCA provider type 49

  • No outstanding program integrity issues, sanctions, or payment suspensions

  • Compliant with all applicable state and federal regulations

• Demonstrate compliance with all rules, regulations, and billing requirements

  • Clean record free from investigations or sanctions for the preceding 24 months

• Hire and train licensed PCCAs

• Coordinate physician authorization and care planning

• Ensure compliance with all documentation, reporting, and review requirements

• Perform annual checks of exclusion lists (LEIE, Montana Department of Labor, SAM.gov)

• While not mandatory, annual background checks are encouraged

Care Coordination and Oversight

• Coordinate physician authorization and work with the Utilization Review contractor
• Develop and implement the person-centered plan of care in collaboration with the physician, family, and other programs (PDN, CFCS, Home Health, Waiver)
• Ensure PCCA service delineation is clearly defined within the care plan

Employment and Training of PCCAs

• Hire and employ qualified PCCAs
• Conduct agency-specific onboarding and training, including:
  • Timekeeping and documentation procedures
  • HIPAA compliance and EVV protocols
  • Emergency protocols and mandatory reporting
  • Complaint and grievance processes
  • Transition of care procedures
  • Quality assurance and review
  • Provider-specific orientation and benefits
• Ensure PCCA licenses are current and in good standing
• Submit Attestation Forms and license documentation as required
• Maintain familiarity with the Provider Manual and Administrative Rules of Montana

Note: PCCAs are “other licensed professionals” and should not be supervised by RNs or LPNs.

• Submission of Annual Provider-Prepared Reports: Providers must complete annual revalidation to confirm continued compliance with enrollment requirements.
• Monitoring and Audits: Montana Medicaid will conduct ongoing monitoring and audits to assess adherence to program policies, quality standards, and billing requirements.

Montana Medicaid: Enrolling PCCA Service Providers

Montana Medicaid will soon be enrolling service providers to deliver PCCA services. These services support children with complex medical needs by enabling licensed family caregivers to provide physician-directed care in the home.

PCCA service providers are the backbone of this effort. They don’t just manage logistics — they create the framework for safe, effective, and compassionate care. By hiring and supporting licensed PCCAs, coordinating with physicians, and ensuring compliance with Medicaid standards, service providers help families navigate a system that prioritizes both medical necessity and personal dignity.

Provider Enrollment Process

1. Selecting taxonomy codes 251E00000X or 251J00000X and choosing the PCCA provider type
2. Adding a team for each service location (one team per location)
3. Submitting PCCA enrollment for review
4. Receiving a welcome letter upon approval of the enrollment unit (EU)

Enrollment cannot begin without valid PCCA licenses.

Enrollment is underway.

The Physician’s Role

Pediatric Complex Care Assistant (PCCA) services are new to Montana. These services support children under age 21 who have complex medical needs. Individuals providing PCCA services must hold a valid and current PCCA license and be employed by a Montana Medicaid-enrolled PCCA provider.

PCCA licensure begins with the parent, family member, kinship caregiver, or foster parent of a child with complex pediatric care needs. The Montana Department of Labor and Industry (DLI) issues PCCA licenses. Licensure information and applications are available on the Montana DLI PCCA Program page. 

PCCA Licensure

To become a licensed PCCA through DLI, applicants must complete the DLI online application and submit the DLI Attestation form for the Montana PCCA Program. A $25 annual licensing fee is required. This process is outlined in 37-2-603, MCA, and administrative rules 24.160.501 and 24.160.505, ARM.

An applicant for licensure needs one of two things: (a) completion of a DLI-approved training program with a valid certificate; or (b) passing a DLI-approved hands-on examination demonstrating competence. The Montana Department of Labor currently does not have an approved training program. Therefore, hands-on training and skills certification are necessary.

Montana physicians who care for children with complex pediatric care needs will provide this training and certification of skill competence. The parent/caregiver seeking licensure must demonstrate skilled competency in providing the PCCA services their child needs to the child’s physician.

PCCA Functions

PCCAs may perform these functions:

• Medication Administration
• Tracheostomy Care: Routine care, suctioning, emergency ventilation, and tube replacement.
• Enteral Care & Therapy
• Airway Clearance: This includes oral suction and device setup/cleaning.
• Additional Tasks: Ostomy, central line, IV fluid, and oxygen management (including CPAP/BIPAP/ventilator support), as regulatory rules allow.

PCCA services do not duplicate health maintenance activities available under Community First Choice Services (CFCS). Certified Nurse Aide services are not reimbursable under PCCA, but may be covered elsewhere. Medical complexity might allow for bowel, bladder, and wound care under PCCA, but other services often cover these.

The parent/caregiver seeking licensure will provide an electronic copy of the Physician Primary Care Provider Attestation form to the child’s physician to attest to his or her proficiency in the appropriate skills. Once the licensure applicant demonstrates competency, the physician completes and signs the form.  This form indicates the PCCA services the applicant can provide for their child. The applicant then submits it to the Department of Labor for final licensure steps.

A PCCA can only provide services based on their training and DLI licensure. The license lists the services the PCCA is certified to perform. If the child needs additional PCCA services, and the licensed PCCA obtains certification for these services from the child’s physician or a DLI-enrolled training program, these services must be added to the existing PCCA license.

After licensure as a PCCA, the parent, guardian, relative, or foster care parent will seek employment through Medicaid providers enrolled in PCCA to begin care.

All PCCA services for the child must match the license and the PCCA prior authorization for services. The Medicaid service provider will coordinate prior authorization for services with the physician and Mountain Pacific. Families and physicians are not responsible for coordinating the prior authorization for services.  However, physicians are responsible for providing the orders and completing the prior authorization form sent by the Medicaid service provider.

Process

The Medicaid-enrolled service provider for PCCA services coordinates prior authorization. To begin the PCCA service process, a physician can refer a child and their family to a Medicaid-enrolled PCCA service provider. This starts the process for prior authorization for services, which will also guide the parent, guardian, relative, kinship caregiver, or foster parent to the Department of Labor and Industry for PCCA licensure.

The physician has a role in licensure as well — providing training, validating skills, and signing and returning the Physician Primary Care Provider Attestation form provided to them by the parent, guardian, relative, or foster parent seeking PCCA licensure. At the same time, the physician will provide orders, sign the PA form, and offer any supporting documents the Medicaid service provider agency requests.

The service provider agency then submits the Department’s utilization review contractor (URC), currently Mountain Pacific (MP).  Once the PA is approved, PCCA services can begin. The licensed PCCA(s) are employed by the service provider agency. MP reviews all services a child receives. This ensures no duplication of Medicaid services. They also check if other resources, like Community First Choice Services/Personal Care Services (CFCS/PCS) or waiver programs, can meet service needs.

PA renewals happen every 90 days for the first six months. After that, renewals are every six months or if a child's condition changes and requires different PCCA services.

Authorized PCCA Tasks

PCCAs with a valid Montana license can perform the following tasks under an enrolled PCCA Medicaid service provider:

• Medication administration
• Tracheostomy care: Routine care, suctioning, emergency ventilation, and tube replacement.
• Enteral care and therapy
• Airway clearance: Oral suction and device setup/cleaning
• Additional tasks, as allowed by regulatory rules: Ostomy care, central line care, IV fluid management, and oxygen therapies (including CPAP, BIPAP, and ventilator support)

What’s Not Covered

PCCA services do not replace private duty nursing (PDN) services. They are not a full substitute for PDN services. PCCA services do not duplicate health maintenance activities available under Montana CFCS/PCS.

Certified nurse aide services are not payable under PCCA. They may be covered elsewhere. Medical complexity may allow for bowel, bladder, and wound care under PCCA, but other programs usually cover these.

PCCAs work as part of a complete, person-centered plan alongside personal care attendants and PDN services.