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 PCCA License 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
• Apply for A PCCA License
• PCCA Services
• PCCA Services Prior Authorization Request Form
• PCCA License Attestation Form

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.

• PCCA FAQ Sheet
• PCCA Marketing Post Card
• PCCA Services
• PCCA Services Prior Authorization Request Form
• PCCA License Attestation Form

Physicians ensure PCCA services are safe and clinically appropriate. Their duties range from verifying caregiver skills to providing medical oversight and collaborating with provider agencies. They are responsible for training and certifying family caregivers, providing medical orders, and supporting prior authorization so children receive safe, effective care at home.

Responsibilities include:

• Review and complete any PCCA Prior Authorization (PA) Request forms sent by service provider agencies.
• Provide physician orders for the child’s plan of care.
• Train and evaluate caregivers on the PCCA skills listed in the PA.
• Complete and sign the PCCA License attestation Form to verify competency.
• Collaborate with provider agencies during utilization review.
• Refer families to Medicaid-enrolled PCCA service providers.
• Update or renew orders if a child’s needs change.

Process

The Medicaid-enrolled service provider for PCCA services coordinates prior authorization (PA). To begin the process, a physician may refer a child and their family to a Medicaid-enrolled PCCA provider. This referral initiates PA and also guides the parent, guardian, relative, kinship caregiver, or foster parent toward licensure through the Montana Department of Labor and Industry (DLI).

Physicians contribute to both the PA and licensure process. They provide medical orders, sign the PA form, and submit any supporting documentation requested by the service provider agency. They also train caregivers, validate their skills, and complete the Physician Primary Care Provider Attestation Form required for licensure.

Once the physician’s documentation is complete, the service provider agency submits the PA request to the Department’s utilization review contractor (URC), currently Mountain Pacific (MP). Upon approval, PCCA services may begin. Licensed PCCAs are employed by the service provider agency.

MP reviews all services provided to ensure there is no duplication of Medicaid benefits. They also assess whether other programs — such as Community First Choice Services/Personal Care Services (CFCS/PCS) or waiver programs — can meet the child’s needs.

Renewal Timeline

• PA renewals occur every 90 days for the first six months.
• After that, renewals are required every six months or sooner if the child’s condition changes.

Authorized PCCA Tasks

PCCAs with a valid Montana license may perform the following tasks under an enrolled 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 permitted by regulation:
  • Ostomy care
  • Central line care
  • IV fluid management
  • Oxygen therapies (CPAP, BIPAP, ventilator support)

What’s Not Covered

• PCCA services do not replace or fully substitute Private Duty Nursing (PDN).
• They do not duplicate health maintenance activities covered under CFCS/PCS.
• Certified nurse aide services are not payable under PCCA.
• Bowel, bladder, and wound care may be covered only if medically complex; otherwise, these are typically addressed through other programs.
• PCCA services do not cover autism and/or other neurodivergent conditions or behavioral health issues.

PCCAs work as part of a person-centered care plan, in coordination with personal care attendants and PDN services.

Caregivers cannot provide PCCA services until they are licensed by the Montana Department of Labor and Industry (DLI). Physicians are central to this process: they train caregivers on required skills, verify competency, and complete the Primary Care Provider Attestation Form that DLI uses to issue the license.

Steps for Physician Involvement in Licensure

• Receive the DLI-issued certification form from the caregiver/applicant
• Provide training on the PCCA skills listed in the prior authorization request
• Verify caregiver competency through hands-on demonstration of each skill
• Complete and sign the Primary Care Provider Attestation Form
• Return the signed form to the caregiver/applicant for submission to DLI
• Complete a new Attestation Form for each renewal or whenever new PCCA services are added

• PCCA FAQ Sheet
• PCCA Marketing Post Card
• PCCA Services
• PCCA Services Prior Authorization Request Form
• PCCA License Attestation Form
• PCCA Physician Service Flow