Personal Care Agencies: Application and Certification Process

Becoming a Medicaid certified PCA is a 2-step process:

1. In order to receive reimbursement for personal care services that your agency provides, you must first have a successful survey by DQA to the regulatory requirements in Wis. Admin. Code § DHS 105.17 and Wis. Admin. Code § DHS 107.112.
2. Upon completion of a successful survey, DQA will recommend approval for Medicaid certification to Wisconsin Medicaid. At that time, the agency will be provided instructions on how to enroll with Wisconsin Medicaid.

First you will need to complete and submit a PCA application. The Division of Quality Assurance (DQA) recommends you review the regulatory requirements in the links below to prepare your application and understand the regulatory requirements to be a personal care agency (PCA) provider.

Regulatory references and resources

• Wis. Admin. Code § DHS 105.17 Personal Care Providers
• Wis. Admin. Code § DHS 107.112 Personal Care Services

Please watch the recorded PCA Forum presentations. The webinars are designed for all new PCAs. The webinars will help you gauge your readiness for applying.

Application process

1. Complete the Personal Care Agency Application, F-00119 (Word) and submit all required documents indicated on the application form. NOTE: A veteran may be eligible for a waiver of the application fee. For information on qualifying for this waiver please review Regulations: Veterans Professional/Occupational License Fee Waiver Program.

2. Use the Personal Care Agency Application Regulatory Guidance Checklist, F-00262A as a reference for the required documents that must be submitted with the application and to develop your agency specific policies and procedures.

   Note: When you submit your agency's policies and procedures with your application, include the Personal Care Agency Application Materials Checklist, F-00262. This checklist should be used to submit the policies and procedures in the order stated on the checklist. Number all of the pages, including forms, and provide that numbering on the F-00262 checklist in the page number column. Enclose the F-00262 checklist with the policies and procedures that are submitted with your application. You may double side the policies and procedures.

3. In order for your application to be considered complete and undergo review, an entity background check must be completed. This process must be completed prior to application submission. Entity background checks must be completed for each owner, managing employee, administrator, and substitute administrator. Entity background checks are completed by the Office of Caregiver Quality (OCQ) on all new and/or existing license applicants/license holders, some principal officers, and non-client residents of DQA regulated facilities/entities. Learn more about the online application process.

Application submission

Upon submission of a complete application packet and completion of the entity background checks, DQA will:

1. Review the application and supporting documents. Your application will be considered incomplete if it is missing any requested application materials, policies and procedures, or entity background checks. Review of the application does not begin until all application materials are submitted and the entity background checks are complete. The application review includes:
   1. Fit and qualified assessment: Demonstrate compliance with Wis. Admin. Code § DHS 105.17(1e). This review evaluates factors including financial solvency (including bankruptcy), personnel qualifications, and criminal background clearance. It also includes history of operating other health-related agencies in Wisconsin or other states, and payment of required fees.
   2. Policies and procedures registered nurse surveyor review: A registered nurse completes the second part. They review the applicant's policies and procedures to decide if they meet Wis. Admin. Code § DHS 105.17 requirements. The registered nurse consults with the applicant during this review if needed.
2. Contact the applicant as necessary to clarify application documents.
3. Notify applicant in writing of approval or denial of application.

The application may be submitted to:

DQA initial approval survey and recommendation to Medicaid process

After an application is approved, the agency must undergo an initial survey conducted by DQA to the regulations within Wis. Admin. Code § DHS 105.17 and Wis. Admin. Code § DHS 107.112. The timeline for an applicant to complete the DQA survey to be approved as a PCA in order for recommendation to be sent to Wisconsin Medicaid is as follows:

1. Following receipt of a complete initial application or for a change in ownership (CHOW), DQA reviews the application and within 90 days either approves or denies the application. Approval is effective for a 1-year period from the date the department determines a complete application was submitted. Note: A CHOW is considered an initial application and requires a new contract with Medicaid after the successful approval survey by DQA.
2. The applicant shall submit a written request to DQA for an on-site survey within 9 months of effective approval date.
3. The applicant needs to have served at least 5 clients requiring personal care services during the period of the approval effective date. At the time of the on-site survey, the applicant or its personnel shall demonstrate provision of personal care services to at least 2 clients.
4. If an applicant does not submit a written request for an on-site survey within 9 months of the effective date of the application approval, the application will no longer be valid.
5. Within 90 days following completion of an on-site survey, the department shall either recommend certification or not recommend certification of the applicant to the department's Division of Medicaid Services (DMS).

Questions regarding the PCA application process may be directed to Lisa Imhof, email lisa.imhof@dhs.wisconsin.gov or call 608-266-2702.

Survey preparedness

Our Compliance Review Tools can help your agency conduct a self-evaluation of compliance. These forms are used by surveyors during on-site state certification surveys.

Refer to Medicaid Contacts for other contact information.

Medicaid certification process with ForwardHealth

In order to receive Medicaid reimbursement, a PCA provider must have a successful initial onsite survey in which DQA will then make a recommendation for certification to Wisconsin Medicaid. The Medicaid certification process is separate and distinct from the PCA application process. After certification is recommended, the PCA must apply for Medicaid certification through the ForwardHealth portal.

ForwardHealth, within the Division of Health Care Access and Accountability (DHCAA), will approve or deny the application. If approved, they will issue a Medicaid certification and certification number.

You may not apply for a Medicaid contract until DQA recommends approval to the Division of Medicaid Services (DMS) and Office of the Inspector General (OIG) after a successful initial survey.

You must contact DQA if your existing PCA is undergoing a:

• Name change.
• Address/location change. Your agency is required to notify the Department in writing within 10 days.
• Administrator or substitute administrator change. Your agency is required to notify the Department in writing within 10 days.
• Contact information. Your agency is required to notify the Department in writing within 10 days.
• Change of ownership (CHOW). The Medicaid contract of the previous owners terminates upon a CHOW and the agency must undergo the application and initial survey approval process for the new owners.

Email any change requests to Lisa Imhof, email lisa.imhof@dhs.wisconsin.gov.