Minnesota HomeCare Association

2011PCA/PCPO APPLICATION

The information on this form is used to update our member database system and verify data to be listed on our membership directory for the term of one year from the enrollment date. Complete this form
and return to MHCA. If there are any questions you may contact us at (651) 635-0607.

Agency Name: / Phone:
Fax:
Mailing Address: / Toll-Free:
Website:
City/State/Zip: / Agency E-Mail Address:
UPS shipping address: (if different from mailing address) / County:
MHCA Region:

2011 Provider ApplicationPage 1 of 4Revised on 10/30/2018

DUES COMPUTATION

2011 Provider ApplicationPage 1 of 4Revised on 10/30/2018

Dues are a flat fee of $250. This membership entitles your organization to Web-based training only.

MHCA FLAT RATE DUES=$ 250.00
New enrollment fee/late fee=$50.00
TOTAL=$
If you select bi-annual or quarterly payment option, we will send you reminder invoice statements.
Payment Option: / Payment Method
Full Payment
Bi-Annual
Quarterly / Check
Credit Card
Bill Me
Credit Card #:
Exp. Date: / CVV2:
Name on Card:
Card Holder Signature:
I hereby certify that the revenue reported is correct.
Signature:
Name:
Date:

2011 Provider ApplicationPage 1 of 4Revised on 10/30/2018

Agency Name:
PROVIDER INFORMATION
Counties your agency serves within MN (REQUIRED):
Provider Type: (Check all that apply) / Structure: / Certification/Accreditation:
Personal Care Provider Organization / Private Non-Profit
Proprietary (for profit)
Other ______/ Personal Care Provider Org. (DHS registered)
Also licensed in (specify state): ______
Payment Methods Accepted: / License Class:
HMO/Managed Care PCA
Medical Assistance (MA PCA) / Non-Licensed Personal Care & Service Provider
Agency Name:
Languages Spoken
Arabic
Chinese
English
French
German
Hmong
Oromo
Russian
Somali
Spanish
Other (Specify): ______

The data below will be used only for MHCA’s reference:

# of employees (full-time): / State House District (if known):
# of employees (part-time): / State Senate District (if known):
# of clients/average daily census(for past fiscal year): / US Congressional District (if known):
Is agency exempt from sales tax? Yes No
Are you a member of the National Association for Home Care (NAHC)? Yes No
Are you a member of Aging Services of Minnesota? Yes No

PRIMARY ADMINISTRATIVE CONTACTS

It is recommended that you assign an individual to be the agency’s Primary Contact Person. This individual person receives all Association mailings, emails, and dues renewal information on behalf of the agency.

MAIN CONTACT PERSON/VOTING REPRESENTATIVE INFORMATION

Name:
Alternate address if different from agency’s address
Direct Phone: / Direct Fax #:
Alternate Phone: / E-mail Address:

ADDITIONAL PERSONNEL INFORMATION (Optional)

You may add any additional personnel whom you would like to receive email communications from us.

Employee #1
Name: / Alternate Phone:
Direct phone: / E-mail Address:
Employee #2
Name: / Alternate Phone:
Direct phone: / E-mail Address:

Minnesota HomeCare Association

Policy Statement - Membership Dues

A. Membership type/Eligibility

  1. Provider1: Agencies who provide home health care services or direct care in a variety of living environment shall be eligible to become a Provider Member of MHCA. Organizations and/or individuals eligible for "Provider Member" status shall not be eligible to join MHCA as a "Business Partner".
  2. Business Partner2: Organizations and/or individuals affiliated with health-related organizations, and/or non-healthcare providers displaying interest in home health care services or products, or recognized as having contributed to the promotion of home care, shall be eligible to become Business Partners of MHCA.
  3. PCA3: Personal Care Provider Organizations are eligible to join at lower rate in order to receive web-based training only. Members who join as PCAs will have no other member benefits beyond web-based training supported through RCTC.
  4. Government Affiliate: Governmental agencies and entities.
  5. Student: Currently registered students interested in the purposes of MHCA shall be eligible to become "Student Members".

1 MHCA Bylaws refer to Providers as “Voting Members”

2 MHCA Bylaws refer to Business Partners as an “Affiliate”.

  1. DUES: MHCA Dues are assessed on a rolling basis.
  2. Provider: Dues are assessed based on the home care agency/program’s adjusted revenue that was received from the last complete fiscal year. Adjusted revenue includes all dollars, regardless of source, that was obtained by your organization for providing home care services; it is the gross revenue less all discounts or allowances (expected amount due from payer).

Minimum Due: If adjusted revenue is less than $268,500, then pay the flat rate of$639.

Maximum Due: If adjusted revenue exceeds $2 million, then pay the flat rate of $4,764.

Variable Due: If adjusted revenue is more than $268,500 but less than $2 million, multiply your adjusted revenue by .002382, then round it to the nearest dollar, this will be your dues rate.

  1. Business Partner: Membership due is a flat rate of $600.
  2. PCA: Membership due is a flat rate of$250.
  3. Government Affiliate: Membership due is a flat rate of $250.
  4. Student: Dues are a flat rate of $50.
  5. New member initiation fee: New members are assessed an additional $50 initiation fee.
  1. Special Considerations
  2. Organizations operating in state line border areas: Use revenue figures generated from Minnesota clientele only.
  3. For organizations with no revenues assigned to the operation of their program: Determine an equivalent measure by asking, "How many dollars did it require to run the home care department/program?"
  4. New Agencies with out a fiscal history: Pay the minimum dues rate for their first year.

NOTE: In order to facilitate timely payment of dues, agencies whose fiscal year ends in December may base their dues from their January - November revenues plus an estimate of December revenues.

In accordance with MHCA Bylaws, dues are not refundable.

MHCA reserves the right to periodically request and review your supporting financial numbers to ensure all members are accurately submitting their fair share of dues.

Further questions regarding membership dues may be directed to MHCA Executive Director, Neil Johnson.

Page 1 of 4