Definitions

As used in 101 CMR 309.00, unless the context requires otherwise, terms have the meanings in 101 CMR 309.02. Activities of Daily Living (ADLs). Those specific activities described in 130 CMR 422.410(A): Activities of Daily Living (ADLs). Such activities are performed by a PCA to physically assist a member with mobility, taking medications, bathing or grooming, dressing, passive range of motion exercises, eating, and toileting. Activity Form. The timesheet designated by the MassHealth agency to be used by the member for recording all PCA activity time for each pay period. The member or the member’s surrogate submits completed activity forms to the fiscal intermediary. Activity Time. The actual amount of time spent by a PCA physically assisting the member with ADLs and instrumental activities of daily living (IADLs). Activity time is reported on the activity form. Consumer. A MassHealth member who is receiving PCA services. The consumer is the employer of the PCA. Employer Expense Component. The portion of the PCA rate designated as reimbursement to members for their mandated employer’s share of Social Security, federal and state taxes, unemployment insurance taxes, Medicare, and worker’s compensation premiums. EOHHS. The Executive Office of Health and Human Services established under M.G.L. c. 6A. Evaluation. An initial determination by the PCM agency of the scope and type of PCA services to be provided to a member who meets the qualifications of 130 CMR 422.403: Eligible Members. The evaluation is conducted by a registered nurse or licensed practical nurse and an occupational therapist in accordance with 130 CMR 422.422(C): Evaluation to Initiate PCA Services or 130 CMR 422.438(B): Evaluation. Fiscal Intermediary. An entity contracting with MassHealth to perform employer-required tasks and related administrative tasks including, but not limited to, tasks described in 130 CMR 422.419(B): The Fiscal Intermediary. Functional Skills Training. Training provided by a PCM agency in accordance with 130 CMR 422.421(B): Functional Skills Training to assist members who have obtained prior authorization (PA) for PCA services and their surrogates or administrative proxies, if necessary, in developing the skills and resources to maximize the member’s management of the PCA program including, but not limited to, personal health care, PCA services, activities of daily living, and activities related to the fiscal intermediary. Governmental Unit. The Commonwealth of Massachusetts and any department, division, agency, board, commission, or political subdivision of the Commonwealth. Individual Consideration. The method to determine payment for services for service codes for which no rate has been established. The governmental unit or purchaser analyzes the eligible provider’s report of services rendered and charges submitted under the appropriate unlisted services or procedures category. The purchaser determines an appropriate payment for individual consideration procedures in accordance with the following standards and criteria: (a) time required to perform the procedure; (b) degree of skill required in care rendered; (c) severity or complexity of the patient’s disease, disorder, or disability; (d) policies, procedures, and practices of other third-party purchasers of care, governmental and private; and (e) applicable relative value studies. Instrumental Activities of Daily Living (IADLs). Those specific activities described in 130 CMR 422.410(B): Instrumental Activities of Daily Living (IADLs) that are instrumental to the care of the member’s health and are performed by a PCA, such as meal preparation and cleanup, laundry, shopping, housekeeping, maintenance of medical equipment, transportation to medical providers, and completion of paperwork required for the member to receive PCA services. Intake and Orientation. Functions performed by a PCM agency for a member who is seeking PCA services, but for whom the MassHealth agency has not yet granted PA for PCA services. These functions include, but are not limited to, instruction and orientation in the rules, policies, and procedures of the PCA program; instruction in the member’s rights and responsibilities when using PCA services; instruction in the role of the PCM agency and the fiscal intermediary, including the use of activity forms; and instruction in the skills and tasks necessary to manage PCA services. MassHealth. The medical assistance program administered by the Executive Office of Health and Human Services pursuant to M.G.L. c. 118E and in accordance with Titles XIX and XXI of the federal Social Security Act and a § 1115 Demonstration Waiver. MassHealth Program Regulations. Regulations governing the PCA program are contained in 130 CMR 422.000: Personal Care Attendant Services and 130 CMR 450.000: Administrative and Billing Regulations. PCA Services. Physical assistance with ADLs and IADLs provided to a member by a PCA in accordance with the member’s authorized evaluation or reevaluation, service agreement, and 130 CMR 422.410: Activities of Daily Living and Instrumental Activities of Daily Living. PCA Wage Component. The portion of the PCA rate that is designated as the PCA’s gross hourly wage. Personal Care Attendant (PCA). A person who meets the requirements of 130 CMR 422.404(A)(1): Personal Care Attendants and who is hired by the member or surrogate to provide PCA services. In addition, for the sole purpose of M.G.L. c. 118E, §§ 70 through 75, a PCA is a person who is hired by the member or surrogate to provide PCA services through a senior care organization (SCO) contracting with the MassHealth agency pursuant to M.G.L. c. 118E, § 9D, or a person who is hired by the member or surrogate to provide PCA services through an integrated care organization (ICO) contracting with the MassHealth agency pursuant to M.G.L. c. 118E, § 9F. Unless explicitly stated in 130 CMR 422.000: Personal Care Attendant Services, in the SCO’s MassHealth contract, or in the ICO’s MassHealth contract, no other provisions of 130 CMR 422.000 apply to any SCO, ICO, or PCA hired by any eligible MassHealth member through a SCO or ICO. Personal Care Management (PCM) Agency. A public or private agency or entity under contract with MassHealth to provide PCM functions to eligible members in accordance with 130 CMR 422.000: Personal Care Attendant Services and the PCM functions contract. Personal Care Management (PCM) Functions. Administrative functions provided by a PCM agency to a member in accordance with a contract with EOHHS including, but not limited to, those services identified in the PCM contract and 130 CMR 422.419(A): The PCM Agency. Prior Authorization (PA). An approval, modification, deferral, or denial for PCA services to the consumer by the MassHealth agency in accordance with 130 CMR 422.416: PCA Program: Prior Authorization for PCA Services and 130 CMR 422.418: PCA Program: Special Payments. Publicly Aided Individual. A person who receives health care and services for which a governmental unit is in whole or in part liable under a statutory program of public assistance. This includes a consumer. Reevaluation. A determination of the scope and type of PCA services to be provided to a member who has requested a continuation of PCA services because the current authorization is expiring. The reevaluation is conducted in accordance with 130 CMR 422.422(D): Reevaluation. Service Agreement. A written plan of services, consistent with the requirements of 130 CMR 422.423: PCA Program: Service Agreement and the PCM functions contract, that is developed jointly by the PCM agency; the member; and the member’s surrogate, if any. The service agreement describes the responsibilities of the PCA, the member, the surrogate, the fiscal intermediary, and the PCM agency. If the member does not require a surrogate, the service agreement must state that the member is solely responsible for the management tasks, including hiring, firing, scheduling, training, supervising, and otherwise directing the PCA. The service agreement must also describe the type and frequency of functional skills training that the member and the surrogate, if appropriate, require from the PCM agency to manage the PCA program successfully. Uniform Financial Statement and Independent Auditor’s Report (UFR). An annual fiscal filing requirement of revenue and expense activity for programs funded fully or in part by contracts with the Commonwealth. The Operational Services Division issues instructions for UFR preparation and compliance under 808 CMR 1.00: Compliance, Reporting and Auditing for Human and Social Services.