Definitions

The following terms used in 130 CMR 422.000 have the meanings given in 130 CMR 422.402 unless the context clearly requires a different meaning. Payment for services defined in 130 CMR 422.402 is not determined by these definitions, but by application of 130 CMR 422.000 and 130 CMR 450.000: Administrative and Billing Regulations. Activities of Daily Living (ADLs). Those specific activities described in 130 CMR 422.410(A) and in the Contract for Personal Care Management (PCM) Services. Such activities are performed by a personal care attendant (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, in a form and format designated by the MassHealth agency, including through the use of Electronic Visit Verification (EVV), to be used by the member, the member’s surrogate or administrative proxy, if any, and the PCA for recording all PCA activity time for each pay period. 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. Administrative Proxy. The member’s legal guardian, a family member, or any other person as identified in the service agreement who is responsible for performing certain administrative functions related to PCA management that the member is unable or unwilling to perform. Administrative Tasks. Tasks, such as claims processing, recordkeeping, and reporting, required by the Executive Office of Health and Human Services (EOHHS) fiscal intermediary contract and performed by the fiscal intermediary. Assessment. A PCM agency’s determination of a member’s ability to manage the PCA program independently and the ability of a surrogate or administrative proxy, if any, to manage the PCA program on behalf of the member. The PCM agency conducts an assessment of a member and surrogate or administrative proxy, if any, in accordance with 130 CMR 422.422(A) and the contract for PCM functions. The result of an assessment of the member is a determination that the member either requires a surrogate or administrative proxy to receive PCA services or can manage the PCA program independently. The result of an assessment of the surrogate or administrative proxy, if any, is a determination about whether the surrogate or administrative proxy can appropriately and effectively manage the PCA program on behalf of the member. Electronic Visit Verification (EVV). The method or system designated or approved by EOHHS to electronically verify service delivery in the form and format as required by the MassHealth agency. 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 workers’ compensation premiums. Employer-required Tasks. Tasks described in the EOHHS contract with the fiscal intermediary that relate to the member’s employment of PCAs, including, but not limited to (a) employer obligations, including filing the member’s federal and state taxes, withholding PCA taxes, paying unemployment insurance taxes, purchasing worker’s compensation insurance, and preparing the PCA payroll; (b) payroll responsibilities, including reviewing activity forms and verifying prior authorization status; and (c) fiscal functions, including generating and distributing checks. 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. The evaluation is conducted in accordance with 130 CMR 422.422(C) or 422.438(B). Family Member. The spouse of the member, the parent of a minor member, including an adoptive parent, or any legally responsible relative. Fiscal Intermediary. An entity contracting with EOHHS to perform employer-required tasks and related administrative tasks including, but not limited to, tasks described in 130 CMR 422.419(B). Functional Skills Training. Instruction provided by a PCM agency in accordance with 130 CMR 422.421(B), including in-person comprehensive functional skills training, in-person issue-focused functional skills training, and telephonic functional skills training, to assist members who have obtained prior authorization for PCA services and their surrogates and 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. Holiday. New Year’s Day; Martin Luther King Jr. Day; Juneteenth; Independence Day; Thanksgiving Day; and Christmas Day. Instrumental Activities of Daily Living (IADLs). Those specific activities described in 130 CMR 422.410(B) that are instrumental to the care of the member’s health and are performed by a PCA, such as meal preparation and clean-up, housekeeping, laundry, shopping, maintenance of medical equipment, transportation to medical providers, and completion of paperwork required for the member to receive PCA services. Intake and Orientation. Functions provided to or for a member who seeks PCA services, but for whom the MassHealth agency has not yet granted a prior authorization for PCA services. These functions include, but are not limited to, determination of initial eligibility for PCA services; 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 EVV; and instruction in the skills and tasks necessary to manage PCA services. Licensed Practical Nurse (LPN). A person currently licensed as a licensed practical nurse by the Massachusetts Board of Registration in Nursing and in good standing with the Board. Member. A person determined by the MassHealth agency to be eligible for MassHealth. Nurse Practitioner. A registered nurse who has successfully completed a formal education program for nurse practitioners as required by the Massachusetts Board of Registration in Nursing, and who is responsible for the oversight of the member’s health care. A nurse practitioner who prescribes medication must be certified by the Federal Drug Enforcement Administration (DEA). Occupational Therapist. A person currently licensed by and in good standing with the Massachusetts Board of Allied Health Professionals, and currently certified by and in good standing with the National Board for Certification in Occupational Therapy. Overtime Requiring Authorization. Activity time performed by a PCA in excess of the weekly hour limit specified in 130 CMR 422.418(A). Paid Earned Time. Paid time off from work used pursuant to a collective bargaining agreement effective in accordance with M.G.L. c. 118E, § 73, and M.G.L. c. 150E. Passive Range of Motion Exercises (Passive ROM). Movement applied to a joint or extremity by another person solely for the purpose of maintaining or improving the distance and direction through which a joint can move. Pay Period. Two consecutive work weeks. PCA Rate. The rate of payment for activity time performed by PCAs in accordance with EOHHS regulations at 101 CMR 309.00: Rates for Certain Services for the Personal Care Attendant Program. PCA Wage Component. The portion of the PCA rate designated as the PCA’s gross hourly wage. Primary Care Physician (PCP) Summary Form. A MassHealth-issued form detailing a member’s medical conditions and care needs signed by a member of the PCP team at the member’s doctor’s office. Personal Care Attendant (PCA). A person who meets the requirements of 130 CMR 422.404(A)(1) 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, the SCO’s MassHealth contract, or 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 Attendant Program (PCA Program). A MassHealth program under which PCA services and associated personal care management and fiscal intermediary functions are available to MassHealth members including, for the sole purpose of M.G.L. c. 118E, §§ 70 through 75, those services and functions when provided through a senior care organization (SCO) as defined in M.G.L. c. 118E, § 9D, or an integrated care organization (ICO) as defined in M.G.L. c. 118E § 9F. Unless explicitly stated in 130 CMR 422.000, the SCO’s MassHealth contract, or the ICO’s MassHealth contract, no other provisions of 130 CMR 422.000 apply to any SCO, ICO, or PCA hired by an eligible MassHealth member through a SCO or ICO. PCA Provider Number. A sequence of characters or numbers provided by the fiscal intermediary and assigned to each PCA that uniquely identifies each PCA, regardless of the number of members who employ the PCA or the number of fiscal intermediaries who perform employer- required tasks for the PCA. 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. Personal Care Management (PCM) Agency. A public or private agency or entity under contract with EOHHS to provide PCM functions in accordance with 130 CMR 422.000 and the PCM agency contract. PCM Functions. Administrative functions provided by a PCM agency to a member in accordance with a contract with EOHHS, including but not limited to, functions identified in the PCM agency contract and 130 CMR 422.419(A). Physician Assistant. A mid-level medical practitioner who works under the supervision of a licensed physician (MD) or osteopathic physician (DO) and who has graduated from an accredited physician assistant program and is certified by and in good standing with the Massachusetts Board of Registration of Physician Assistants. Prior Authorization (PA) Period. The dates authorized by the MassHealth agency designating the duration of services covered by the prior authorization. PA Request. A request to initiate, continue, or adjust a member’s prior authorization for PCA services or transitional living services that the PCM agency must submit to the MassHealth agency in accordance with 130 CMR 422.416, the PCM agency contract, or 130 CMR 422.431. The MassHealth agency may approve, deny, modify, or defer a PA request. Reevaluation. An assessment of a member’s continuing need for PCA services to be provided to a member who requests a continuance of PCA services because the current authorization is expiring. The reevaluation must be conducted in accordance with 130 CMR 422.422(D). Registered Nurse. A person currently licensed as a registered nurse by the Massachusetts Board of Registration in Nursing and in good standing with the Board. Service Agreement. A written plan of services, consistent with the requirements of 130 CMR 422.423 and the PCM agency contract, that is developed jointly by the PCM agency, the member, and the member’s surrogate or administrative proxy, if any. The service agreement describes the responsibilities of the PCA, the member, the surrogate or administrative proxy, the fiscal intermediary, and the PCM agency as they relate to the management of the member’s PCA program. If the member does not require a surrogate or administrative proxy, the service agreement must state that the member is solely responsible for the management tasks, including hiring, firing, scheduling, training, supervising, and otherwise directing PCAs. The service agreement must also describe the type and frequency of functional skills training that the member and the surrogate or administrative proxy, if appropriate, receives from the PCM agency to manage the PCA program successfully. Surrogate. The member’s legal guardian, family member, or other person older than 18 years of age as identified in the service agreement, who is responsible for performing certain PCA management tasks that the member is unable or unwilling to perform. Transitional Living Program. A program of services that may be offered by an organization in a structured group-living environment, for members with severe disabilities who demonstrate an aptitude for independent living, but who can clearly benefit from functional skills training and supervised experience in management of health care, PCA services, and community activity in gaining the ability and confidence necessary to achieve independent living. Weekly Hour Limit. The weekly hour limit established pursuant to 130 CMR 422.418(A)(1). Work Week. A seven-day period beginning Sunday at 12:00 A.M. and ending the consecutive Saturday at 11:59 P.M.