PCA Program: Special Payments

(A) Overtime Requiring Authorization. (1) Weekly Hour Limit. Subject to the conditions for authorization set forth in 130 CMR 422.418(A)(2), all members are limited to scheduling an individual PCA to work no more than 50 hours per week, inclusive of time during which such individual PCA works providing PCA services for other members. (2) Authorization to Schedule an Individual PCA to Work in Excess of the Weekly Hour Limit. Before scheduling a PCA to work in excess of the weekly hour limit, a member must obtain authorization from the MassHealth agency, or its designee. The MassHealth agency, or its designee, will provide such authorization only if one or more of the following conditions apply and the member has satisfied the conditions for authorization at 130 CMR 422.418(A)(4). (a) The member has a temporary need to schedule an individual PCA to work in excess of the weekly hour limit, but not more than 60 hours per week; (b) The member has a long-term need to require an individual PCA to work in excess of the weekly hour limit but not more than 60 hours per week to provide continuity of care; or (c) The member has an emergency need that requires an individual PCA to work in excess of the weekly hour limit due to an unforeseen event that prevented the member’s regularly scheduled PCA from providing PCA services to the member in a particular work week, resulting in an emergency need for another PCA to immediately provide PCA services in excess of the weekly hour limit for that week, but not more than 60 hours per week. (3) Member Responsibility. (a) A member must submit a request for authorization to schedule a PCA to work in excess of the weekly hour limit in the following manner. 1. For requests for authorization pursuant to 130 CMR 422.418(A)(2)(a) or (b), prior to scheduling an individual PCA to work in excess of the weekly hour limit, the member must submit a request to the PCM agency in the form and format specified by the MassHealth agency, and in accordance with 130 CMR 422.420(A)(13). 2. For requests for authorization pursuant to 130 CMR 422.418(A)(2)(c), the member must immediately notify the PCM agency of the request in accordance with 130 CMR 422.420(A)(13) and if such emergency arises during nonbusiness hours, the member must notify the PCM agency’s 24-hour messaging service. (b) When submitting a request pursuant to 130 CMR 422.418(A)(3), the member must provide the PCM agency with, at a minimum, information sufficient to demonstrate the satisfaction of each of the conditions in 130 CMR 422.418(A)(4)(a). (4) Conditions for Authorization. (a) The MassHealth agency, or its designee, authorizes a member to schedule an individual PCA to work in excess of the weekly hour limit only when all of the following conditions are met. 1. The member has demonstrated, to the satisfaction of the MassHealth agency, that the member’s request to schedule an individual PCA to work in excess of the weekly hour limit meets one or more of the conditions set forth in 130 CMR 422.418(A)(2); 2. The member has demonstrated, to the satisfaction of the MassHealth agency, that the member has attempted to contact, at a minimum, all persons who are either employed by the member or listed as available in accordance with 130 CMR 422.419(A)(15) and 422.420(A)(16); and 3. The request meets the requirements of 130 CMR 422.418(A)(3). (b) The MassHealth agency may, at its discretion, request additional information to evaluate a member’s request to schedule an individual PCA to work in excess of the weekly hour limit including, but not limited to 1. the member’s PCA schedule for a specific work week that includes the names of all PCAs employed by the member; 2. for requests for authorization pursuant to 130 CMR 422.418(A)(2)(c), the name of the regularly scheduled PCA that was unable to provide PCA services; 3. documentation that demonstrates, to the satisfaction of the MassHealth agency, that the member has attempted to hire additional PCAs; and 4. the list of PCAs contacted in accordance with 130 CMR 422.418(A)(4)(a)2. (5) Notification to the Member, PCM Agency, and Fiscal Intermediary. (a) Notice of Approval. If the MassHealth agency approves a request to schedule an individual PCA to work in excess of the weekly hour limit, it sends written notice to the member, the PCM agency, and the fiscal intermediary. (b) Notice of Denial or Modification. If the MassHealth agency denies or modifies a request to schedule an individual PCA to work in excess of the weekly hour limit, the MassHealth agency notifies the member, the PCM agency, and the fiscal intermediary. The notice states the reason for the denial or modification and informs the member of the right to appeal and of the appeal procedure. (c) Request for Fair Hearing. If the MassHealth agency denies or modifies a request to schedule an individual PCA to work in excess of the weekly hour limit, a member may appeal the denial or modification by requesting a fair hearing. The request for a fair hearing must be made in writing to the MassHealth Board of Hearings in accordance with the timelines in 130 CMR 610.015(B): Time Limitation on the Right of Appeal. Requests for continuation of services during an appeal must be made in accordance with 130 CMR 610.036: Continuation of Benefits Pending Appeal. The MassHealth Board of Hearings conducts fair hearings in accordance with 130 CMR 610.000: MassHealth: Fair Hearing Rules. (6) Expiration of Authorizations to Schedule an Individual PCA to Work in Excess of the Weekly Hour Limit. (a) The MassHealth agency’s authorization for a member to schedule an individual PCA to work in excess of the weekly hour limit will expire in accordance with the following. 1. For temporary authorizations pursuant to 130 CMR 422.418(A)(2)(a), the authorization will expire no longer than 12 weeks after the date of authorization; 2. For long-term authorizations pursuant to 130 CMR 422.418(A)(2)(b), the authorization will align with the clinical prior authorization dates established in accordance with 130 CMR 422.416; and 3. For emergency authorizations pursuant to 130 CMR 422.418(A)(2)(c), the authorization will be limited to the particular work week specified in the request. (b) Members who continue to require an individual PCA to work in excess of the weekly hour limit may submit new requests for authorization to schedule a PCA to work in excess of the weekly hour limit. (B) Juror Service Performed by a Personal Care Attendant. MassHealth provides reimbursement to members for PCAs who are required to perform juror service during regularly scheduled work hours for a maximum of three days when the following conditions are met. (1) Member Responsibility. Within 14 days of the PCM agency’s receipt of documentation from the state or federal court that the personal care attendant has performed juror service, the member must provide the PCM agency with (a) the number of hours that the PCA was regularly scheduled to work during the time juror service was required; and (b) documentation from the appropriate state or federal court that the PCA has performed juror service. This documentation must consist of either 1. for state jury service, a copy of the Certificate of Juror Service issued by the Massachusetts Office of the Jury Commissioner, verifying the date(s) that the PCA has been called for juror service; or 2. for federal jury service, a copy of the Attendance Sheet issued by the Federal District Court, verifying the date or dates that the PCA has been called for juror service. (2) PCM Agency Responsibility. Within three days of receipt of the required documentation from the member in accordance with 130 CMR 422.418(B)(1), the PCM agency must forward to the MassHealth agency (a) a written request for an increase in the number of hours of PCA services based on the number of hours of juror service performed by the PCA during regularly scheduled work hours, but no greater than three working days; and (b) documentation provided by the member as specified in 130 CMR 422.418(B)(1). (3) Conditions for Payment. MassHealth will provide reimbursement to members for regular rates paid to PCAs who performed juror service up to the first three days of juror service if the following conditions are met. (a) The time that the PCA is required to perform juror service must occur during the same time that the PCA was regularly scheduled to work for the member; (b) The number of hours requested for reimbursement by the member for juror service performed by a PCA must not be greater than the number of hours the PCA was regularly scheduled to work for the member; and (c) All the requirements in 130 CMR 422.418(B) must be met. (C) Complex Care Differential Payment. MassHealth will pay a differential to individuals who provide PCA services to a member with a complex care authorization in accordance with 130 CMR 422.414. (1) Conditions for Authorization. The MassHealth agency, or its designee, determines a member has a complex care authorization only when the conditions provided at 130 CMR 422.414 are met. (2) Conditions for Payment. The complex care differential payment is paid in addition to the applicable PCA rate for that PCA when all the following conditions are met. (a) The MassHealth member has a complex care authorization pursuant to 130 CMR 422.414; (b) The PCA has completed new hire orientation (NHO), or is exempt from the NHO requirement, in accordance with the collective bargaining agreement; and (c) The PCA provides MassHealth-covered PCA services to a member with a complex care authorization pursuant to 130 CMR 422.414. (3) Applicability of Complex Care Differential Payments. The complex care differential payment is applicable only to activity time providing MassHealth-covered PCA services to a member with a complex care authorization. The complex care differential payment is not applicable to activity time for members without a complex care authorization or other time or payments that are not activity time, such as payment for juror service in accordance with 130 CMR 422.413(C), payment for paid earned time in accordance with 130 CMR 422.413(E), NHO payments in accordance with 130 CMR 422.413(F), and travel time in accordance with 130 CMR 422.413(G).