PCA Program: Scope of PCA Services and Personal Care Management and Fiscal

Intermediary Functions (A) The PCM Agency. The PCM agency must provide personal care management functions in accordance with 130 CMR 422.000 and its contract with EOHHS, including, but not limited to (1) maintaining a communication system that is accessible to members on a 24-hour basis; (2) responding to member inquiries about the MassHealth agency’s prior authorization decisions within the timeframes specified in the contract and in 130 CMR 422.000; (3) maintaining records in accordance with 130 CMR 422.446 and the PCM agency contract; (4) conducting a formal, written assessment of the member’s ability to manage the PCA program independently and, if applicable, conducting a formal, written assessment of the ability of the surrogate or administrative proxy to manage the PCA program on behalf of the member in accordance with 130 CMR 422.422(A) and the PCM agency contract, and in the form and format required by the MassHealth agency; (5) performing evaluations and reevaluations of members who are eligible for PCA services in accordance with 130 CMR 422.422(C) and (D) and the PCM agency contract; (6) submitting to the MassHealth agency all requests for prior authorization for PCA services in accordance with the procedures and timelines identified in the PCM agency contract, 130 CMR 422.416(A) through (C), and 422.418; (7) developing in conjunction with the member and the member’s surrogate, if any, a formal, written service agreement for the member in accordance with 130 CMR 422.423 and the PCM agency contract, and in the form and format required by the MassHealth agency; (8) providing intake and orientation to determine a member’s initial eligibility for PCA services, and to instruct the member in the rules, policies, and regulations of the PCA program and the skills and functions necessary to manage the PCA program in accordance with 130 CMR 422.421(A) and the PCM agency contract; (9) providing functional skills training to instruct the member and the surrogate or administrative proxy, if applicable, as necessary, in the basic requisites of appropriate management of the PCA program in accordance with 130 CMR 422.421(B) and the PCM agency contract; (10) maintaining policies and procedures for the receipt and timely resolution of member complaints in accordance with the PCM agency contract; (11) providing written information to members in a language and format that is understandable to them; (12) providing PCM functions that are culturally sensitive; (13) seeking out and including member input and feedback into the PCM functions provided by the PCM agency; (14) educating members and surrogates and administrative proxies about the tools available to promote PCA services that are safe, such as the availability of Criminal Offender Record Information (CORI), Disabled Persons Protection Commission (DPPC), the sex offender registry, and reporting abuse of those 60 and older to Adult Protective Services; (15) working with the member to establish and maintain a current list of available PCAs who can be contacted when an unforeseen event occurs that prevents the member’s regularly scheduled PCA from providing services; (16) developing creative methods to assist members in the recruitment of PCAs; (17) establishing a cooperative working relationship with the fiscal intermediary by (a) working with the fiscal intermediary for all members served by the PCM agency; (b) assisting new members in enrolling with the fiscal intermediary before hiring PCAs; (c) educating members about the role of the fiscal intermediary; (d) working with the fiscal intermediary to resolve member and PCA complaints; (e) sharing information with the fiscal intermediary, as needed, about the status of a member’s prior authorization decision, including, but not limited to, the member’s name, address, and date of birth; (f) providing the fiscal intermediary with the name, address, and phone number of the member’s surrogate or administrative proxy, if any, and any changes in the surrogate or administrative proxy information; and (g) responding to the fiscal intermediary’s request for skills training for a member or surrogate who is having difficulty managing the PCA program, including, but not limited to, a member or surrogate who repeatedly submits activity forms in excess of the PCA hours per week authorized by the MassHealth agency pursuant to 130 CMR 422.416(E), the scheduling and provision of PCA services resulting in overtime hours in excess of those authorized by 130 CMR 422.418(A), or noncompliance with the use of EVV pursuant to 130 CMR 422.420(A)(3) and 422.420(A)(5)(c); (18) reporting suspicion of fraud to the MassHealth agency in the format specified by the MassHealth agency and cooperating with any subsequent investigation; (19) assisting the member and the MassHealth agency in coordinating for, or providing education about, the use of EVV as required by the MassHealth agency; and (20) notifying the MassHealth agency if, in the opinion of the PCM agency, the member’s surrogate or administrative proxy is not managing PCA tasks for the member in accordance with 130 CMR 422.000. (B) The Fiscal Intermediary. The fiscal intermediary must ensure that each member it serves has a current prior authorization for PCA services from the MassHealth agency. The fiscal intermediary must fulfill its responsibilities in accordance with its contract with EOHHS, including, but not limited to (1) obtaining the signed MassHealth consumer agreement from each member that describes the roles and responsibilities of both the member and the fiscal intermediary; (2) establishing a member services unit with staff trained to answer member telephone calls about activity forms, tax forms, and the functions of the fiscal intermediary. When member concerns cannot be resolved by telephone, the member can be referred to a PCM agency for functional skills instruction (see also 130 CMR 422.419(A)(17)(g) and 422.421(B)(2)). (3) operating a toll-free telephone service during business hours (from 9:00 A.M. to 5:00 P.M., Monday through Friday, holidays excluded); (4) operating a toll-free answering or voice messaging service during nonbusiness hours; (5) in conjunction with the PCM agency, establishing systems to resolve member and PCA complaints in a timely fashion; (6) sharing information about a member’s prior authorization with the PCM agency, including notifying the PCM agency when a member is repeatedly submitting activity forms in excess of the PCA hours per week authorized by the MassHealth agency; (7) establishing cooperative working relationships with PCM agencies; (8) developing, using, distributing, and collecting standardized PCA activity forms and schedules to document the use of PCA services and to meet the requirements for reimbursement, including through the development, implementation, and operation of EVV; (9) reviewing PCA activity forms to ensure accuracy; (10) processing all claims for PCA services; (11) developing and distributing to members an employment package that includes a user- friendly personnel form, all required employer and employee federal and state tax forms, other employment-related forms, and instructions in their use; (12) issuing direct deposit payments, or other payments as appropriate, to PCAs equal to the PCA wage component of the PCA rate, with appropriate taxes withheld and other applicable required withholdings; and (13) reporting suspicion of fraud to the MassHealth agency in the format requested by the MassHealth agency and cooperating with any subsequent investigation. (C) The PCA. The PCA must provide PCA services pursuant to 130 CMR 422.000 and in accordance with the following: (1) provide assistance with ADLs and IADLs as described in 130 CMR 422.410 and the service agreement established pursuant to 130 CMR 422.423; (2) not provide any noncovered services as described in 130 CMR 422.412 as part of the PCA program; (3) adhere to the following weekly hour limit when working for one or more members: PCAs are limited to working no more than 50 hours per week for one or more members unless the additional hours worked are overtime hours authorized pursuant to 130 CMR 422.418(A); (4) in accordance with 130 CMR 450.238: Sanctions: General, the MassHealth agency may impose sanctions including, but not limited to, termination or suspension of the PCA’s participation in MassHealth, for a PCA’s failure to comply with MassHealth regulations including, but not limited to, repeated failure to work within the weekly hour limit or authorized overtime hours in accordance with 130 CMR 422.419(C)(3), and failure to use EVV in accordance with 130 CMR 422.419(C)(5), including falsely filing EVV exemptions; (5) use EVV, and attend related trainings, as required by the MassHealth agency; (6) provide PCA services at a maximum of 60 hours per week; and (7) supply any information required by the MassHealth agency or the fiscal intermediary pertaining to the administration of PCA services, such as contact information including, but not limited to, email.