PCA Program: Personal Care Management Agency Operating Procedures

(A) Assessment. For each member determined initially eligible for PCA services in accordance with 130 CMR 422.421(A)(2), the PCM agency must conduct a written assessment of the member’s capacity to manage PCA services independently and, if applicable, a written assessment of the ability of the surrogate or administrator proxy to manage PCA services on the member’s behalf. If a member has a court-appointed legal guardian or is a minor child, a surrogate is required and the agency is not required to conduct an assessment of the member, but is required to conduct an assessment of the surrogate. The PCM agency must document the assessments in the application for PCA services and in the member’s record. The assessments must be in a form and format required by the MassHealth agency. The process for assessment of the member must include the member and may include participation of family members or other member representatives. The PCM agency must (1) based on an in-person visit with the member, conduct a written assessment of the member’s ability to manage PCA services and to function as an employer of PCAs. The assessment must be conducted before submitting an initial request for prior authorization for PCA services to the MassHealth agency, at least annually thereafter, and whenever necessary due to a change in circumstances that may affect a member’s ability to manage PCA services independently or function as an employer of PCAs. The result of an assessment of the member is that the member either (a) is able to perform independently all tasks required to manage the PCA program (the PCM agency will conduct a PCA evaluation and submit the request for prior authorization to the MassHealth agency); or (b) requires the assistance of a surrogate or administrative proxy to perform some or all of the PCA management tasks that the member is unable or unwilling to perform. (A surrogate or administrative proxy must be identified before the PCM agency submits a prior authorization request to the MassHealth agency); (2) if the member requires the assistance of a surrogate or administrative proxy, based on an in-person visit with the surrogate or administrative proxy, conduct a written assessment of the ability of the surrogate or administrative proxy to manage PCA services on behalf of the member. The assessment must be conducted before submitting an initial request for prior authorization for PCA services to the MassHealth agency and whenever necessary due to a change in circumstances that may affect the ability of the surrogate or administrative proxy to manage PCA services on the member’s behalf. The result of an assessment of a surrogate or administrative proxy is that the surrogate or administrative proxy is either (a) able to perform the tasks designated to the surrogate or administrative proxy to manage the PCA program on behalf of the member; or (b) unable to perform the tasks designated to the surrogate or administrative proxy to manage the PCA program on behalf of the member; (3) complete an assessment of the member at the time of the member’s reevaluation, which must occur at least annually and whenever necessary due to a change in circumstances that may affect a member’s ability to manage PCA services independently or function as an employer of PCAs; (4) complete an assessment of any new surrogate or administrative proxy; (5) review the assessment of the member and modify it, as appropriate, when (a) the member’s medical, cognitive, or emotional condition changes in a way that affects the member’s ability to manage PCA services independently; (b) the member exhibits a pattern of overutilization of authorized PCA services, an inappropriate use of PCA services, or potential fraud, and does not discontinue such behavior after intervention from a skills trainer; or (c) the member, the fiscal intermediary, or the MassHealth agency requests review of an assessment; (6) review the assessment of the surrogate or administrative proxy and modify it, as appropriate, when (a) there is a change in circumstances that may affect the ability of the surrogate or administrative proxy to manage PCA services on behalf of the member; or (b) the member, the surrogate or administrative proxy, the fiscal intermediary, or the MassHealth agency requests review of an assessment; (7) review the assessment of the member with the member and obtain the signature of the member. If the member does not agree with the assessment, provide a process for resolving the disagreement; and (8) notify the MassHealth agency and the fiscal intermediary in writing of any change in the member’s assessment findings. (B) Surrogates and Administrative Proxies. (1) If the PCM agency’s assessment described in 130 CMR 422.422(A) determines that the member requires the assistance of a surrogate or administrative proxy, the member must appoint a surrogate or administrative proxy who meets the criteria described in 130 CMR 422.402, who is not the member’s PCA or an employee or contractor of the member’s PCM agency or fiscal intermediary, and who can help the member manage the PCA program in accordance with MassHealth regulations and the member’s service agreement. The PCM agency must assist the member or legal guardian in locating a surrogate or administrative proxy. The PCM agency will document the name, address, telephone number, email address, and relationship to the member on the MassHealth evaluation and submit it to the MassHealth agency, along with the prior authorization request for PCA services. (2) If the member does not locate or appoint a surrogate or administrative proxy, the PCM agency must refer the member to an appropriate service provider, and must not submit a PA request for PCA services to the MassHealth agency. (3) If a member’s surrogate or administrative proxy becomes unavailable at any time during the prior authorization period, or the MassHealth agency requires the member to replace the surrogate or administrative proxy pursuant to 130 CMR 422.420(B)(3), the PCM agency must immediately notify the member of the need to locate another surrogate or administrative proxy within 30 days. (a) If another surrogate or administrative proxy cannot be identified within 30 days, the PCM agency must notify the MassHealth agency in writing and refer the member to an appropriate service provider. (b) The MassHealth agency may terminate a member’s PCA services in accordance with 130 CMR 422.420(B) when a surrogate or administrative proxy cannot be identified. (4) If a member’s capacity to independently manage PCA services changes during the prior authorization period, the PCM agency will conduct an assessment in accordance with 130 CMR 422.422(A). (a) If the assessment determines that the member requires a surrogate or administrative proxy, the member will appoint a surrogate or administrative proxy and the PCM agency will notify the MassHealth agency and the fiscal intermediary in writing of the name, address, phone number, email address, and relationship to the member. (b) If the PCM agency’s assessment determines that the member needs a surrogate or administrative proxy but one cannot be identified within 30 days of the assessment, the PCM agency must notify the MassHealth agency and the member in writing, including a copy of the assessment, and refer the member to an appropriate service provider. (c) If a surrogate or administrative proxy cannot be identified, the MassHealth agency may terminate the member’s PCA services in accordance with 130 CMR 422.420(B). (5) The PCM agency must provide the MassHealth agency and the fiscal intermediary with the name, address, email address, and phone number of the member’s surrogate or administrative proxy, and report any changes in surrogate information. (C) Evaluation to Initiate PCA Services. (1) An evaluation team consisting of a registered nurse, or licensed practical nurse under the supervision of a registered nurse, and an occupational therapist must conduct an initial evaluation, only for members who meet the criteria described in 130 CMR 422.403(A), (B), and (C)(1) through (3). The evaluation must accurately represent the member’s need for physical assistance with ADLs and IADLs. The evaluation team must consider the member’s physical and cognitive condition and resulting functional limitations to determine the member’s ability to benefit from PCA services, and parental responsibility for a child younger than 18 years of age as indicated by the child’s developmental milestones, as detailed in the operating standards. (2) The evaluation must take place in the member’s presence and in the member’s actual or proposed place of residence in the community, or in the following locations, if these situations apply: (a) at the transitional living program site where the member lives if the member has completed functional skills training, but is unable to find housing; or (b) at a hospital or institution if the member has been hospitalized or institutionalized for an extended period, unless the MassHealth agency exercises its option of conducting the initial evaluation in accordance with 130 CMR 422.416(D). (3) All evaluations must be completed on the MassHealth evaluation form by the registered nurse, or a licensed practical nurse under the supervision of a registered nurse, or the occupational therapist who conducted the evaluation. (a) The completed evaluation must be reviewed, approved, and signed by the member, the member’s legal guardian and the member’s surrogate or administrative proxy, if appropriate. (b) The completed evaluation must be sent to the MassHealth agency, with the documentation described in 130 CMR 422.416(A). (4) The MassHealth agency may defer or deny requests for prior authorization for PCA services when (a) the applicant does not meet the eligibility criteria defined in 130 CMR 422.403; (b) the standard MassHealth personal care application and evaluation forms are not submitted or are incomplete; (c) the evaluation provides insufficient information to determine if PCA services are medically necessary; (d) the member or the surrogate or administrative proxy has not signed the evaluation; (e) the surrogate or administrative proxy information is not provided in the format requested by the MassHealth agency, or the PCM agency has determined that a surrogate or administrative proxy is required but one is not identified in the evaluation; or (f) the services being requested in the evaluation are not covered under the MassHealth PCA program. (See 130 CMR 422.410 through 422.412.) (D) Reevaluation. Reevaluations must be conducted by a registered nurse or a licensed practical nurse or an occupational therapist under the supervision of a registered nurse, and must include a review of the service agreement and the assessment by qualified PCM agency staff. Requirements cited in 130 CMR 422.422(C)(2) through (4) also apply to reevaluations. (1) Except as described in 130 CMR 422.422(D)(2), reevaluations must be conducted annually, or more frequently when a significant change in the member’s physical condition or living situation has occurred. The reevaluation must accurately represent the member’s need for physical assistance with ADLs and IADLs, and must consider the member’s physical and cognitive condition and resulting functional limitations to determine ability to benefit from PCA services, and parental responsibility for a child younger than 18 years of age as indicated by the child’s developmental milestones, as detailed in the operating standards. (2) The MassHealth agency may, at its discretion, grant prior authorization beyond the usual one year period for services requested in a reevaluation in cases where the member (a) is 22 years of age or older; (b) had no significant change in medical condition, functional status, or living situation within the previous year that may increase or decrease the member’s need for PCA services, and no significant change is anticipated; and (c) is not requesting an increase in the number of PCA hours provided per week. (E) Authorization. The MassHealth agency, at its sole discretion, may elect to conduct the PCA evaluation for purposes of authorizing PCA services in accordance with 130 CMR 422.416(D).