PCA Program: Service Agreement

(A) Before the initiation of PCA services, the PCM agency, in conjunction with the member and the member’s surrogate or administrative proxy, if any, must develop a written service agreement that is unique to the member and in a form and format required by the MassHealth agency. The service agreement must be established in person with the member. The service agreement must include, at a minimum (1) a detailed description of the responsibilities of the PCA, the fiscal intermediary, the member, the surrogate or administrative proxy, if any, and the PCM agency; (2) if a surrogate or administrative proxy is required, the identity of the surrogate or administrative proxy and a detailed description of the surrogate or administrative proxy’s responsibilities, including the PCA management tasks the surrogate or administrative proxy will perform or assist the member to perform, and the frequency of the surrogate or administrative proxy’s visits to the member. The surrogate’s responsibilities may include some or all of the responsibilities for PCA management that will be performed on the member’s behalf, whereas the responsibilities for the administrative proxy may include only certain administrative functions related to PCA management as specified by the MassHealth agency and specified in the member’s service agreement. The surrogate or administrative proxy must perform these tasks in the best interest of the member, and in accordance with 130 CMR 422.000. The service agreement will ensure the member’s maximum participation in the management of the PCA tasks; (3) if a surrogate or administrative proxy is not required, the service agreement must clearly state that the member has the sole responsibility of managing the PCA services; (4) the current and updated list of PCAs available when an unforeseen event occurs that prevents the member’s regularly scheduled PCA from providing services, developed in accordance with 130 CMR 422.420(A)(16), and which is sufficient to address the member’s needs and contains the PCA’s contact information and available schedule; (5) the type and frequency of functional skills training that the PCM agency has provided to the member, and the surrogate or administrative proxy, if any, to manage PCA services effectively or address issues related to PCA management; and (6) whether the member is authorized to schedule an individual PCA to work in excess of the weekly hour limit, as described in 130 CMR 422.418(A). (B) Before implementing or modifying the service agreement, the PCM agency must provide to the member and surrogate or administrative proxy, if any, (1) a copy of the plan; (2) an explanation, if necessary, of the terms of the plan; (3) an opportunity to object to any terms of the plan; and (4) a process to resolve any objections or disagreements as soon as possible, including an opportunity to meet with all interested persons. (C) A review of the service agreement must include a review of the needs and circumstances of the member, the services provided by the PCA, and, if appropriate, the surrogate or administrative proxy’s role related to management of PCA services on behalf of the member. (1) The PCM agency will complete a service agreement with the member and surrogate or administrative proxy, if any, before the initiation of PCA services and at least annually thereafter, and as needed due to a change of circumstances that may affect a member’s ability to manage PCA services independently or function as an employer of PCAs. (2) The PCM agency will review the service agreement with the member, and surrogate or administrative proxy, if any, at least quarterly in the first year of prior authorization for PCA services and at least annually thereafter, and when one of the following conditions exists, and modify, as appropriate: (a) the member or surrogate is not managing PCA services effectively, as evidenced by consistent overutilization of PCA hours, scheduling overtime requiring authorization absent such authorization by the MassHealth agency, inappropriate submission of activity forms, difficulty in retaining PCAs, suspicion of fraud, or other indication that the member or surrogate or administrative proxy is not able to manage PCA services; (b) the member identifies a new surrogate or administrative proxy, and in accordance with the PCM agency contract; or (c) the member, the MassHealth agency, or the surrogate or administrative proxy requests a review. (D) All service agreements must be signed by the parties involved. (E) The PCM agency is responsible for monitoring the overall implementation of the service agreement. (130 CMR 422.424 through 422.430 Reserved)