Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 422.000 - Personal Care Attendant Services › Section 422.402 - Definitions

Current through Register 1525, July 5, 2024
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.
Day/Evening Hours
- 6:00 A.M. to 12:00
				A.M.
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
- January
				1st, July 4th,
				Thanksgiving Day, and December 25th.
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
				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 Agency (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 Executive Office of Health
				and Human Services (EOHHS) regulations at
				101 CMR
				309.00:
Independent Living Services for the
				Personal Care Attendant Program
.
PCA Wage Component
- the portion of
				the PCA rate designated as the PCA's gross hourly wage.
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, in the SCO's MassHealth contract, or in 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.
Personal Care Attendant (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.
Personal Care Attendant Services (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.
Personal Care Management (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 Period
- the dates
				authorized by the MassHealth agency designating the duration of services
				covered by the prior authorization.
Prior Authorization Request (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, a family member, or other person 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 persons 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.