Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 422.000 - Personal Care Attendant Services › Section 422.418 - PCA Program: Special Payments

Current through Register 1525, July 5, 2024
(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
. Prior
			 to 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;
(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 66 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.
(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 set forth 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
			 130 CMR
			 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 time lines
			 described 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 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.