reglab/statecodes huggingface dataset:
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 421.000 - Family Planning Agency Services › Section 421.426 - Consumer Participation

Current through Register 1525, July 5, 2024
A family planning agency must be responsive to its consumers'
				needs and desires. A family planning agency must have at least one consumer on
				its board or a consumer advisory group. Consumer representatives may not be
				employed by the agency while they are members of the board or group. Matters
				subject to review by the board or group must include, but are not limited to,
				policy development, service delivery, and program evaluation.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 421.000 - Family Planning Agency Services › Section 421.427 - Assurance of Member Rights

Current through Register 1525, July 5, 2024
(A) Services must be
			 made available to all members who request services, without regard to race,
			 color, national origin, religion, creed, age, sex, parity, marital status, or
			 handicap.
(B) A member's use of
			 family planning services must be completely voluntary. No provider may coerce
			 members in any way to receive services or to employ any particular method of
			 family planning. Neither the MassHealth agency nor any provider, nor any agent
			 or employee of a provider, may mislead any member into believing that a
			 decision to accept or not to accept family planning services will adversely
			 affect his or her entitlement to benefits or services.
(C) The design of the agency's facilities
			 must ensure privacy, confidentiality, and regard for the dignity of the member
			 during personal interviews, consultations, medical examinations, and treatment.
			 All information disclosed to agency personnel by the member or found as a
			 result of the member's examination, care, and treatment must be held in strict
			 confidentiality.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 421.000 - Family Planning Agency Services › Section 421.431 - Maximum Allowable Fees

Current through Register 1525, July 5, 2024
The Massachusetts Division of Health Care Finance and Policy
				determines the maximum allowable fees for family planning agency services.
				Payment is always subject to the conditions, exclusions, and limitations set
				forth in
				130 CMR 421.000. The
				payment for a service is the lower of the following:
(A) the amount specified in the applicable
			 fee schedule of the Division of Health Care Finance and Policy; or
(B) the agency's usual and customary fee (if
			 the agency uses a sliding fee scale, this is the highest level of the
			 scale).
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 421.000 - Family Planning Agency Services › Section 421.432 - Payment: Visits

Current through Register 1525, July 5, 2024
(A) The payment for
			 a family planning visit includes payment for the administrative operation of
			 the family planning agency and for all aspects of service delivery, excluding
			 laboratory tests, supplies, and drugs. Other than payment for laboratory tests,
			 supplies, and drugs, no additional fees will be paid by the MassHealth
			 agency.
(B) For each member
			 encounter, the MassHealth agency pays for only one of the following types of
			 visits.
(1)
Comprehensive
			 Visit
. The MassHealth agency pays for a comprehensive visit only
			 when the encounter is an initial, annual, or extended visit. An initial or
			 annual visit must include all of the medical, laboratory, and counseling
			 services required in
			 130 CMR 421.412(A)
			  and
			 421.413. The
			 MassHealth agency pays for only one initial or annual visit per member per
			 year. An encounter is considered to be an extended visit when it is not routine
			 in nature because extensive medical attention is necessary. Such a visit must
			 last approximately 30 minutes. For an extended visit, the need for such
			 services and the time elapsed must be documented in the medical record by the
			 physician. The MassHealth agency pays for HIV pre- and post-test counseling
			 services in addition to a comprehensive visit.
(2)
Routine Visit
.
			 The MassHealth agency pays for a routine visit when the encounter is a return,
			 follow-up, or other visit that is neither comprehensive nor minimal. A routine
			 visit must include all of the medical, laboratory, and counseling services
			 required in
			 130 CMR 421.412(B)
			  and
			 421.413. The
			 MassHealth agency pays for HIV pre- and post-test counseling services in
			 addition to a routine visit.
(3)
Minimal Service Visit
. The MassHealth agency pays for
			 a minimal service visit when the encounter is a return visit consisting of
			 counseling services only, or of a brief medical encounter and counseling
			 services. The purpose of a minimal service visit is to reinforce contraceptive
			 instructions, to monitor the member's use of a contraceptive method, or to
			 provide education and counseling. A minimal service visit may not be billed in
			 addition to HIV pre- and post-test counseling services.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 421.000 - Family Planning Agency Services › Section 421.433 - Payment: Laboratory Services

Current through Register 1525, July 5, 2024
(A)
Covered Services
. The MassHealth agency pays for
			 laboratory services listed in Subchapter 6 of the
Family Planning
			 Agency Manual
that are performed either at the agency or at an outside
			 laboratory as a result of specimen referral. For tests performed at an outside
			 laboratory, the MassHealth agency pays according to the laboratory's charge to
			 the agency or the laboratory fee schedule amount, whichever amount is
			 less.
(B)
Noncovered
			 Services
. The MassHealth agency does not pay separately for
			 routine specimen collection and preparation for the purpose of clinical
			 laboratory analysis (for example, venipunctures; urine, fecal, and sputum
			 samples; Pap smears; cultures; and swabbing and scraping for removal of
			 tissue). The MassHealth agency does not pay for laboratory tests associated
			 with male or female infertility or such calculations as red blood cell indices,
			 A/G ratio, creatinine clearance, and those ratios calculated as part of a
			 profile.
(C)
Profile or
			 Panel Tests
.
(1) A profile or
			 panel test is defined as any group of tests, whether performed manually,
			 automatedly, or semiautomatedly, that is ordered for a specified member on a
			 specified day and has at least one of the following characteristics.
(a) The group of tests is designated as a
			 profile or panel by the family planning agency performing the tests.
(b) The group of tests is performed by the
			 agency at a usual and customary fee that is lower than the sum of that agency's
			 usual and customary fees for the individual tests in that group.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 421.000 - Family Planning Agency Services › Section 421.434 - Payment: Contraceptive Supplies and Drugs

Current through Register 1525, July 5, 2024
(A)
Contraceptive
			 Supplies
. The MassHealth agency pays for contraceptive supplies
			 listed in Subchapter 6 of the
Family Planning Agency Manual
.
			 If the family planning agency purchases supplies at a price lower than that
			 allowed in the fee schedule, the agency must bill the MassHealth agency at that
			 lower price.
(B)
Drugs
. The MassHealth agency pays for drugs at the
			 actual acquisition cost. A copy of the current invoice showing the actual
			 acquisition cost must be attached to the claim form. Claims for dispensing
			 drugs must include the following information: the name of the drug; the
			 strength; the dosage; and the number of units. Claims without this information
			 will be denied. Payment for drugs is determined on an individual consideration
			 (I.C.) basis by the MassHealth agency, based on the information entered on the
			 claim.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 421.000 - Family Planning Agency Services › Section 421.438 - Sterilization Services: Introduction

Current through Register 1525, July 5, 2024
(A)
Covered Services
. The MassHealth agency pays for a
			 sterilization provided to a member only if all of the following conditions are
			 met.
(1) The member has voluntarily given
			 informed consent for the sterilization procedure in the manner and at the time
			 described in
			 130 CMR
			 421.439, and such consent is documented in
			 the manner described in
			 130 CMR
			 421.440.
(2) The member is at least 18 years old at
			 the time consent is obtained.
(3)
			 The member is not a mentally incompetent individual or an institutionalized
			 individual.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 421.000 - Family Planning Agency Services › Section 421.439 - Sterilization Services: Informed Consent

Current through Register 1525, July 5, 2024
A member's consent for sterilization is considered informed and
				voluntary only if such consent was obtained in accordance with the requirements
				specified in 130 CMR 421.439(A) and (B), and such consent is documented as
				specified in
				130 CMR
				421.440.
(A)
Informed Consent
			 Requirements
.
(1) The person who
			 obtains consent (a physician, nurse, or counselor, for example) must orally
			 provide all of the following information and advice to the member requesting
			 sterilization:
(a) advice that the member is
			 free to withhold or withdraw consent for the sterilization procedure at any
			 time prior to that procedure without affecting the right to future care or
			 treatment and without loss of any federal- or state-funded program benefits to
			 which the member might be entitled;
(b) a description of available alternative
			 methods of family planning and birth control;
(c) advice that the sterilization procedure
			 is considered irreversible;
(d) a
			 thorough explanation of the specific sterilization procedure to be
			 performed;
(e) a full description
			 of the discomforts and risks that may accompany or follow the procedure,
			 including an explanation of the type and possible effects of any anesthetic to
			 be used;
(f) a full description of
			 the benefits or advantages that may be expected as a result of the
			 sterilization; and
(g) advice that
			 the sterilization will not be performed for at least 30 days from the date
			 consent is given, except in circumstances specified in 130 CMR
			 421.439(B)(1).
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 421.000 - Family Planning Agency Services › Section 421.440 - Sterilization Services: Consent Form Requirements

Current through Register 1525, July 5, 2024
Informed consent for sterilization must be documented by the
				completion of the MassHealth agency's Consent for Sterilization form in
				accordance with the following requirements. (Instructions for obtaining the
				Consent for Sterilization forms are located in Subchapter 5 of the
Family Planning Agency Manual
.)
(A)
Required Consent
			 Form
.
(1) One of the following
			 Consent for Sterilization forms must be used:
(a) CS-18 - for members aged 18 through 20;
			 or
(b) CS-21 - for members aged 21
			 and older.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 422.000 - Personal Care Attendant Services › Section 422.401 - Introduction

Current through Register 1525, July 5, 2024
130 CMR
				422.000 contains regulations governing the Personal
				Care Attendant (PCA) program under MassHealth. All PCAs and transitional living
				providers participating in MassHealth, as well as all Personal Care Management
				(PCM) agencies and fiscal intermediaries under contract with MassHealth to
				provide PCM and fiscal intermediary functions, must comply with regulations
				governing MassHealth including, but not limited to, MassHealth regulations at
				130 CMR
				422.000, and
				130 CMR
				450.000:
Administrative and Billing
				Regulations
.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 422.000 - Personal Care Attendant Services › Section 422.403 - Eligible Members

Current through Register 1525, July 5, 2024
(A)
(1)
MassHealth
			 Members
. MassHealth covers PCA services only when provided to
			 eligible MassHealth members, subject to the restrictions and limitations
			 described in 130 CMR 450.105:
Coverage Types
specifically
			 states, for each MassHealth coverage type, which services are covered and which
			 members are eligible to receive those services.
(2)
Recipients of the Emergency
			 Aid to the Elderly, Disabled and Children Program
. For information
			 on covered services for recipients of the Emergency Aid to the Elderly,
			 Disabled and Children Program,
see
130 CMR 450.106:
Emergency Aid to the Elderly, Disabled and Children
			 Program
.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 422.000 - Personal Care Attendant Services › Section 422.404 - Provider Eligibility

Current through Register 1525, July 5, 2024
(A)
Provider Qualifications
.
(1)
Personal Care
			 Attendants
. To provide personal care attendant (PCA) services
			 described in 130 CMR 422.411(A) and the service agreement established pursuant
			 to 130 CMR 422.423, the PCA must
(a) be
			 legally authorized to work in the United States;
(b) not be on the List of Excluded
			 Individuals and Entities as provided by the Office of Inspector General of the
			 U.S. Department of Health and Human Services, or other applicable lists
			 excluding individuals or entities from participating in MassHealth under state
			 or federal law;
(c) have a current
			 and valid PCA provider number;
(d)
			 be employed by a member to provide PCA services. To be eligible to be employed
			 by a member to provide PCA services, a PCA must:
1. not be a family member, as defined in 130
			 CMR 422.402;
2. not be the member's
			 surrogate;
3. not be the member's
			 foster parent;
4. be able to
			 understand and carry out directions given by the member or the member's
			 surrogate;
5. be willing to receive
			 training and supervision in all PCA services provided by the member or the
			 member's surrogate;
6. not be
			 receiving compensation from any other person or entity for that activity time;
			 and
7. enter into a PCA provider
			 agreement to perform PCA services.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 422.000 - Personal Care Attendant Services › Section 422.405 - Personal Care Management Agency and Fiscal Intermediary Functions

Current through Register 1525, July 5, 2024
(A)
Personal Care Management
			 Agencies
.
(1)
Personal Care Management Agency Functions
.
			 Organizations that contract with the MassHealth agency to provide PCM agency
			 functions must perform the range of functions specified in the PCM agency
			 contract and contained within 130 CMR 422.000. Such functions include, but are
			 not limited to, those described in 130 CMR 422.419(A).
(2)
Selecting a Personal Care
			 Management Agency
. The member selects the PCM agency from the PCM
			 agencies under contract with MassHealth to perform this function. The PCM
			 agency selected by the member will conduct the PCA evaluation and provide PCM
			 functions to the member.
(3)
Reassignment to a Personal Care Management Agency
. The
			 MassHealth agency may reassign a member to another PCM agency selected by the
			 MassHealth agency, if, in the sole determination of the MassHealth agency, the
			 PCM agency selected by the member:
(a)
			 becomes unavailable for any reason;
(b) is unable or unwilling to provide PCM
			 functions pursuant to the requirements set forth in 130 CMR 422.000;
			 or
(c) is not in compliance with
			 its obligations as set forth in its contract with the MassHealth
			 agency.
(4) An
			 organization may apply to the MassHealth agency to become a PCM agency only
			 during the time that the MassHealth agency opens a request for responses for
			 PCM functions.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 422.000 - Personal Care Attendant Services › Section 422.410 - Activities of Daily Living and Instrumental Activities of Daily Living

Current through Register 1525, July 5, 2024
(A)
Activities of Daily Living
			 (ADLs)
. Activities of daily living include the following
			 categories of activities. Any number of activities within one category of
			 activity is counted as one ADL:
(1) mobility:
			 physically assisting a member who has a mobility impairment that prevents
			 unassisted transferring, walking, or use of prescribed durable medical
			 equipment;
(2) assistance with
			 medications or other health-related needs: physically assisting a member to
			 take medications prescribed by a physician that otherwise would be self
			 administered;
(3) bathing or
			 grooming: physically assisting a member with bathing, personal hygiene, or
			 grooming;
(4) dressing: physically
			 assisting a member to dress or undress;
(5) passive range-of-motion exercises:
			 physically assisting a member to perform range-of-motion exercises;
(6) eating: physically assisting a member to
			 eat. This can include assistance with tube feeding and special nutritional and
			 dietary needs; and
(7) toileting:
			 physically assisting a member with bowel or bladder needs.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 422.000 - Personal Care Attendant Services › Section 422.411 - Covered Services

Current through Register 1525, July 5, 2024
(A) MassHealth
			 covers activity time performed by a PCA in providing assistance with ADLs and
			 IADLs as described in 130 CMR 422.410, as specified in the evaluation described
			 in 130 CMR 422.422(C) and (D), and as authorized by the MassHealth
			 agency.
(B) MassHealth covers
			 transitional living program services provided by an organization in accordance
			 with 130 CMR 422.431 through 422.441 and the MassHealth agency's proposal
			 requirements.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 422.000 - Personal Care Attendant Services › Section 422.412 - Non-covered Services

Current through Register 1525, July 5, 2024
MassHealth does not cover any of the following as part of the
				PCA program or the transitional living program:
(A) social services including, but not
			 limited to, babysitting, respite care, vocational rehabilitation, sheltered
			 workshop, educational services, recreational services, advocacy, and liaison
			 services with other agencies;
(B)
			 medical services available from other MassHealth providers, such as physician,
			 pharmacy, or community health center services;
(C) assistance provided in the form of
			 cueing, prompting, supervision, guiding, or coaching;
(D) PCA services provided to a member while
			 the member is a resident of a nursing facility or other inpatient facility, or
			 a resident of a provider-operated residential facility subject to state
			 licensure, such as a group home;
(E) PCA services provided to a member during
			 the time a member is participating in a community program funded by MassHealth
			 including, but not limited to, day habilitation, adult day health, adult foster
			 care, or group adult foster care;
(F) services provided by family members, as
			 defined in 130 CMR 422.402;
(G)
			 surrogates, as defined in 130 CMR 422.402; or
(H) PCA services provided to a member without
			 the use of EVV as required by the MassHealth agency.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 422.000 - Personal Care Attendant Services › Section 422.413 - Payment for PCA Services

Current through Register 1525, July 5, 2024
MassHealth authorizes the following types of payment to PCAs
				for the performance of PCA services:
(A) activity time performed pursuant to 130
			 CMR 422.411(A);
(B) overtime
			 requiring authorization in accordance with 130 CMR 422.418(A);
(C) payment for juror service in accordance
			 with 130 CMR 422.418(B);
(D) PCA
			 holiday rate determined in accordance with 101 CMR 309.00:
Independent
			 Living Services for the Personal Care Attendant Program
for activity
			 time performed between the hours of 6:00 A.M. through 12:00 A.M. on January
			 1st, July 4th,
			 Thanksgiving Day and December
25th;
(E) paid earned time used pursuant to a
			 collective bargaining agreement effective in accordance with M.G.L. c. 118E,
			 § 73 and c. 150E; and
(F)
			 completed new hire orientation pursuant to a collective bargaining agreement
			 effective in accordance with M.G.L. c. 118E, § 73 and c. 150E.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 422.000 - Personal Care Attendant Services › Section 422.416 - PCA Program: Prior Authorization for PCA Services

Current through Register 1525, July 5, 2024
The PCM agency must request prior authorization from the
				MassHealth agency as a prerequisite to payment for PCA services. Prior
				authorization determines only the medical necessity of the authorized service
				and does not establish or waive any other prerequisites for payment such as
				member eligibility or utilization of other potential sources of health care as
				described in
				130
				CMR 503.007:
Potential Sources of
				Health Care
and
				130
				CMR 517.008:
Potential Sources of
				Health Care
. Prior authorization for PCA services does not authorize
				member scheduling of PCA overtime, which is described in
				130
				CMR 422.418. All requests for prior
				authorization for PCA services must include the provider number of the fiscal
				intermediary selected by the PCM agency pursuant to
				130
				CMR 422.405(B)  and be
				submitted on MassHealth forms in accordance with the billing instructions in
				the Personal Care Manual Subchapter 5, and
				130
				CMR 422.416. The MassHealth agency responds
				to requests for prior authorization in accordance with
				130
				CMR 450.303:
Prior
				Authorization
.
(A)
Initial Request for Prior Authorization for PCA
			 Services
. With the exception of
			 130
			 CMR 422.416(D), PCM agencies
			 must submit the initial request for prior authorization for PCA services to the
			 MassHealth agency within 45 calendar days of the date of the initial inquiry
			 about a member to the PCM agency for PCA services. Requests for prior
			 authorization for PCA services must include:
(1) the completed MassHealth Application for
			 PCA Services and MassHealth Evaluation for PCA Services;
(2) the completed MassHealth Prior
			 Authorization Request form;
(3) any
			 documentation that supports the member's need for PCA services. This
			 documentation must:
(a) identify a permanent
			 or chronic disability that impairs the member's ability to perform ADLs and
			 IADLs without physical assistance; and
(b) state that the member requires physical
			 assistance with two or more ADLs as defined in
			 130
			 CMR
			 422.410(A).
(4) the completed and signed assessment of
			 the member's ability to manage the PCA program
			 independently.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 422.000 - Personal Care Attendant Services › Section 422.417 - PCA Program: Notice of Approval, Denial, or Modification of Prior-authorization Request

Current through Register 1525, July 5, 2024
(A)
Notice of Approval
. If the MassHealth agency approves
			 a PA request for PCA services, the MassHealth agency will send written notice
			 to the member, the PCM agency, and the fiscal intermediary regarding the
			 frequency, duration, and intensity of care authorized, as well as the
			 expiration date of the authorization.
(B)
Notice of Denial or
			 Modification and Right of Appeal
.
(1) If the MassHealth agency denies or
			 modifies a prior-authorization request for PCA services, the MassHealth agency
			 will send written notice to the member, the PCM agency, and the fiscal
			 intermediary. The notice will state the reason for the denial or modification
			 and will inform the member of the right to appeal and of the appeal
			 procedure.
(2) If the MassHealth
			 agency denies or modifies a prior-authorization request for PCA services, a
			 member may appeal 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 will conduct the fair
			 hearing in accordance with
			 130 CMR 610.000:
MassHealth: Fair Hearing Rules
.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 422.000 - Personal Care Attendant Services › Section 422.421 - PCA Program: Personal Care Management Agency Intake and Orientation and Functional Skills Training

Current through Register 1525, July 5, 2024
(A)
Intake and Orientation
. Intake and orientation
			 functions are provided to members about whom an inquiry is made to the PCM
			 agency for PCA services and do not yet have a prior authorization for PCA
			 services. The PCM agency must ensure that each member who seeks PCA services
			 receives sufficient in-person intake orientation to the PCA program to ensure
			 that the member, or surrogate or administrative proxy, if any, understands the
			 rules, policies, and procedures of the PCA program. The PCM agency must provide
			 intake and orientation to the member that include, but are not limited to, the
			 following:
(1) responding, either by telephone
			 or in person, to an initial request for PCA services within three business days
			 of the inquiry submitted to the PCM agency for PCA services;
(2) completing an in-person determination of
			 the member's initial eligibility for the PCA program within ten business days
			 of the initial inquiry about a member to the PCM agency for PCA services in
			 accordance with 130 CMR 422.403 and the PCM agency contract;
(3) ensuring that the member is eligible for
			 MassHealth and meets the eligibility criteria for PCA services as described in
			 130 CMR 422.403(C)(1) through (4);
(4) providing in-person intake and
			 orientation to each member who is determined initially eligible for the PCA
			 program, but has not yet been granted a prior authorization for PCA services
			 that includes, at minimum:
(a) a description
			 of the member's rights and responsibilities when using the PCA program,
			 including the member's responsibilities defined under 130 CMR 422.420(A);
(b)  the rules, regulations, and
			 policies governing the PCA program including, but not limited to, the member's
			 responsibility to use PCA services as authorized by the MassHealth agency
			 pursuant to 130 CMR 422.416(E);
(c)
			 the roles and responsibilities of the PCM agency and the fiscal
			 intermediary;
(d) the appropriate
			 use of activity forms; and
(e)
			 instruction in the skills and tasks necessary to manage PCA services;
(5) informing the member of the
			 member's responsibility for enrolling with the fiscal intermediary before
			 employing PCAs and assist the member with this process, if necessary;
			 and
(6) notifying the fiscal
			 intermediary of the name, MassHealth ID number, address, and telephone number
			 of the member, and the name, address, and phone number of the surrogate, if
			 any, who is responsible for submitting, reviewing, and/or signing the activity
			 forms.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 422.000 - Personal Care Attendant Services › Section 422.422 - PCA Program: Personal Care Management Agency Operating Procedures

Current through Register 1525, July 5, 2024
(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);
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 422.000 - Personal Care Attendant Services › Section 422.423 - PCA Program: Service Agreement

Current through Register 1525, July 5, 2024
(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).
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 422.000 - Personal Care Attendant Services › Section 422.431 - Transitional Living Program: Prior Authorization

Current through Register 1525, July 5, 2024
A provider of transitional living services must obtain prior
				authorization from the MassHealth agency as a prerequisite to payment for
				transitional living services. Prior authorization determines only the medical
				necessity of the authorized service and does not establish or waive any other
				prerequisites for payment, such as member eligibility or resort to health
				insurance payment. All requests for prior authorization for transitional living
				services must be submitted on MassHealth forms in accordance with the billing
				instructions in the Personal Care Manual Subchapter 5. A completed assessment,
				evaluation, and service agreement prepared in accordance with
				130 CMR
				422.438 and
				130 CMR
				422.439 that are signed by both the member
				and the program's director must be submitted to the MassHealth agency with a
				request for prior authorization.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 422.000 - Personal Care Attendant Services › Section 422.432 - Transitional Living Program: Notice of Approval or Denial for Transitional Living Services

Current through Register 1525, July 5, 2024
(A)
Notice of Approval
. If the MassHealth agency approves
			 a prior-authorization request for transitional living services, the MassHealth
			 agency will send written notice to the member and the transitional living
			 provider about the frequency, duration, and intensity of care authorized, as
			 well as the effective date of the authorization.
(B)
Notice of Denial and Right of
			 Appeal
.
(1) If the MassHealth
			 agency denies a prior-authorization request for transitional services, the
			 MassHealth agency notifies both the member and the transitional living
			 provider. The notice states the reason for the denial and informs the member of
			 the right to appeal and of the appeal procedure.
(2) If the MassHealth agency denies a PA
			 request for transitional living services, a member may appeal by requesting a
			 fair hearing from the MassHealth agency. 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
.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 422.000 - Personal Care Attendant Services › Section 422.433 - Transitional Living Program: Scope of Services

Current through Register 1525, July 5, 2024
A transitional living provider must, at a minimum, provide the
				following services in accordance with each member's needs as documented in the
				member's service agreement:
(A)
			 transitional living services, as described in
			 130 CMR
			 422.431 through
			 130 CMR
			 422.441; and
(B) transportation to health-care facilities
			 when public transportation is unavailable.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 422.000 - Personal Care Attendant Services › Section 422.434 - Transitional Living Program: Administrative Day Rate

Current through Register 1525, July 5, 2024
If a member has completed the program of transitional living
				services but cannot secure an appropriate living arrangement, the MassHealth
				agency will pay an administrative day rate covering the program's overhead
				expenses and the member's personal care services. The MassHealth agency will
				pay this rate contingent upon documentation provided by the transitional living
				provider in the form and frequency determined by the MassHealth
				agency.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 422.000 - Personal Care Attendant Services › Section 422.435 - Transitional Living Program: Leaves of Absence

Current through Register 1525, July 5, 2024
(A)
Medical Absence
.
			 If a member in a transitional living program is hospitalized, the MassHealth
			 agency will pay the transitional living provider for a maximum of 13 days per
			 member per episode of hospitalization.
(B)
Nonmedical Leave of
			 Absence
. If a member leaves the transitional living program for
			 personal reasons, the MassHealth agency will pay the transitional living
			 provider for a cumulative maximum of ten calendar days of nonmedical leave of
			 absence during the member's stay in the transitional living program.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 422.000 - Personal Care Attendant Services › Section 422.436 - Transitional Living Program: Staffing Requirements

Current through Register 1525, July 5, 2024
The transitional living provider must have the following staff
				at each transitional living program site:
(A) a program director who must be on site
			 for at least 20 hours per week;
(B)
			 a registered nurse who must be on site at least 15 hours per week, and who must
			 supervise functional skills training in matters of personal health care
			 (
see
130 CMR
			 422.437(C) ) and PCA
			 services provided at the transitional living site;
(C) an occupational therapist who will assist
			 in the provision of functional skills training and in meeting the functional
			 needs of program participants;
(D)
			 skills instructors or peer counselors to provide functional skills
			 training;
(E) a part time driver
			 who has a current, valid driver's license and is qualified to use adapted,
			 accessible vehicles; and
(F)
			 additional staff as necessary to meet individual health and health-related
			 needs as detailed in the service plan.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 422.000 - Personal Care Attendant Services › Section 422.437 - Transitional Living Program: Functional Skills Training

Current through Register 1525, July 5, 2024
The need for and benefit from functional skills training is to
				be determined as part of the assessment described in
				130 CMR
				422.438(A). At a minimum,
				each service agreement must contain provisions and a schedule for functional
				skills training in the four areas listed in 130 CMR 422.437(A) through
				(D).
(A)
PCA
			 Training
. PCA training must instruct the member and the member's
			 surrogate, if any, in the functions and scheduling of PCAs in relation to the
			 member's needs.
(B)
PCA
			 Management
. The member and the member's surrogate, if any, will be
			 instructed in:
(1) hiring of PCAs, including
			 identification of local resources, advertising for PCAs, and interviewing
			 techniques;
(2) use of activity
			 forms and schedules in documenting the use of PCAs and meeting the requirements
			 for reimbursement;
(3) methods for
			 evaluating PCA competence and effectiveness and requesting assistance in
			 dealing with training or other issues as necessary; and
(4) firing and replacing PCAs, including
			 maintenance of a backup system as necessary.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 422.000 - Personal Care Attendant Services › Section 422.438 - Transitional Living Program: Operating Procedures

Current through Register 1525, July 5, 2024
(A)
Assessment
. The
			 assessment identifies the member's needs and functional capabilities, including
			 the ability to manage PCA services independently. For an individual who cannot
			 manage PCA services independently, the assessment must identify a surrogate or
			 administrative proxy; if a surrogate or administrative proxy is not available,
			 the agency must refer the member to an appropriate service provider. The
			 assessment process must include the member and may include participation of
			 family members and advocates. The product of an assessment is either an
			 evaluation or a referral to an appropriate service provider.
(B)
Evaluation
.
(1) An evaluation team consisting of a
			 registered nurse and an occupational therapist must conduct an initial
			 evaluation under the supervision of a registered nurse. The evaluation team
			 must consider the member's physical and cognitive condition to determine the
			 member's ability to benefit from PCA services. All evaluations are subject to
			 the approval of the member's physician.
(2) The evaluation must take place 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.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 422.000 - Personal Care Attendant Services › Section 422.439 - Transitional Living Program: Service Agreement

Current through Register 1525, July 5, 2024
(A)
(1)
			 Before the initiation of PCA services, the transitional living provider, with
			 the participation of the member and the surrogate (if any), must develop a
			 written individual service agreement, which must describe in detail the
			 responsibilities of the PCA, the member, the member's surrogate or
			 administrative proxy, if any, and the transitional living provider.
(2) On the basis of an assessment as provided
			 in
			 130 CMR
			 422.438(A), the transitional
			 living provider, with the participation of the member to the fullest extent
			 possible, must determine whether a surrogate is needed to manage the personal
			 care services. If no surrogate or administrative proxy is needed, the service
			 agreement must clearly state that the member has sole responsibility to manage
			 PCA services.
(3) If a surrogate or
			 administrative proxy is needed, the service agreement must name the surrogate
			 or administrative proxy, and pursuant to and as described in the service
			 agreement, the member must be involved in managing PCA services to the maximum
			 extent possible. The service agreement's description of the surrogate or
			 administrative proxy's responsibilities must include the frequency of the
			 surrogate or administrative proxy's visits with the member. The transitional
			 living provider is responsible for monitoring the overall implementation of the
			 service agreement.
(4) Before
			 implementing or modifying the service agreement, the transitional living
			 provider must provide to the member or surrogate:
(a) a copy of the service
			 agreement;
(b) an explanation, if
			 necessary, of the terms of the agreement;
(c) an opportunity to object to any terms of
			 the agreement; and
(d) a process to
			 resolve any objections as soon as possible, including an opportunity to meet
			 with all interested persons.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 422.000 - Personal Care Attendant Services › Section 422.440 - Transitional Living Program: Physical Plant

Current through Register 1525, July 5, 2024
Each transitional living program site must be inspected and
				approved by the MassHealth agency before its use in providing the program. Each
				site must, at a minimum, meet the following standards.
(A) The site must be accessible to and
			 suitable for persons with multiple physical disabilities.
(B) The site must comply with the laws and
			 regulations of 521 CMR:
Architectural Access Board
.
(C) There must be documentation of a site
			 inspection and approval by the Massachusetts Department of Public Safety, local
			 fire department, and building inspector, and compliance with all applicable
			 federal, state, and local statutes, laws, and ordinances.
(D) Members' quarters must be near to and
			 easily accessible from staff and attendant quarters.
(E) The site must have an accessible,
			 appropriate telephone or emergency call device located in each
			 bedroom.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 422.000 - Personal Care Attendant Services › Section 422.441 - Transitional Living Program: Emergency Procedures

Current through Register 1525, July 5, 2024
(A) Each member must know how to contact
			 program staff and attendants in case of an emergency.
(B) An emergency evacuation plan must be in
			 effect, practiced by all members, and provide for evacuation of members who
			 cannot exit unassisted.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 422.000 - Personal Care Attendant Services › Section 422.446 - Recordkeeping Requirements

Current through Register 1525, July 5, 2024
Providers of any service covered under
				130 CMR
				422.000 must maintain, for at least four years after
				the date of service, records for each member that include at least the
				following:
(A) the member's name,
			 social security number (SSN), address, telephone number, case number, member
			 identification number (RID), sex, date of birth, marital status, and next of
			 kin;
(B) the name, address, and
			 telephone number of the surrogate, where applicable;
(C) the date of the member's first contact
			 with the PCM agency;
(D) a copy of
			 the MassHealth agency written authorization regarding the frequency, duration,
			 and intensity of care to be provided;
(E) the name and address of the member's
			 primary physician or medical clinic; and
(F) any other records required by the
			 provider's contract with the MassHealth agency.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 422.000 - Personal Care Attendant Services › Section 422.447 - Billing Responsibility

Current through Register 1525, July 5, 2024
Except for personal care attendants, providers of any service
				covered under
				130 CMR
				422.000 are responsible for billing the MassHealth
				agency in accordance with the Personal Care Manual Subchapter
				5.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 422.000 - Personal Care Attendant Services › Section 422.448 - Rates of Payment

Current through Register 1525, July 5, 2024
The MassHealth agency pays for PCA services at the rates
				determined in accordance with
				101 CMR
				309.03:
General Rate
				Provisions
and for transitional living program services at the rates
				determined in accordance with 114.5 CMR 4.00:
Rates for Certain Social,
				Rehabilitation, and Health Care Services
.