Code of Massachusetts Regulations › 101 CMR - EXECUTIVE OFFICE FOR HEALTH AND HUMAN SERVICES › Title 101 CMR 309.00 - Rates for Certain Services for the Personal Care Attendant Program › Section 309.02 - Definitions

Current through Register 1525, July 5, 2024
As used in
				101 CMR
				309.00, unless the context requires otherwise, terms
				have the meanings in
				101
				CMR 309.02.
Activities of Daily Living (ADLs)
.
				Those specific activities described in
				130
				CMR 422.410(A):
Activities of Daily Living (ADLs).
Such activities are
				performed by a 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
				designated by the MassHealth agency to be used by the member for recording all
				PCA activity time for each pay period. The member or the member's surrogate
				submits completed activity forms to the fiscal intermediary.
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.
Consumer
. A MassHealth member who is
				receiving PCA services. The consumer is the employer of the PCA.
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 worker's compensation
				premiums.
EOHHS
. The Executive Office of Health
				and Human Services established under M.G.L. c. 6A.
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:
Eligible
				Members
. The evaluation is conducted by a registered nurse or licensed
				practical nurse and an occupational therapist in accordance with
				130
				CMR 422.422(C):
Evaluation to Initiate PCA Services
or
				130
				CMR 422.438(B):
Evaluation
.
Fiscal Intermediary
. An entity
				contracting with MassHealth to perform employer-required tasks and related
				administrative tasks including, but not limited to, tasks described in
				130
				CMR 422.419(B):
The
				Fiscal Intermediary
.
Functional Skills Training
. Training
				provided by a PCM agency in accordance with
				130
				CMR 422.421(B):
Functional Skills Training
to assist members who have obtained
				prior authorization (PA) for PCA services and their surrogates or
				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.
Governmental Unit
. The Commonwealth of
				Massachusetts and any department, division, agency, board, commission, or
				political subdivision of the Commonwealth.
Individual Consideration
. The method
				to determine payment for services for service codes for which no rate has been
				established. The governmental unit or purchaser analyzes the eligible
				provider's report of services rendered and charges submitted under the
				appropriate unlisted services or procedures category. The purchaser determines
				an appropriate payment for individual consideration procedures in accordance
				with the following standards and criteria:
(a) time required to perform the
			 procedure;
(b) degree of skill
			 required in care rendered;
(c)
			 severity or complexity of the patient's disease, disorder, or
			 disability;
(d) policies,
			 procedures, and practices of other third-party purchasers of care, governmental
			 and private; and
(e) applicable
			 relative value studies.
Instrumental Activities of Daily Living
				(IADLs)
. Those specific activities described in
				130
				CMR 422.410(B):
Instrumental Activities of Daily Living (IADLs)
that are
				instrumental to the care of the member's health and are performed by a PCA,
				such as meal preparation and cleanup, laundry, shopping, housekeeping,
				maintenance of medical equipment, transportation to medical providers, and
				completion of paperwork required for the member to receive PCA services.
Intake and Orientation
. Functions
				performed by a PCM agency for a member who is seeking PCA services, but for
				whom the MassHealth agency has not yet granted PA for PCA services. These
				functions include, but are not limited to, 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.
MassHealth
. The medical assistance
				program administered by the Executive Office of Health and Human Services
				pursuant to M.G.L. c. 118E and in accordance with Titles XIX and XXI of the
				federal Social Security Act and a § 1115 Demonstration Waiver.
MassHealth Program Regulations
.
				Regulations governing the PCA program are contained in
				130 CMR
				422.000:
Personal Care Attendant
				Services
and
				130 CMR
				450.000:
Administrative and Billing
				Regulations
.
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:
Activities of Daily
				Living and Instrumental Activities of Daily Living
.
PCA Wage Component
. The portion of the
				PCA rate that is 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):
Personal Care Attendants
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:
Personal Care Attendant
				Services
, 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 Management (PCM) Agency
.
				A public or private agency or entity under contract with MassHealth to provide
				PCM functions to eligible members in accordance with
				130 CMR
				422.000:
Personal Care Attendant
				Services
and the PCM functions 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,
				those services identified in the PCM contract and
				130
				CMR 422.419(A):
The
				PCM Agency
.
Prior Authorization (PA)
. An approval,
				modification, deferral, or denial for PCA services to the consumer by the
				MassHealth agency in accordance with
				130
				CMR 422.416:
PCA Program: Prior
				Authorization for PCA Services
and
				130
				CMR 422.418:
PCA Program: Special
				Payments
.
Publicly Aided Individual
. A person
				who receives health care and services for which a governmental unit is in whole
				or in part liable under a statutory program of public assistance. This includes
				a consumer.
Reevaluation
. A determination of the
				scope and type of PCA services to be provided to a member who has requested a
				continuation of PCA services because the current authorization is expiring. The
				reevaluation is conducted in accordance with
				130
				CMR 422.422(D):
Reevaluation
.
Service Agreement
. A written plan of
				services, consistent with the requirements of
				130
				CMR 422.423:
PCA Program: Service
				Agreement
and the PCM functions contract, that is developed jointly by
				the PCM agency; the member; and the member's surrogate, if any. The service
				agreement describes the responsibilities of the PCA, the member, the surrogate,
				the fiscal intermediary, and the PCM agency. If the member does not require a
				surrogate, the service agreement must state that the member is solely
				responsible for the management tasks, including hiring, firing, scheduling,
				training, supervising, and otherwise directing the PCA. The service agreement
				must also describe the type and frequency of functional skills training that
				the member and the surrogate, if appropriate, require from the PCM agency to
				manage the PCA program successfully.
Uniform Financial Statement and Independent
				Auditor's Report (UFR)
. An annual fiscal filing requirement of
				revenue and expense activity for programs funded fully or in part by contracts
				with the Commonwealth. The Operational Services Division issues instructions
				for UFR preparation and compliance under
				808 CMR
				1.00:
Compliance, Reporting and Auditing for
				Human and Social Services.