Commonwealth of Massachusetts Executive Office of Health and Human Services Office of Medicaid www.mass.gov/masshealth MassHealth Transmittal Letter PCA-19 September 2013 TO: Personal Care Agencies Participating in MassHealth FROM: Kristin L. Thorn, Acting Medicaid Director RE: Personal Care Manual (Integrated Care Organizations) The Executive Office of Health and Human Services (EOHHS) and Centers for Medicare & Medicaid Services (CMS) have contracted with One Care plans (also known as integrated care organizations or ICOs) using a blended global financial arrangement to provide integrated, comprehensive medical, behavioral-health care, and long-term services and supports for those who are eligible for both Medicare and Medicaid (“dually eligible members”) and who meet the specific criteria set forth below. The purpose of the Duals Demonstration is to improve quality of care and reduce health disparities, improve health and functional outcomes, and contain costs for dually eligible members who participate in Duals Demonstration by enrolling in a One Care p`lan. One Care plans are responsible for providing enrollees with the full continuum of Medicare- and MassHealth-covered services. In order to be eligible to enroll in a One Care plan, a MassHealth member must meet all of the following criteria: . be aged 21 through 64 at the time of enrollment; . be eligible for MassHealth Standard as defined in 130 CMR 450.105(A) or MassHealth CommonHealth as defined in 130 CMR 450.105(E); . be enrolled in Medicare Parts A and B, be eligible for Medicare Part D, and have no access to other health insurance that meets the basic-benefit level as defined in 130 CMR 501.001; and . live in a designated service area of a One Care plan. In addition, Duals Demonstration enrollees eligible for MassHealth Standard may elect to remain in the Duals Demonstration after age 65. One Care plans will employ or contract with a network of providers that will deliver team-based integrated medical and behavioral-health care and long-term services and supports and will coordinate care across providers. The Interdisciplinary Care Team, led by a care coordinator and, if appropriate, an independent living and long-term services and supports coordinator, will arrange for the availability of care and services by specialists, hospitals, and providers of longterm services and supports and other community supports. The One Care plan will be the direct payer for all covered services. Enrollment in a One Care plan for eligible members will start on or after October 1, 2013. MassHealth Transmittal Letter PCA-19 September 2013 Page 2 MassHealth Website This transmittal letter and attached pages are available on the MassHealth website at www.mass.gov/masshealth. Questions If you have any questions about the information in this transmittal letter, please contact MassHealth Customer Service at 1-800-841-2900, e-mail your inquiry to providersupport@mahealth.net, or fax your inquiry to 617-988-8974. These regulations are effective October 1, 2013. NEW MATERIAL (The pages listed here contain new or revised language.) Personal Care Manual Pages 4-3 and 4-4 OBSOLETE MATERIAL (The pages listed here are no longer in effect.) Personal Care Manual Pages 4-3 and 4-4 — transmitted by Transmittal Letter PCA-18 Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 4 Program Regulations (130 CMR 422.000) Page 4-3 Personal Care Manual Transmittal Letter PCA-19 Date 10/01/13 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 — instructional services provided by a personal care agency in accordance with 130 CMR 422.421(B) to assist members who have obtained prior authorization for PCA services and their surrogates, if necessary, in developing the skills and resources to maximize the member’s management of personal health care, personal care services, activities of daily living, and activities related to the fiscal intermediary. Holidays — New Year’s Day (January 1), July 4, Thanksgiving Day, and Christmas (December 25). 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 personal care services. Intake and Orientation Services — services provided to a member who has been referred to a personal care agency for PCA services, but for whom the MassHealth agency has not yet granted a prior authorization for PCA services. These services include, but are not limited to, determination of 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; and instruction in the role of the personal care agency and the fiscal intermediary, including the use of activity forms. Member — a person determined to be eligible for MassHealth. Night Hours — midnight to 6:00 A.M. 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 the Massachusetts Division of Registration in Allied Health Professions and in good standing with the Division of Registration; and currently certified by the National Board for Certification in Occupational Therapy and in good standing with the Board. Overtime — activity time performed by a PCA for one member in excess of 40 hours per workweek. 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. Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 4 Program Regulations (130 CMR 422.000) Page 4-4 Personal Care Manual Transmittal Letter PCA-19 Date 10/01/13 Pay Period — two consecutive work-weeks. PCA Rate — the rate of payment for activity time performed by PCAs during day/evening hours and night hours in accordance with Executive Office of Health and Human Services (EOHHS) regulations at 114.3 CMR 9.00: 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 Agency — a public or private agency or entity under contract with EOHHS to provide PCM services in accordance with 130 CMR 422.000 and the PCM services contract; or a public or private agency or entity that has been approved by EOHHS to provide transitional living services covered under 130 CMR 422.431 to 422.441. Personal Care Attendant (PCA) — a person who meets the requirements of 130 CMR 422.411(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 personal care management services, fiscal intermediary services, and PCA services are available to MassHealth members including, for the sole purpose of M.G.L. c. 118E, §§ 70 through 75, those services 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 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) Services — services provided by a personal care 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). Personal Care Services — services provided to an eligible MassHealth member for the purpose of assisting the member to achieve independent living, including PCM services, PCA services, and fiscal intermediary services.