Commonwealth of Massachusetts Executive Office of Health and Human Services Office of Medicaid 600 Washington Street Boston, MA 02111 www.mass.gov/masshealth MassHealth Personal Care Agency Bulletin 4 August 2009 TO: Personal Care Agencies Participating in MassHealth FROM: Tom Dehner, Medicaid Director RE: Changes to MassHealth Policy about the Provision of MassHealth Personal Care Attendant (PCA) Services to Hospice Members Background Upon electing hospice, a MassHealth member waives the right to receive other MassHealth services related to his or her terminal illness. MassHealth’s policy about the continued provision of Personal Care Attendant (PCA) services to members who have elected hospice has been to allow such members to continue receiving PCA services at the amount authorized before their election of hospice. However, because hospice is an all-inclusive benefit, MassHealth has considered it the hospice provider’s responsibility to provide any additional personal care services needed once the member has elected hospice. Changes in CMS Hospice Rules The Centers for Medicare & Medicaid Services (CMS) recently revised the hospice rules under 42 C.F.R. 418 Hospice Care. As part of these revisions, hospice providers may now coordinate their provision of hospice services with Medicaid-funded personal care services. Specifically, the changes in the CMS hospice rules provide, in part, that: • services under the Medicaid personal care benefit may be used by a Medicaid-eligible individual receiving hospice care to the extent that the hospice provider would routinely use the services of a hospice patient’s family in implementing the patient’s plan of care; • when an individual receiving hospice services is also receiving Medicaid personal care services, the hospice provider must coordinate its hospice aid and homemaker services with the individual’s Medicaid personal care benefit to ensure that the individual receives the hospice aide and homemaker services he or she needs; and • the hospice provider must document the coordination of its services with any Medicaid personal care services provided to an individual receiving hospice care in the individual’s hospice plan of care. Currently, MassHealth is in the process of amending its hospice regulations to reflect these changes to the CMS hospice rules, including changes related to the provision of Medicaid funded personal care services to members who have elected hospice. (continued on next page) Changes in MassHealth Policy Effective immediately and in accordance with the above referenced changes to the CMS hospice rules, MassHealth will authorize medically necessary PCA services for MassHealth members who have elected hospice to the extent that a hospice provider would routinely use the services of a hospice patient’s family in implementing a hospice patient’s plan of care. It is the hospice provider’s responsibility to coordinate hospice services with any PCA services that a member is authorized to receive and it is the hospice provider’s responsibility to document its coordination of services with PCA services provided to a member in the member’s hospice plan of care. If Personal Care Management (PCM) agencies receive referrals from sources other than the member’s hospice provider, the PCM agency must obtain authorization from the member or the member’s legal representative to immediately contact the hospice provider to determine if the referral for PCA services is appropriate and the PCM agency must document any such communication in the member’s record. PCA services furnished to members in hospice must be provided under the same rules and regulations as the MassHealth PCA program at 130 CMR 422.000. PCM Agency Requirements To ensure that PCA services are provided in accordance with the revised CMS hospice rules, when requesting prior authorization for PCA services for members who have elected hospice, MassHealth is requiring that PCM agencies obtain a copy of the member’s hospice plan of care from the hospice provider and submit it along with other required documentation for the prior authorization. PCM agencies may contact the hospice provider’s clinical manager to request this document. In the event that a PCM agency encounters difficulty obtaining the required physician or nurse practitioner sign-off on a PCA evaluation, the providers from the Hospice Federation informed MassHealth that a PCM agency could request sign-off from a member’s hospice provider’s medical director or nurse practitioner. Additionally, in the event that a PCM agency encounters difficulty securing an occupational therapist (OT) to complete the initial evaluation, the PCM agency may request that the hospice provider’s occupational therapist assist with completion of the Occupational Therapist page of the PCA evaluation. (continued on next page) Expediting PCA PA Requests for Members Who Have Elected Hospice Given the life-limiting conditions of members who have elected hospice, the processing of prior authorization (PA) requests for PCA services for such members, including initial evaluations, re-evaluations and adjustments, must be expedited by the PCM agency. MassHealth is committed to processing requests for prior authorization for members who have elected hospice within two business days of receipt. MassHealth is requesting that PCM agencies respond to and process all requests for PCA services for members who have elected hospice as soon as possible, but no later than two weeks from the date of the member’s referral to the PCM agency. When submitting PCA PA requests, including adjustments, to MassHealth electronically, PCM agencies must: • Enter a statement that the member has elected hospice in the Comments field: “PCA for member in HOSPICE–hospice provider name, address and phone.” • Contact the PA unit at the appropriate phone number listed below and inform the PA unit that a PCA PA request for a member in hospice has been electronically submitted. Be prepared to provide the PA unit with the member’s name, ID, date the member elected hospice, and the name, address and contact information of the member’s hospice provider. If a PCM agency is not submitting the request electronically: • Fax the PA request to the PA unit at the appropriate fax number listed below. Mark on the fax cover sheet “PCA REQUEST FOR MEMBER IN HOSPICE.” • Contact the PA unit at the appropriate phone number listed below. Inform the PA unit that a PA request for PCA services for a member in hospice has been submitted via fax. Be prepared to provide the PA unit with the member’s name, ID, date the member elected hospice, and the name, address and contact information of the member’s hospice provider. In all cases, PCM agencies must ensure that the PA request is fully completed and signed, including: • Prior Authorization Form PA-1 (paper requests): o Box 13 (Description of Treatment): State consumer is in hospice and state the number of PCA hours being requested for day/evening and for night. • PCA Application o Box 22(f): Provide the hospice provider’s name, address and phone. • PCA Evaluation o Page 6: Ensure that verbal authorization documentation is provided, or that the physician or nurse practitioner has signed the (continued on next page) Expediting PCA PA Requests for Members Who Have Elected Hospice (cont.) evaluation. MassHealth will accept the signature of the hospice medical director and nurse practitioner. o Ensure that the OT page is fully completed. MassHealth will accept this form being completed and signed by the hospice OT, providing the hospice OT has reviewed and concurs with the evaluation in its entirety. PCM agencies must include a copy of the member’s hospice plan of care whether the request is submitted electronically or on paper. In addition, MassHealth requests that PCM agencies ensure skills training is provided in an expeditious manner to ensure that members, or their surrogates, receive the assistance necessary to complete and forward all required paperwork to the fiscal intermediary as soon as possible. PA Unit Phone Numbers and Contacts PA Unit phone numbers and contacts are listed below. Contact Phone Fax Clinical Manager 617-451-7652 617-451-7094 Clinical Lead 617-451-7159 617-451-7105 Adhering to the policies and procedures described in this bulletin will allow MassHealth members who have elected hospice to receive medically necessary PCA services in a timely fashion. Questions If you have any questions about the information in this bulletin, 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. .