(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).
(B) Before implementing or modifying the
service agreement, the PCM agency must provide to the member and surrogate or
administrative proxy, if any:
(1) a copy of
the plan;
(2) an explanation, if
necessary, of the terms of the plan;
(3) an opportunity to object to any terms of
the plan; and
(4) a process to
resolve any objections or disagreements as soon as possible, including an
opportunity to meet with all interested persons.
(C) A review of the service agreement must
include a review of the needs and circumstances of the member, the services
provided by the PCA and, if appropriate, the surrogate or administrative
proxy's role related to management of PCA services on behalf of the member.
(1) The PCM agency will complete a service
agreement with the member and surrogate or administrative proxy, if any, before
the initiation of PCA services and at least annually thereafter, and as needed
due to a change of circumstances that may affect a member's ability to manage
PCA services independently or function as an employer of PCAs.
(2) The PCM agency will review the service
agreement with the member, and surrogate or administrative proxy, if any, on at
least a quarterly basis in the first year of prior authorization for PCA
services and at least annually thereafter, and when one of the following
conditions exists, and modify, as appropriate:
(a) the member or surrogate is not managing
PCA services effectively, as evidenced by consistent overutilization of PCA
hours, scheduling overtime requiring authorization absent such authorization by
the MassHealth agency, inappropriate submission of activity forms, difficulty
in retaining PCAs, suspicion of fraud, or other indication that the member or
surrogate or administrative proxy is not able to manage PCA services;
(b) the member identifies a new surrogate or
administrative proxy, and in accordance with the PCM agency contract;
or
(c) the member, the MassHealth
agency, or the surrogate or administrative proxy requests a
review.
(D) All
service agreements must be signed by the parties involved.
(E) The PCM agency is responsible for
monitoring the overall implementation of the service
agreement.
