Temporary & Continuity of Care Approval
MassHealth PCA Overtime Policy: Temporary and Continuity of Care Approval Criteria November 22, 2016
A consumer may request authorization to schedule a PCA to work in excess of 10 hours of overtime in a single week under certain circumstances. When authorizing a consumer to schedule a PCA to work overtime in excess of 10 hours, MassHealth will review the consumer’s request and, if approved, will provide either a temporary authorization of up to 12 weeks or a continuity of care authorization for the duration of the consumer’s prior authorization period. MassHealth will use health and safety guidelines in making approval determinations.
Described below are the circumstances under which MassHealth will approve overtime in excess of 10 hours in a single week.
• A consumer may request a Temporary approval to schedule a PCA to work overtime when:
o The consumer has a temporary need to schedule one PCA to work overtime hours, including:
The consumer has planned travel, and it would not be feasible to bring multiple PCAs to provide the consumer’s PCAs services.
The consumer’s PCAs is temporary unavailable (e.g. vacation, winter break, family leave).
The consumer has a temporary need to schedule their PCA to work additional approved PA hours. (e.g. post-acute hospitalization)
The consumer’s PCA works greater than 66 hours per week and the Consumer needs time to hire additional PCAs.
• Requests for a temporary approval must include the specific reason(s) for such request.
CONTINUITY OF CARE APPROVAL
• A consumer may request a continuity of care approval to schedule a PCA to work overtime when:
o The consumer has complex medical needs that require the specialized skills of the experienced PCA.
o The consumer has communication barriers that require the specialized skills of the experienced PCA.
o The consumer has specialized medical conditions that necessitate fewer PCAs. Examples might include circumstances in which additional PCAs in the consumer’s home would compromise the consumer’s health due to a highly compromised immune system, or a circumstance in which a consumer has significant cognitive impairments or behaviors that impact safety, and that the hiring additional PCAs would cause disruption in security, health and/or safety to the consumer.
o The consumer receives Hospice care.
o The consumer’s PCA has worked with the consumer for 5 or more years.
• Continuity of care Approvals are for the duration of the consumer’s Prior Authorization.
• Continuity of care Approvals must be resubmitted for subsequent Prior Authorization periods.
• Requests for continuity of care Approvals must include the specific reason(s) for such request.
• If a PCA works greater than 66 hours per week, the consumer must apply for a Temporary Authorization.
I. Temporary Approvals
Temporary approvals will be granted when one or more of the following circumstances are present. Approvals will be granted when the consumer provides evidence that the request is time limited (for example, that the PCA is going on maternity leave and expected delivery date).
The consumer will be traveling, and it is not feasible to bring multiple PCAs to provide PCA Services during planned travel.
Increased need for personal care services
The consumer has a temporary need to schedule their PCA to work additional approved PA hours (e.g. post-acute needs).
Significant challenges in hiring/retaining additional PCAs
o Placed multiple ads/used multiple resources for seeking PCAs, but received no responses, including evidence that the consumer registered on the rewarding work website and is using that website to try to recruit PCAs
o Interviewed multiple PCAs but no PCAs would accept the position
o The PCA did not remain in employment because PCA could not attain basic knowledge to safely carry out the PCA assigned tasks
o The PCA left employment suddenly
PCA short term leaves or short term fluctuations in schedule (PCA will return to work)
o Is in school and absent due to school breaks
o Has child care needs
o Family leave
o Sick leave
o Maternity leave
The consumer’s PCA works greater than 66 hours per week and the consumer needs time to hire additional PCAs.
II. Continuity of Care Approvals
Continuity of Care Approvals will be granted for the life of the Prior Authorization only when one or more of the below circumstances is present:
The Consumer has Complex Medical Needs:
1. The consumer has Intensive ADL and health care needs that require the specialized skills of a specific PCA. Training levels exceed basic ADL/IADL tasks. Hiring additional PCAs will cause a disruption in security and increased vulnerability to secondary, co-morbid, and age-related conditions.
Physical, mental, and behavioral impairments have a significant impact on ADL and IADL performance status. Consumers approved for moderate to dependent level of physical assist with ADLS (from PCA evaluation) require 50% to 100% physical assist with ADLs. (Defined on Time for Task tool).
Procedures performed and equipment utilized are factors for consideration of complex care needs. (Time for Task tool)
o Tube feedings
o Tracheostomy care
o Vent and respiratory treatments
o Ostomy care
o Bowel regimes
o Catheter care
o Subcutaneous injections
o Transfer and mobility aids ( mechanical and manual)
o G-tube equipment
o Urological equipment and drainage systems
o Respiratory equipment /oxygen
o Assistive devices for Communication
And the consumer provides evidence that they have complex medical needs:
2. Complex Medical Needs Include: (indicators found in MMIS or PCA evaluation)
o Hospitalization admission (over the past year reports acute hospitalization requiring SNF admission)
o SNF admissions (over past two years; reports 1 or more SNF admission > 90 days)
o Behavioral health impairments which result in difficulty engaging with new people, impacting daily function. (Examples includes: Social anxiety disorder or Post-traumatic stress disorder and Autism Spectrum, Schizo-affective disorder)
o 3 or more ADL impairments
o Community Case Management- consumer using the PCA under the nurse/ PCA option
The consumer has communication barriers that require the specialized skills of the experienced PCA.
Hiring additional PCAs will cause a disruption in care and increased vulnerability to the consumer. Includes communication barriers which impair the ability of the consumer/surrogate to hire PCAs and effectively direct his/her own care.
Evidence of Communication barriers include:
o Consumer requires use of augmentative or assistive devices to direct PCA and communicate effectively.
o Consumer may have difficulty understanding or expressing self-due to diagnosis/condition (examples include dementia, Cerebral Vascular Accident, or aphasia).
Differentiate between impairments/deficit due to dx versus consumer does not speak English but is able to direct care using primary language or requires an interpreter. Can express and understand in primary language.
• The consumer has entered into Hospice care
Length of Service
• PCA has worked for the consumer on an ongoing basis for 5 or more years
One on One Relationship
• Consumer is approved for 50 to, up to 66 hours of PCA services
• Consumer has one PCA who provides all of the consumer’s PCA services
• Consumer and PCA reside together (confirmed via 3rd party documentation)