Attachment A - Model Contract~13.docx

Model Contract for Personal Care Management Functions between The Executive Office of Health and Human Services Commonwealth of Massachusetts and [Personal Care Management Agency NAME]

TABLE OF CONTENTS

Attachment A – Model Contract for PCM Functions Page 2 of 2 This Agreement constitutes the Personal Care Management Functions Contract between the Commonwealth of Massachusetts, acting by and through the Executive Office of Health and Human Services (EOHHS), and [PCM NAME]. The Contractor's principal place of business is: [XX] WHEREAS, EOHHS is an agency of the Commonwealth of Massachusetts responsible for administration of the Medicaid program and the State Children’s Health Insurance Program within Massachusetts (collectively, MassHealth) and other health and human services programs designed to pay for medical services for eligible individuals pursuant to M.G.L. c. 118E, Title XIX of the Social Security Act (42 U.S.C. sec. 1396 et seq.), Title XXI of the Social Security Act (42 U.S.C. sec. 1397aa et seq.), and other applicable laws and waivers;

WHEREAS, the Contractor is in the business of Personal Care Management functions, and EOHHS is in need of such functions to be performed;

WHEREAS, on XXX, 2026, EOHHS posted on the Commonwealth of Massachusetts procurement website, COMMBUYS, a Request for Responses for Personal Care Management Functions (“RFR”);

WHEREAS, on XXX, EOHHS selected the Contractor, based on the Contractor’s response to the RFR submitted by XXX (electronic) and XXX (hard copy and flash drives);

WHEREAS, the Contractor appears qualified and is willing to perform its duties as set forth herein subject to the terms and conditions thereof;

NOW, THEREFORE, in consideration of the mutual covenants and agreements contained herein, EOHHS and the Contractor agree as follows:

Definition of Terms Activities of Daily Living (ADLs) — those specific activities described in 130 CMR 422.410(A) and this Contract that are performed by a PCA to physically assist a Consumer with mobility, taking medications, bathing or grooming, dressing, passive range of motion exercises, eating, and toileting.

Activity Form — the timesheet, in a form and format designated by EOHHS, to be used by the Consumer, the Surrogate or Administrative Proxy, if any, and the PCA, for recording all PCA Activity Time for each pay period.

Activity Time — the actual amount of time spent by a PCA physically assisting a Consumer with ADLs and IADLs. Activity Time is reported on an Activity Form.

Administrative Proxy — the Consumer’s legal guardian, a family member, or any other person located and appointed in accordance with 130 CMR 422.420(A)(22), and as identified in the service agreement, who is responsible for performing certain administrative functions related to PCA management that the Consumer is unable or unwilling to perform.

Assessment — a determination of a Member/Consumer’s ability to manage PCA Services independently, and a determination of a Surrogate or Administrative Proxy’s ability to manage PCA Services on behalf of a Consumer, conducted in accordance with 130 CMR 422.422(A) and the requirements of this Contract.

Closed case — a Consumer who has a current Prior Authorization for PCA Services, but who is no longer utilizing PCA Services.

Complaint — a telephonic, In-person, or written expression of dissatisfaction with the Contractor that is made to the Contractor, EOHHS, FI, or other relevant entities by the Consumer, Surrogate, or Administrative Proxy, and logged and reviewed by the Contractor for resolution in accordance with the Contractor’s policies and procedures for addressing complaints.

Consumer — a MassHealth Member who has been approved to receive PCA Services. The Consumer is the employer of the PCA.

Consumer Agreement — the MassHealth standard agreement that the Consumer must sign prior to enrolling with a Fiscal Intermediary.

Contract — this Contract entered into between EOHHS and the Personal Care Management Agency.

Contract Effective Date — the date on which the Contract is effective, which shall be the date this Contract is fully executed by both parties.

Contractor — any entity that enters into this Contract with EOHHS for the provision of Personal Care Management Functions.

Date of Inquiry — initial date the Contractor is contacted via telephone, fax, in person, in writing, or other method by or about a Member seeking PCA Services.

Eligibility Verification System (EVS) — a system used to provide day-specific MassHealth eligibility, service-authorization requirements, and third party-liability information about Members.

Employer Required Tasks — tasks described in the EOHHS contract with the fiscal intermediary that relate to the member’s employment of PCAs, including, but not limited to:

a) employer obligations, including filing the member’s federal and state taxes, withholding PCA taxes, paying unemployment insurance taxes, purchasing worker’s compensation insurance, and preparing the PCA payroll;

b) payroll responsibilities, including reviewing activity forms and verifying prior-authorization status; and

c) fiscal functions, including generating and distributing checks.

Evaluation — an initial determination of the scope and type of PCA Services to be provided to a member who meets the qualifications of 130 CMR 422.403 and that is conducted by a Registered Nurse, and/or an Occupational Therapist, in accordance with 130 CMR 422.422(C) and the requirements of this Contract.

Electronic Medical Record (EMR) – a digital version of a Consumer’s medical history, including diagnoses, treatments, and other relevant information.

Electronic Visit Verification (EVV) — an electronic method or system designated by EOHHS to be used as an activity form and that requires verification of PCA services at the time PCA services are provided Executive Office of Health and Human Services (EOHHS) — the executive agency within Massachusetts that is the single state agency responsible for the administration of the MassHealth program (Medicaid), pursuant to M.G.L. c. 118E, Titles XIX and XXI of the Social Security Act, and other applicable laws and waivers thereto.

Family Member — the spouse of the Consumer, the parent of a minor Consumer, including an adoptive parent, or any legally responsible relative, including a relative who is a legal (court-appointed) guardian of the Consumer.

Fiscal Intermediary (FI) — 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 Management Agency, in accordance with 130 CMR 422.421(B) and the requirements of this Contract, including In-person Comprehensive Functional Skills Training, In-person Issue-focused Functional Skills Training, and Telephonic Functional Skills Training, to assist Consumers who have obtained Prior Authorization for PCA services and their Surrogates or Administrative Proxies, if any, in developing the skills and resources required to maximize the Consumers’ management of the PCA Program, including, but not limited to, personal health care, PCA services, ADLs, emergency needs, and activities related to the Fiscal Intermediary.

Grievance — an expression of dissatisfaction with the Contractor made to the Contractor, EOHHS, FI, or other relative entities by the Consumer, Surrogate, or Administrative Proxy that remains unresolved after proceeding through the Contractor’s complaint review and resolution process and that has been escalated for further or heightened review with the Contractor in accordance with the Contractor’s policies and procedures for addressing grievances.

Health Insurance Portability and Accountability Act of 1996 (HIPAA) — federal legislation (Pub. L. 104-191), enacted to improve the continuity of health insurance coverage in group and individual markets, combat waste, fraud, and abuse in health insurance and health-care delivery, simplify the administration of health insurance and protect the confidentiality and security of individually identifiable health information.

Holiday — New Year’s Day, Martin Luther King Jr. Day, Juneteenth, Independence Day, Thanksgiving Day, and Christmas Day Inquiry — initial contact to the Contractor via telephone, fax, in person, in writing, or other method by or about a Member seeking PCA Services.

Instrumental Activities of Daily Living (IADLs) — those specific activities described in 130 CMR 422.410(B) that are instrumental to the care of a Consumer’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 Consumer to receive PCA Services.

Intake and Orientation — functions the Contractor provides to Members seeking PCA Services who have not yet received Prior Authorization for PCA Services, and as conducted in accordance with 130 CMR 422.421(A) and Section 2.1.B.

Key Personnel — those individuals identified by the Contractor as performing the key functions identified in Section 2.3.B.2 of the Contract.

Licensed Practical Nurse (LPN) — a person currently licensed as a licensed practical nurse by the Massachusetts Board of Registration in Nursing and in good standing with the Board.

MassHealth — the Medicaid program of the Commonwealth of Massachusetts, administered by EOHHS pursuant to M.G.L. c. 6A s. 16, 118E, Titles XIX and XXI of the Social Security Act, and other applicable laws and waivers thereto.

Material Subcontractor — any entity to which the Contractor delegates the responsibility to meet a key function or requirement under the RFR or Contract.

Medicaid Management Information System (MMIS) — the federally mandated management information system of software, hardware, and manual procedures used to process MassHealth claims and to retrieve and produce service utilization and management information.

Member — a person determined by EOHHS to be eligible for MassHealth.

Nurse Practitioner — a Registered Nurse who is currently licensed by the Board of Registration in Nursing, in good standing, and meets the requirements detailed in 244 CMR 4.05.

Occupational Therapist — a person currently licensed by and in good standing with the Massachusetts Board of Allied Health Professions, and currently certified by and in good standing with the National Board for Certification in Occupational Therapy.

Operational Start Date — the date on which the Contractor starts to provide PCM functions as determined by EOHHS.

Overtime — Activity Time worked in excess of 40 hours in a Work Week.

Overtime In the Aggregate — Activity Time worked by a PCA for multiple Consumers, where the time worked may not exceed 40 hours per Work Week for any individual Consumer, but where the time worked exceeds 40 hours per Work Week when time worked for each Consumer is added together.

Overtime Requiring Authorization — activity time performed by a PCA in excess of the weekly hour limit specified in 130 CMR 422.418(A).

PCA New Hire Orientation — The required orientation new PCAs must complete within nine months from their date of hire.

PCA Paid Earned Time — The PCA collective bargaining agreement provides that Personal Care Attendants (PCAs) shall accrue one hour of paid earned time for every thirty hours worked. PCAs shall begin accruing paid earned time commencing with the date of hire of the PCA. PCAs may use paid earned time as it accrues.

Primary Care Provider (PCP) Summary Form — a MassHealth required form detailing the member’s medical conditions and care needs.

Personal Care Attendant (PCA) — a person who meets the requirements described in 130 CMR 422.404(A)(1) and this Contract, who is hired by the Consumer to provide PCA services.

Personal Care Attendant Program (PCA Program) — a MassHealth program under which PCA services and associated Personal Care Management and Fiscal Intermediary functions are available to MassHealth members.

Personal Care Attendant Services (PCA Services) — physical assistance with ADLs and IADLs provided to a Consumer by a PCA in accordance with the member’s authorized initial Evaluation or Re-evaluation, Service Agreement, and 130 CMR 422.000.

Personal Care Management Agency (PCM Agency) — a public or private agency under contract with EOHHS to provide PCM Functions in accordance with 130 CMR 422.000 and the requirements of this Contract.

Personal Care Management Functions (PCM Functions) — administrative functions conducted by a Personal Care Management Agency in accordance with this Contract, including, but not limited to, those functions described in Section 2.1 of this Contract and at 130 CMR 422.419(A), 422.421, 422.422, and 422.423.

Prior Authorization (PA) — a MassHealth determination that PCA services are medically necessary.

Prior Authorization Period (PA Period) — the dates authorized by EOHHS or its agent designating the duration of services covered by the Prior Authorization.

Prior Authorization Request (PA Request) — a request to initiate, continue, or adjust a Member’s or Consumer’s Prior Authorization for PCA Services that must be submitted by the Personal Care Management Agency to EOHHS or its agent in accordance with 130 CMR 422.416 and 422.418 and the requirements of this Contract. EOHHS or its agent may approve, modify, defer, or deny a PA Request.

Privacy and Security Rules — the privacy, security and related regulations promulgated under the Health Insurance Portability and Accountability Act of 1996, as amended (HIPAA) (found at 45 CFR Parts 160 and 164).

Protected Information (PI) — any “protected health information” (PHI) as used in the Privacy and Security Rules, any “personal data” as defined in M.G.L. c. 66A, any “patient identifying information” as used in 42 CFR Part 2, any “personally identifiable information” as used in 45 CFR §155.260 and/or any other individually identifiable information that is treated as confidential under applicable privacy or security law or regulation that the Contractor (or its subcontractor or agent) creates, receives, acquires, uses, transmits or maintains in connection with its provision of PCM functions and/or its performance of a function or activity for or on behalf of EOHHS under this Contract. Information, including aggregate information, is considered PI if it is not fully de-identified in accord with 45 CFR §§164.514(a)-(c).

Public Assessor Option (PAO) — An entity contracted by and acting on behalf of EOHHS to administer initial Member Assessments and Evaluations for in scope LTSS services, only if a Member selects the Public Assessor Option Re-evaluation — an assessment of a Consumer’s continuing need for PCA services to be provided to a Consumer who requests a continuance of PCA services because the current authorization is expiring. The Re-evaluation must be conducted in accordance with 130 CMR 422.422(D) and the requirements of this Contract.

Registered Nurse — a person licensed as a Registered Nurse by the Massachusetts Board of Registration in Nursing and in good standing with the Board.

Request for Responses (RFR) — the Request for Responses for Personal Care Management Functions for the MassHealth Personal Care Attendant Program issued by EOHHS.

Same-day Travel Time — time spent by a PCA that works for more than one Consumer, and which is spent traveling between one Consumer’s home and another Consumer’s home on the same day to provide PCA services. Same-day Travel Time does not include travel to or from the PCA’s home.

Service Agreement — a written or electronic plan of services, consistent with the requirements of 130 CMR 422.423 and this Contract, that is developed by the Contractor, the Consumer, and the Surrogate or Administrative Proxy, if any, which describes the responsibilities of the PCA, the Consumer, the Surrogate or Administrative Proxy, the Fiscal Intermediary, and the Personal Care Management Agency.

Subcontractor — any consultant or non-employee personnel or staff member, whether short term or long duration.

Surrogate — the Consumer’s legal guardian, a family member, or any other person located and appointed in accordance with 130 CMR 422.420(A)(22), and as identified in the service agreement, who is responsible for performing certain PCA management tasks that the Consumer is unable or unwilling to perform Uniform Financial Statements 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.

Weekly Hour Limit — the weekly hour limit established pursuant to 130 CMR 422.418(A)(1).

Work Week — a seven-day period beginning Sunday at 12:00 A.M and ending the consecutive Saturday at 11:59 PM

Contractor Responsibilities Public Assessor Option Functions The Public Assessor Option (PAO) is available for initial inquiries for the PCA program and is provided through self-selection into the PAO. The purpose of the PAO is to provide another “door” for Members to access LTSS services. Once a Member selects the PAO, the PAO then administers the initial evaluation and consumer assessment in the Member’s home.

Specifically, if the Member selects into the PAO, the PAO will:

Confirm the Member’s eligibility for MassHealth Complete a telephonic screening with Member and confirm a chronic and disabling condition. The PAO provides the Member with an overview of the PCA Program and the self-direction model.

Complete an Assessment of the Member’s ability to independently perform PCA management tasks and to function as an employer of PCAs, in the form and format required by EOHHS.

Schedule and conduct an in-person initial Evaluation for PCA Services using the Time to Task Tool (TTT) with the Member and discuss nearby PCM options.

Request the PCP Summary Form from the Member’s PCP office.

Assist the Member with identifying a potential Surrogate based on the results of the Consumer Assessment. If surrogate is identified, PAO will then complete a Surrogate Assessment in the form and format required by EOHHS.

Contact the selected PCM to confirm availability for Member. Once confirmation is received, PAO will provide the PCM with the completed Telephonic screen, completed Consumer Assessment, completed Surrogate Assessment (if completed), completed TTT and signed PCP Summary form.

Submit the Prior Authorization (PA) to TPA Once PA is submitted and approved, the Contractor will begin I&O process as outlined below. Any documents provided by the PAO will not have to be completed in the I&O visits. Contractor responsibilities include ongoing functional skills training and all future re-evaluations and re-assessments.

The Contractor cannot refer a Consumer to the PAO based on the Contractor’s inability to assess the Member within the timelines specified in the contract unless otherwise approved or directed to by EOHHS. The Contractor may only refer the Member to the PAO if, based on the initial screening, the Member does not meet the minimum eligibility requirements for PCA Services but may be eligible for other LTSS programs.

The remainder of the Contract will apply only to when a Member is onboarded directly by the PCM and does not engage with the PAO.

PCM Functions Eligibility Verification

1. The Contractor shall query MassHealth’s Eligibility Verification System (EVS) to determine each Member/Consumer’s eligibility for MassHealth as of the date of each Intake and Orientation session, initial Evaluation, Re-evaluation, and Functional Skills Training session, and monthly at the beginning of each month for Administrative Payments. The contractor must check (EVS) prior to submitting any Prior Authorization requests confirming the member has MassHealth eligibility.

2. For all Members identified by EVS during the eligibility verification process as “Community Case Management” (CCM) members, the Contractor should refer the Member to CCM. CCM is responsible for conducting the PCA initial Evaluation and Re-evaluation and authorizing PCA Services for all CCM members. For Members enrolled in CCM and receiving PCA services, the Contractor is responsible for providing all other PCM functions, including, but not limited to, intake and orientation, conducting the Assessment, Functional Skills Training, and developing the Service Agreement. The Contractor should coordinate with CCM regarding Members enrolled in CCM with details from the Assessment, Functional Skills Training, and Service Agreement, and continuously as needed.

Intake and Orientation When the Contractor receives an Inquiry for receipt of PCA services from a Member, the Contractor shall perform the following functions prior to submitting a Prior Authorization (PA) request for PCA services for the Member:

1. Respond, by telephone, to the Inquiry within three business days of the Inquiry, collecting the Member’s information including the Member’s Primary Care Provider (PCP), demographic information, chronic disabling condition, and email address, and provide the Member with a PCA Program fact sheet in the form and format as required by EOHHS;

2. Complete an In-person initial determination of the Member’s eligibility for the PCA program within 10 business days of the Date of Inquiry, at the first Intake and Orientation session, in accordance with 130 CMR 422.403 and 422.421, and maintain all documentation related to said initial determination in the Member’ record. The initial determination includes the Assessment of the Member to Manage PCA Services conducted in accordance with Section 2.2.A, and if the Member is found to require a Surrogate or Administrative Proxy, an assessment of the identified Surrogate or Administrative Proxy, as applicable and conducted in accordance Section 2.2.B If the Surrogate or Administrative Proxy is not present at the initial Intake and Orientation session, an assessment can be conducted at a subsequent Intake and Orientation session or other In-person visit;

3. Obtain a PCP Summary Form, in the form and format required by EOHHS, detailing the members disabling condition(s),

a. A PCP Summary Form does not have an expiration date, but a new PCP Summary Form must be requested for every new Re-evaluation.

b. A PCP Summary Form cannot be submitted for more than one Prior Authorization request.

4. Once the PCP Summary Form has been received, provide a second In-person Intake and Orientation session regarding the PCA Program to each Member, and Surrogate or Administrative Proxy as applicable, that the Contractor has initially determined meets the eligibility requirements of the PCA Program. This orientation session shall include, at minimum:

a description of all the components and structure of the PCA Program, including Electronic Visit Verification System (EVV), assist member in obtaining an email address and using EVV as the timekeeping system, education about a Consumer’s duties and responsibilities as an employer of PCAs, a description of the PCAs as employees as well as providers of personal care services, including PCA job description, education about how a Consumer and Surrogate or Administrative Proxy, if any, can appropriately manage PCA services, a description of a Consumer’s rights and responsibilities as described in 130 CMR 422.420 and the rules, regulations, and policies governing the PCA Program, including but not limited to the Consumer’s responsibility to use PCA Services as authorized by EOHHS, pursuant to 130 CMR 422.416(E), assist the Consumer to enroll with the Fiscal Intermediary (FI) by completing and signing the Consumer Agreement prior to employing PCAs, as well as completing all required FI paperwork. The Contractor must notify the Fiscal Intermediary of the name, MassHealth ID number, address, email, and telephone number of the Consumer Upon completion of the Initial Evaluation, but prior to the submission of the Prior Authorization, the Contractor must complete a third Intake and Orientation session, which may be completed In-person or virtually, that includes the following, at minimum:

a. Education on unallowable services and fraud, waste, and abuse,

0. Education on employment and labor laws including but not limited to timely payment;

A description of a Consumer’s right to obtain a CORI or SORI and the process to obtain each. The Contractor must obtain an acknowledgement form signed by the Member, or Surrogate as applicable, including information about the right to obtain Criminal Offender Record Information (CORI) or Sex Offender Record Information (SORI);

Education on the PCA New Hire Orientation Requirements;

Assistance in registering for an EVV training and review of EVV requirements, and;

Education on how to complete new hire paperwork in the form and format required by EOHHS and that a PCA should not be scheduled to work until completed new hire paperwork has been received and processed by the fiscal intermediary.

5. Document Intake and Orientation sessions in accordance with Section 2.3.D.5.

Assessment of Ability to Manage PCA Services For each Member initially determined by the Contractor to meet the eligibility criteria in 130 CMR 422.403, the Contractor shall conduct an Assessment of the Member to determine the Member’s ability to independently perform PCA management tasks. The Assessment of the Member shall be completed in accordance with Section 2.2.A of the Contract. If the Member is assessed to require, or otherwise requests, the use of a Surrogate or Administrative Proxy to assist in managing their PCA services, the Contractor shall assist the Member in designating a Surrogate or Administrative Proxy.

If the Member requires a Surrogate or Administrative Proxy, or elects to have a Surrogate or Administrative Proxy, the Contractor shall conduct an Assessment to determine the Surrogate or Administrative Proxy’s ability to perform this function in accordance with Section 2.2.B of the Contract. A Consumer may not have both a Surrogate and Administrative Proxy. The Contractor must perform the Assessment of the identified Surrogate or Administrative Proxy, as applicable, prior to submitting a request for Prior Authorization to EOHHS or its designee.

If the Member has a court-appointed legal guardian, or if the Member is under 18 years of age (a minor child), it is presumed that a Surrogate is required and no Assessment of the Member’s ability to manage PCA services is required. In such circumstances, an Assessment of the Surrogate’s capacity to manage PCA services must be conducted in accordance with Section 2.2.B of this Contract.

The Contractor shall ensure that the designated staff who oversee and conduct Assessments are accessible to EOHHS by telephone for questions related to Assessments of particular Consumers and Surrogates and Administrative Proxies. The Contractor staff must respond to each EOHHS inquiry within three business days of the contact.

Conducting Member Assessments The Contractor shall:

1. Based on an In-person visit with the Member, conduct an Assessment of the Member’s ability to independently perform PCA management tasks and to function as an employer of PCAs, in the form and format required by EOHHS. The Assessment must meet the requirements of 130 CMR 422.422(A) and must be conducted prior to submitting the request for Prior Authorization for PCA Services to EOHHS or its designee.

0. The Assessment determines whether the Member:

Is able to perform independently all tasks required to manage PCA Services;

Requires the assistance of an Administrative Proxy to perform some or all of the administrative tasks related to PCA management that the Member is unable or unwilling to perform; or Requires the assistance of a Surrogate to perform some or all of the PCA management tasks that the Member is unable or unwilling to perform.

The Contractor shall conduct a subsequent assessment of a Consumer’s ability to independently perform PCM management functions that includes a review of the prior year, at an In-person visit with the Consumer. Subsequent assessments must occur at the following times:

At the Annual In-person Comprehensive Functional Skills Training visit;

When the Consumer’s medical, cognitive, or emotional condition changes in a way that affects the Consumer’s ability to manage PCA Services independently;

When the Consumer exhibits a pattern of overutilization, inappropriate use of PCA Services including the scheduling of overtime requiring authorization without obtaining proper authorization;

When a Consumer fails to use or demonstrates inappropriate use of the Electronic Visit Verification system required by EOHHS;

When the contractor suspects potential fraud; or;

If the Consumer or EOHHS requests an Assessment.

After reviewing the Assessment with the Member, or after completing a subsequent Assessment of a Consumer, obtain the signature of the Member/Consumer, and inform the Member/Consumer of the right to file a complaint with the Contractor, in accordance with the Contractor’s complaint and grievance policy (see Section 2.2.G.1);

Maintain a copy of the completed and signed Assessments in the Member/Consumer’s record and make it available to EOHHS or the Member/Consumer upon request.

0. Conducting Surrogate and Administrative Proxy Assessments If a Member/Consumer is assessed to require or requests a Surrogate or Administrative Proxy, the Contractor shall conduct an Assessment of the ability of the Surrogate to manage PCA services or an Administrative Proxy to perform administrative tasks, as applicable, on behalf of the Member/Consumer based on an In-person meeting with the Surrogate or Administrative Proxy, and in the form and format as required by EOHHS. Such In-person meeting may occur during an Intake and Orientation session or Functional Skills Trainings session, if appropriate. If the selected Surrogate is found to be unable to manage PCA services or the Administrative Proxy is found to be unable to perform administrative tasks, as applicable, on behalf of the Member/Consumer, the Member/Consumer will be required to select a different Surrogate or Administrative Proxy. The Contractor, or EOHHS, may require an alternative Surrogate or Administrative Proxy to be identified based on the results of the Assessment. The Contractor must maintain this Assessment of the ability of a Surrogate to manage PCA services or the Administrative Proxy to perform administrative tasks, as applicable, on behalf of the Member/Consumer in the Member/Consumer’s record. If a Member is assessed to require or request a Surrogate or Administrative Proxy prior to initial PA submission, the Assessment of the Surrogate or Administrative Proxy must be conducted prior to submitting the request for Prior Authorization for PCA Services to EOHHS or its designee.

If a Member/Consumer requires or requests a Surrogate or Administrative Proxy, and the Member/Consumer has difficulty selecting a Surrogate or Administrative Proxy, the Contractor shall assist the Member/Consumer or the Member/Consumer’s legal guardian in selecting a Surrogate or Administrative Proxy. In performing this function, the Contractor shall maintain the Surrogate’s or Administrative Proxy’s name, address, email address, telephone number, and relationship to the Member/Consumer in the Member/Consumer’s record and forward a copy of the information to the Fiscal Intermediary within two business days following the submission of the Prior Authorization request. Submit requests for Prior Authorization to MassHealth only when a Surrogate or Administrative Proxy has been selected and assessed to be able to manage PCA services on behalf of the Member;

When a Consumer identifies a new Surrogate or Administrative Proxy or if a Surrogate or Administrative Proxy is newly required:

Notify the Fiscal Intermediary if the Consumer’s Surrogate or Administrative Proxy changes and include the new Surrogate’s or Administrative Proxy’s name, address, telephone number, email address, and relationship to the Consumer. Any new Surrogate or Administrative Proxy information must be sent to the Fiscal Intermediary within three business days following the Contractor’s retrieval of such information; and Within 2 business days, submit to EOHHS or its agent documentation of the new Surrogate or Administrative Proxy in the form and format specified by EOHHS.

If a Consumer has been assessed to require a Surrogate or Administrative Proxy, and the identified Surrogate or Administrative Proxy becomes unavailable during the Prior Authorization period, the Contractor must notify the Consumer in writing that the Consumer must identify a new Surrogate or Administrative Proxy within 30 calendar days. The Contractor must notify MassHealth in writing in the form and format specified by EOHHS within 2 business days that the Consumer has been notified of the Surrogate or Administrative PA requirement. At the culmination of the 30-day period, if a new Surrogate or Administrative Proxy cannot be identified, the Contractor must initiate the EOHHS termination policy and refer the Consumer to an appropriate service provider and conduct transition planning in accordance with Section 2.2.I.2;

If the Contractor’s Assessment determines that a Consumer’s capacity to manage PCA Services independently has changed during the Prior Authorization period and that the Consumer now requires a Surrogate or Administrative Proxy, the Contractor must notify the Consumer in writing that he or she has 30 calendar days from the date of the Assessment to select a Surrogate or Administrative Proxy. The contractor must notify MassHealth or its designee in writing in the form and format specified by EOHHS within 2 business days of the notification of the Consumer with a copy of the assessment. If the Consumer cannot select a Surrogate or Administrative Proxy within 30 calendar days of the Contractor’s Assessment, the Contractor must refer the Consumer to an appropriate service provider and conduct transition planning in accordance with Section 2.2.I.2;

The Contractor shall conduct a Surrogate or Administrative Proxy Assessment on any new Surrogate or Administrative Proxy that is selected by the Consumer. If the selected Surrogate or Administrative Proxy is found to be unable to manage PCA services on behalf of the Consumer, the Consumer will be required to select a different Surrogate or Administrative Proxy;

If the Contractor obtains evidence that the Consumer’s Surrogate or Administrative Proxy is not managing PCA tasks for the Consumer in accordance with 130 CMR 422.419(A)(20), the Contractor must provide Functional Skills Training to educate the Consumer’s Surrogate or Administrative Proxy about proper management of the PCA program. If, after the training, the Surrogate or Administrative Proxy continues to demonstrate the inability to properly manage the PCA Program, the Contractor must notify the Consumer in writing that the Consumer’s Surrogate or Administrative Proxy is not managing PCA tasks for the Consumer in accordance with 130 CMR 422.419(A)(20) and provide 30 calendar days to obtain a new Surrogate or Administrative Proxy. Such notice shall include:

A summary of the Functional Skills Training the Contractor has provided to educate the Consumer’s Surrogate or Administrative Proxy regarding the proper management of PCA tasks; and The reason(s) the Contractor concludes that the Consumer’s Surrogate or Administrative Proxy is not managing PCA tasks for the Consumer in accordance with 130 CMR 422.419(A)(20).

The contractor must notify EOHHS or its designee in writing in the form and format specified by EOHHS within 2 business days of the notification to the Consumer that a new Surrogate or Administrative Proxy is required. If after 30 calendar days, the Consumer has not selected a new Surrogate or Administrative Proxy, the contractor must refer the Consumer to an appropriate service provider and conduct transition planning in accordance with Section 2.2.I.2;

The Contractor shall notify MassHealth or its designee and the Fiscal Intermediary of any change in the Consumer’s Surrogate or Administrative Proxy status within three business days of the Contractor’s knowledge of such change. Where such change was a result of subsequent Assessment in accordance with Section 2.2.B.1, the Contractor shall follow the requirements of that section;

Document the roles and responsibilities of the Surrogate or Administrative Proxy in the Consumer’s Service Agreement and complete the Service Agreement in accordance with 130 CMR 422.423(C); and If the Contractor’s Assessment determines that the Surrogate or Administrative Proxy is required, but one cannot be identified, the Contractor shall refer the Consumer to an appropriate services provider.

Initial Evaluations, Re-evaluations, and Requests for Prior Authorization Initial Evaluations and Re-evaluations The Contractor shall:

Conduct initial Evaluations and Re-evaluations for PCA Services in accordance with 130 CMR 422.422(C) and (D) and the requirements of this Contract.

Initial Evaluations must be conducted by an RN and an Occupational Therapist, or an LPN under the direction of an RN and an Occupational Therapist; and Re-evaluations must be conducted by an RN, or by an LPN or an Occupational Therapist at the option of the Contractor under supervision of an RN. Such supervision of an LPN or an OT by an RN must be documented in the written plan for supervising personnel in accordance with Section 2.3.B.4.

Conduct initial Evaluations and Re-evaluations that accurately reflect the Consumer’s functional abilities and need for physical assistance in performing ADLs and IADLs using the standard MassHealth PCA Evaluation in the form and format as required by EOHHS, and submit requests for Prior Authorization for medically necessary PCA Services where the Consumer meets the eligibility requirements for the PCA Program to MassHealth as specified in 130 CMR 422.403;

Prior to submitting a request for Prior Authorization in accordance with Section 2.2.C.2, the Contractor shall complete an Assessment of the Consumer’s ability to manage PCA Services, and, if applicable, the Surrogate or Administrative Proxy’s ability to manage PCA services on behalf of the Consumer;

Complete the Surrogate and Administrative Proxy section of the MassHealth Evaluation for PCA Services in the form and format as required by EOHHS and include all Surrogate or Administrative Proxy information. The Contractor must ensure that the Surrogate has reviewed and signed the MassHealth PCA Evaluation in the form and format as required by EOHHS;

Review the completed initial Evaluation or Re-evaluation with the Consumer or Consumer’s Legal Guardian and the Consumer’s Surrogate, if any, to ensure that the Consumer and the Consumer’s Surrogate, if any, understand the content of the Prior Authorization request that the Contractor is submitting to MassHealth and document such review;

Provide a copy of the completed MassHealth Evaluation for PCA Services in the form and format as required by EOHHS to the Consumer within 10 business days following the Contractor’s submission of such forms for a request for Prior Authorization in accordance with Section 2.2.C.2.a. The PCM Agency shall maintain documentation that the Contractor sent the MassHealth Evaluation for PCA Services in the form and format as required by EOHHS to the Consumer, including the date and method of sending. Said records, documenting compliance, shall be produced to EOHHS, or its designee, upon request;

Ensure that the Registered Nurse, LPN, or OT who oversees or conducts initial Evaluations and Re-evaluations is accessible to EOHHS by telephone for questions related to initial Evaluations and Re-evaluations of particular Consumers by providing to EOHHS the name, telephone number, and available days and times of the Registered Nurses, LPNs, and OTs, including the Registered Nurses designated as Key Personnel. The Registered Nurse, LPN, or OT must respond to each EOHHS inquiry within three business days of the contact.

Prior Authorization The Contractor shall submit in a timely manner all requests for Prior Authorization including adjustments and premium pay for overtime, in accordance with 130 CMR 450.000, 130 CMR 422.416 and 422.418, and the requirements of this Contract. The Contractor shall submit all requests for Prior Authorization electronically using EOHHS’s electronic Prior Authorization system and as follows:

Submit the following documentation with each Prior Authorization request, in accordance with 130 CMR 422.416:

The completed MassHealth Application for PCA Services form;

The completed MassHealth Evaluation for PCA Services form. The MassHealth Evaluation for PCA Services form must:

a) Be reviewed, approved, and signed by the Consumer or the Consumer’s legal guardian, and the Consumer’s Surrogate, if any (see Section 2.2.D.1.d); and

b) For initial Prior Authorization requests, contain the PCP Summary Form, signed by the members PCP outlining the members’ medical conditions, care needs, and complex care needs, if any. For Re-evaluations, a copy of the Consumer’s Electronic Medical Record (EMR) can be substituted for the PCP Summary Form if the Re-evaluation does not include Complex Care tasks.

The Assessment of the Consumer’s ability to manage PCA Services was made in accordance with Section 2.2.A.

The Contractor may include other available documentation that supports the Consumer’s need for PCA Services.

In submitting requests for Prior Authorization, the Contractor shall:

Request initial Prior Authorization from EOHHS or its designee for PCA Services in accordance with 130 CMR 422.416(A) and forward the request to EOHHS or its designee no later than 45 calendar days after the date the PCP Summary Form is received by the PCM;

Request Prior Authorization from EOHHS or its designee for a continuation of PCA Services by forwarding the request in accordance with 130 CMR 422.416(C) at least 21 calendar days prior to the expiration date of the current Prior Authorization period. EOHHS or its designee must have received the new Prior Authorization request in this timeframe, and if not received in a timely manner, EOHHS will stop payment for PCA Services after the expiration date;

If the Consumer requests an adjustment to the Prior Authorization pursuant to 130 CMR 422.416(B), the Contractor must determine whether the request meets the requirements of 130 CMR 422.416(B)(3) or 422.418(B) and, if appropriate, submit the request for an adjustment of the Prior Authorization to EOHHS or its designee within 30 calendar days of the Consumer’s request. The Contractor may submit the completed PCA Prior Authorization Adjustment request in the form and format as required by MassHealth when requesting a change in the number of authorized PCA hours;

Within three business days of a Consumer’s request for approval to schedule an individual PCA to work more than the Weekly Hour Limit, submit the request to EOHHS or its designee in accordance with 130 CMR 422.418(A); and Upon receiving notification that a Consumer’s MassHealth ID number has changed, request a new Prior Authorization for the Consumer from EOHHS or its designee within three business days.

The Contractor shall take appropriate measures to ensure continuity of PCA services for Consumers who will require a new Prior Authorization after the expiration of their current Prior Authorization, including, but not limited to:

Contacting the Consumer to schedule a Re-evaluation at least 45 calendar days in advance of the current Prior Authorization expiration; and requesting a PCP Summary Form from the Consumer’s PCP or EMR, if appropriate, at least 90 days prior to the current Prior Authorization expiration. If Contractor has not received PCP Summary Form or EMR, if appropriate, 45 days prior to the Prior Authorization expiration, Contractor shall send a follow up request to both the Consumer at the PCP indicating that the PCP Summary Form has not been received and as a result the Consumer may experience a gap in PCA coverage when their Prior Authorization expires. The Contractor shall document in its record keeping system all requests made for a PCP Summary Form or EMR, if appropriate, including the date and method of communicating. Said records, documenting requests for a PCP Summary Form or EMR, if appropriate, shall be produced to EOHHS, or its designee, upon request;

Submitting to EOHHS or its designee the completed Re-evaluation and all required documentation to request Prior Authorization at least 21 calendar days prior to the expiration of the current Prior Authorization in accordance with Section 2.2.C.2.b.2. and 130 CMR 422.416(C); and The Contractor shall not submit requests for Transition of Care in excess of one extension totaling 90 days. The end date of SCO/ICO enrollment can be no more than 90 days prior to the date received.

Service Agreement The Contractor shall develop, review, modify, and maintain a Service Agreement for each Consumer in the following manner.

The Service Agreement must be completed in person by the skills trainer with the Consumer and the Consumer’s Surrogate or Administrative Proxy, if any, prior to receiving PCA services, and in the form and format required by EOHHS. This must be done at a separate visit from the initial Evaluation and Re-evaluation. The Service Agreement must be developed in accordance with 130 CMR 422.423 and include:

A detailed description of the responsibilities of the Consumer, the PCA, the Contractor, and the Fiscal Intermediary;

Information on the Consumer’s Surrogate or Administrative Proxy, as applicable:

If the Contractor determined a Surrogate or Administrative Proxy is required, the Service Agreement must identify the Surrogate or Administrative Proxy and describe in detail the responsibilities of the Surrogate or Administrative Proxy and any tasks performed by the Surrogate or Administrative Proxy. The Service Agreement shall include the required frequency of the visits to the Consumer by the Surrogate or Administrative Proxy, while affording the Consumer as much involvement in managing PCA Services as possible. A Consumer cannot have both a Surrogate and Administrative Proxy at the same time.

If the Contractor determined that a Surrogate or Administrative Proxy is not required, the Service Agreement must clearly state that the Consumer has the sole responsibility for managing PCA Services.

Information on Functional Skills Training and Intake and Orientation Sessions: The type and frequency of Functional Skills Training and Intake and Orientation sessions, that the Consumer and the Consumer’s Surrogate or Administrative Proxy, if any, has been provided;

PCA Non-Availability Plan: A description of the Consumer’s plan if a PCA is unable to report to work.

Information on Informal Supports: A list of persons who would be available to provide informal supports with personal care tasks if a Consumer’s PCA becomes unavailable.

Information on Backup PCAs: A back up plan developed with the Consumer in the event that a Consumer’s regularly scheduled PCA is unavailable. If the Consumer identifies a backup PCA, or if the Consumer identifies a PCA who does not regularly provide PCA services to the Consumer and may do so on an irregular basis, the Contractor must list these backup PCAs. If the Consumer does not identify any Informal Supports as described in Section 2.2.D.1.e, the Contractor must work with the Consumer to help identify backup PCAs. The Contractor must inform the Consumer of the need for all backup PCAs to be hired as a PCA of the Consumer, including contacting the FI to ensure the required new hire paperwork is completed and registering for and being trained how to use EVV.

Emergency Contact Information: Contact information of at least two individuals who the Contractor can contact in case of an emergency affecting the Consumer, or in the event the Contractor cannot get in touch with the Consumer to address a matter that, as determined by the Contractor or EOHHS, requires urgent attention by the Consumer.

Review the Service Agreement annually in person with the Consumer and the Consumer’s Surrogate or Administrative Proxy, if any, and document in the Consumer’s record.

Review the Service Agreement and list of active PCAs at all In-person Comprehensive Functions…