MassHealth Community Programs

Mass Families Organizing for Change
Annual Conference
MassHealth Community Programs
Robin Y. Lee
Director of Day and Residential Programs, MassHealth
September 27, 2014
• Overview
• Adult Foster Care
• Personal Care Attendant
• Premium Assistance
• Resources
The MassHealth Office of Long Term Services and
Supports (OLTSS) is responsible for providing elders
and individuals with disabilities of all ages with
services and supports that best meet their needs; we
do this by ensuring the availability of, and managing,
a broad range of long term care services provided in a
range of settings.
Our work supports the missions and goals of the
Executive Offices of Health and Human Services
(EOHHS) and Elder Affairs, and requires
collaboration with numerous departments and
agencies involved in the administration of
disability programs.
Adult Day Health
Adult Foster Care
Chronic Disease and Rehabilitation Hospitals
Day Habilitation
Durable Medical Equipment/Oxygen & Respiratory
Early Intervention
Group Adult Foster Care
Home Health
Independent Nursing
Nursing Facilities
Orthotics & Prosthetics
Personal Care Attendant
Program for All-Inclusive Care for the Elderly
Senior Care Options
Targeted Case Management
• Activities of Daily Living (ADLs):
• Bathing
• Dressing
• Toileting
• Transferring
• Ambulating
• Eating
• Instrumental Activities of Daily Living (IADLs):
• Shopping
• Managing finances
• Preparing meals
• Managing medications
• Housework
• Laundry
• Using the telephone or other
communication devices
Adult Foster Care (AFC)
AFC Program Description
• AFC services are provided in a qualified home
setting. Member lives with a qualified paid caregiver
who is responsible for providing personal care with
activities of ADLs, IADLs and other services as
needed. Nursing oversight and care management are
provided by the professional staff. Services are
provided at two levels designed to provide care at
varying levels of intensity.
How do you become an AFC Consumer?
• A physician orders AFC services for an individual.
• The individual contacts an AFC provider.
• The AFC provider conducts intake and assessment
services to:
assess your need for AFC services
inform you about the scope of AFC services
identify potential AFC caregiver and schedule a
• The AFC provider submits a request to
MassHealth for authorization of payment.
Who is eligible for the AFC program?
• Must be MassHealth eligible (Standard or
• Must be 16 years of age or older.
• Must have a physician approval for AFC services.
• Requires daily physical assistance or cuing and
supervision with at least one ADL task.
AFC Program Statistics
• As of 7/1/14, there are 9,213 MassHealth individuals
enrolled in the AFC program.
• There are over 70 AFC providers providing services
to these individuals.
Personal Care Attendant (PCA)
PCA Program Description
• The PCA Program helps people with permanent or
chronic disabilities.
• PCAs provide hands-on assistance with ADLs.
• In addition PCAs can also help with IADLs to assist
individuals maintain their independence, stay in the
community and manage their own personal care.
PCA Program Description (cont)
• PCA Program is a consumer-directed program,
whereby the consumer employs the PCA(s) and is
fully responsible for recruiting, qualifying, hiring,
and firing, if necessary, his/her PCA(s).
• The consumer is also responsible for training and
scheduling his/her PCA(s).
• MassHealth contracts with Personal Care
Management (PCM) Agencies and Fiscal
Intermediaries to support Consumers in managing
the PCA program.
How do you become a PCA Consumer?
• To apply for PCA services, the individual must
contact a PCM agency.
• The PCM agency will evaluate your need for PCA
services and submit a prior-authorization request to
MassHealth for you.
How do you become a PCA Consumer?
• The PCM agency services:
explain the rules and regulations and consumer responsibilities of
the PCA Program
evaluate the consumer’s need for PCA services and submitting the
consumer’s prior authorization request for PCA services to
assess the consumer’s ability to manage the PCA Program
provide ongoing skills training to help consumers manage their
PCA program successfully
assist the consumer in developing a written service
agreement that describes the consumer’s role and
responsibilities, as well as those of others involved in
supporting the consumer’s use of the PCA Program
(e.g. a surrogate).
Who is eligible for the PCA program?
• Is MassHealth eligible (Standard or CommonHealth)
• Has a permanent or chronic disability that prevents
the member from performing activities of daily
living without physical assistance from another
• Requires physical assistance with at least 2 or more
• Has a prescription from the member’s doctor
for PCA services
• Obtains prior authorization for PCA
services from MassHealth.
Why PCA over another similar program, like HH?
The PCA Program is consumer-directed.
The consumer is the employer and hires the PCA(s),
determines schedules, trains the PCA, defines job tasks,
supervises and evaluates the PCA’s performance, and
may fire the PCA.
In comparison, Home Health workers are employed by a
Home Health Care agency and are supervised by a
Registered Nurse. The MassHealth PCA
Program provides for consumer control.
PCA Program Statistics
• 29,000 MassHealth individuals utilizing the PCA
• Approximately 33,000 PCAs providing services to
these MassHealth individuals.
• 27 PCM agencies (to provide assessment services
and skills training for consumers)
• 4 Fiscal Intermediaries (to process payroll for the
• The PCA program is also offered through the Senior
Care Options and One Care Managed Care
MassHealth Premium Assistance Programs
MassHealth provides financial assistance to families who
have a family member with eligible MassHealth
coverage AND pay other health insurance premiums.
MassHealth offers five premium assistance programs:
• MassHealth Standard
• MassHealth CommonHealth
• MassHealth CarePlus
• MassHealth Family Assistance
• MassHealth Small Business Employee
MassHealth Premium Assistance Programs
MassHealth Standard:
• Comprehensive health insurance that includes longterm care.
• For low-income Massachusetts residents who are
eligible parents with children under 19 years of age;
pregnant women, children up to 19 years of age; the
elderly; the disabled and women needing
treatment for breast cancer or cervical cancer.
MassHealth Premium Assistance Programs
MassHealth CommonHealth:
• Coverage similar to MassHealth Standard.
• For eligible disabled adults and disabled children
through age 18 years who cannot get MassHealth
Standard because their incomes are too high.
MassHealth Premium Assistance Programs
MassHealth CarePlus:
• Coverage similar to MassHealth Standard.
• For eligible adults between 21 and 64 years old whose
income is at or below 133% of federal poverty
guideline (FPL), and who do not quality for
MassHealth Standard.
• Provided through managed care organizations.
MassHealth Premium Assistance Programs
MassHealth Family Assistance:
• Coverage includes most of the MassHealth Standard
• For eligible children under 19 years of age and people
with HIV who are not eligible for MassHealth Standard
or CommonHealth.
MassHealth Premium Assistance Programs
MassHealth Small Business Employee:
• For eligible individuals 19 and 64 years old
• Do not qualify for MassHealth Standard,
CommonHealth, CarePlus, or Family Assistance
• Works for a small employer with 50 or fewer full-time
• The employer offers health insurance
MassHealth Premium Assistance Programs
These programs have certain eligibility criteria and may
have required member contributions.
• The health insurance coverage meets the Basic
Benefit Level as defined by MassHealth.
• One or more family members must be eligible for
one of the five MassHealth benefits.
• The family member must be covered by
your other health insurance.
MassHealth Premium Assistance Programs
• Required Member Contribution:
• MassHealth may require that a member
contribute toward the cost of their health
insurance coverage.
• Member contribution depends on the type of
MassHealth coverage the member has, and
household income and size relative to
federal poverty guidelines.
MassHealth Premium Assistance Programs
The following do NOT have a required member
• MassHealth Standard
• MassHealth CommonHealth members with
household income at or below 150% of FPL.
• MassHealth CarePlus
• MassHealth Family Assistance members with
household income at or below 150% of FPL.
• MassHealth members who have verified that
they are American Indians or Alaska
Natives (with certain limitations).
MassHealth Premium Assistance Programs
Current range of estimated required member contribution (depends on %
above FPL):
• MassHealth CommonHealth:
• For children <19 YO with income between 150% and 300%
• $12 to $28 per child per month
• For adults with >150% FPL and children > 300% FPL:
• $15 to $928+ per month
• MassHealth Family Assistance:
• For children with income between 150% and 300% FPL:
• $12 to $28 per child per month
• For adults with HIV with income between 150%
and 300% FPL:
• $15 to $35 per month
MassHealth Customer Service:
MassHealth 2014 Income Standards and FPL:
• OLTSS Contact Information:
Ken Smith, Director of OLTSS
Phone: 617-222-7508
Email: [email protected]
Robin Lee, Director of Day and Residential
Phone: 617-222-7463
Email: [email protected]
Questions and Answers

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