Mass Families Organizing for Change Annual Conference MassHealth Community Programs Robin Y. Lee...

Mass Families Organizing for ChangeAnnual 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• Hospice • Independent Nursing• Nursing Facilities• Orthotics & Prosthetics• Personal Care Attendant• Program for All-Inclusive Care for the Elderly• Senior Care Options• Targeted Case Management• Therapy

• Activities of Daily Living (ADLs):• Bathing• Dressing• Toileting• Transferring• Ambulating• Eating

Definitions:

• Instrumental Activities of Daily Living (IADLs):• Shopping• Managing finances• Preparing meals• Managing medications• Housework• Laundry• Using the telephone or other

communication devices

Definitions:

Adult Foster Care (AFC)

• 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.

AFC Program Description

• 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

meeting.

• The AFC provider submits a request to MassHealth for authorization of payment.

How do you become an AFC Consumer?

• Must be MassHealth eligible (Standard or CommonHealth)

• 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.

Who is eligible for the AFC program?

• 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.

AFC Program Statistics

Personal Care Attendant (PCA)

• 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

• 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.

PCA Program Description (cont)

• 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 MassHealth

• assess the consumer’s ability to manage the PCA Program independently

• 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).

How do you become a PCA Consumer?

• 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 person

• Requires physical assistance with at least 2 or more ADLs

• Has a prescription from the member’s doctor for PCA services

• Obtains prior authorization for PCA services from MassHealth.

Who is eligible for the PCA program?

• 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.

Why PCA over another similar program, like HH?

• 29,000 MassHealth individuals utilizing the PCA program.

• 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 PCAs)

• The PCA program is also offered through the Senior Care Options and One Care Managed Care programs.

PCA Program Statistics

• 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 long-

term 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 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 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 Family Assistance:• Coverage includes most of the MassHealth Standard

services.• For eligible children under 19 years of age and people

with HIV who are not eligible for MassHealth Standard or CommonHealth.


• 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

employees• The employer offers health insurance


• These programs have certain eligibility criteria and may have required member contributions.

• Criteria:• 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.


• 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.


• The following do NOT have a required member contribution:

• 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).


• Current range of estimated required member contribution (depends on % above FPL):

• MassHealth CommonHealth: • For children <19 YO with income between 150% and 300%

FPL:• $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: www.mass.gov/masshealth

• MassHealth Customer Service: 1-800-841-2900

• MassHealth 2014 Income Standards and FPL: http://www.mass.gov/eohhs/docs/masshealth/deskguides/fpl-deskguide.pdf

Resources

http://www.mass.gov/masshealth

http://www.mass.gov/eohhs/docs/masshealth/deskguides/fpl-deskguide.pdf

• OLTSS Contact Information:Ken Smith, Director of OLTSSPhone: 617-222-7508Email: [email protected]

Robin Lee, Director of Day and Residential ProgramsPhone: 617-222-7463Email: [email protected]

Resources

mailto:[email protected]

mailto:[email protected]

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