Personal Care Attendant (PCA) Program

This fact sheet helps you determine if you qualify for the Medicaid funded Personal Care Assistance program and how to apply for it if you do qualify.

Determining Eligibility

The following areas determine whether an applicant is eligible for the Medicaid funded Personal Care Assistance program:

Physical need

The applicant must have a need for hands-on, physical assistance (personal care) in two or more activities of daily living, such as bathing, in addition to housekeeping assistance.

The PCA Program is designed to provide assistance for people that have limited upper body strength or mobility, making it difficult to perform ADLs, activities of daily living Tasks such as, bathing, dressing, toileting, and home care are typical PCA activities. PCA services are designed to provide physical assistance. Supervision and teaching/cueing are not allowable PCA activities.

Insurance Coverage

The applicant must have an active Medicaid (MassHealth/CommonHealth) Number
Medicaid comes in many forms. In Massachusetts a valid MassHealth Standard or CommonHealth number is require to begin the process of applying for the personal care attendant program. One can apply for Medicaid (MassHealth or CommonHealth) by calling 888-665-9993 (Voice) or 888-665-9997 (TTY).

How to apply for MassHealth or CommonHealth

If, for any reason, the applicant needs assistance to complete the Medicaid application, an independent living center and other programs, such as an Aging Services Access Point (ASAP or elder services program) and the SHINE program can provide assistance. Other forms of Medicaid, such as MassHealth Basic and Medicare do not cover the PCA program. CommonHealth is a form of Medicaid for persons with disabilities who are over income for standard Medicaid. There is a work requirement of 40 hours per month to be eligible for CommonHealth, but even a minimal amount of work is acceptable if the applicant is not able to maintain a fixed schedule or physical labor. The liberal work requirements allow many people with disabilities to re-enter the workforce and still maintain PCA services. If the applicant is over-income for MassHealth Standard or CommonHealth they may be asked to meet a spend down. The agencies noted above can also offer help with questions regarding Medicaid spend downs.

How to apply for the Personal Care Assistance Program in Massachusetts

The Personal Care Attendant (PCA) program is a MassHealth program that helps people with permanent or chronic disabilities keep their independence, stay in the community, and manage their own personal care by providing funds to hire PCAs.

The PCA consumer is the person receiving PCA services. They employ the PCA, and are fully responsible for recruiting, hiring, scheduling, training, and, if necessary, firing PCAs.

Personal Care Management Agencies

The PCM agency will:

• Explain the rules of the PCA Program to you, including your responsibilities as a PCA Consumer-employer;
• Assess your ability to manage the PCA Program independently;
• Evaluate your eligibility for PCA services;
• Submit requests for prior authorization to MassHealth, if you are deemed to be eligible;
• Provide you with ongoing skills training to help you manage the PCA Program successfully; and
• Work with you to develop a written Service Agreement that describes your roles and responsibilities, as well as those of others involved in supporting your use of the PCA Program. The Service Agreement will include a backup plan if your regularly scheduled PCA is unable or unavailable to work for you.

Determining Medical Necessity

A letter of medical necessity from the primary care doctor stating a medical need for hands-on assistance is required as well as a face-to-face evaluation from a registered nurse. The primary care doctor must also state how the disability limits mobility and that it is expected to last for a full year or more. The evaluation is then sent to Masshealth for prior approval.

Denials/Appeals

If the Division of Medical Assistance denies a PCA request the appeals process allows consumers to review Medicaid decisions with a hearing officer. Appeals often, though not always, result in decisions favorable to the applicant. A PCA skills trainer can assist consumers in understanding the appeals process and filing appeals. If desired, staff from an ILC can also attend the hearing with the applicant.

Consent

PCA services are designed to be consumer controlled. The person in charge of managing the program must want the services and understand how the program works. The PCA application will not be completed unless directed to do so by the consumer who will become the employer of his or her PCAs. Consent is essential as the consumer, and/or the consumer’s chosen surrogate, is responsible for all aspects of PCA program management. The PCA employer must consent to recruiting, hiring, training, scheduling, supervising, and screening his/her personal care attendants. The personal care assistance program provides skills training to teach people how to manage the program and how to chose and use the Fiscal Intermediary to manage the time sheets and the program.

Personal Care Attendant Workforce Council

FAQs

How does the PCA program differ from other in home assistance programs?

The PCA program is managed completely by the person with the disability. Once the number of personal care hours is determined by the evaluating team, the person with the disability decides whom to hire and how to schedule his/her attendant care. The PCA user keeps records and sends in time sheets for the hours each PCA worked each month. Care assistants are then paid, with Medicaid funding. Tax documentation is the responsibility of the PCA user who may sign an agreement to assume total responsibility for tax obligations, or request help of the Fiscal Intermediary.

Who can be hired as a PCA?

Personal Care Attendants may be any individual including a friend, parent of adult children, or family member (excluding spouses, surrogates, or legal guardians). No special license or certification is needed. The Personal Care Attendant must be legally eligible for employment in Massachusetts.

What is Fiscal Intermediary?

People with disabilities (as employers of PCAs) are advised about income tax withholding information and assisted in withholding taxes by agencies that have agreed to serve as Fiscal Intermediaries. The Fiscal Intermediary agency is responsible, except in rare cases, for insuring that the IRS tax requirements for PCAs are met. One can apply for PCA services with an agency that is not the fiscal intermediary, but they will need to work with a fiscal intermediary for the financial aspects of the program.

How long does it take to get on the PCA Program?

The PCA application process, unlike home health care services, may take a few weeks to complete. This is due in part to the fact that it is designed to serve people with long term care needs. It takes several weeks to determine eligibility, exactly what assistance the person requires, if the person’s doctor agrees with the request, and whether Medicaid, the Division of Medical Assistance (DTA) approves the request. Home health care providers and hospital discharge planners should be forewarned that the PCA program is not an immediate solution. If one thinks he/she cannot wait out the application and training process for the PCA program the Primary Care Doctor can request temporary home health care services.

As Home Health Services are designed strictly for people with a need for Skilled Nursing Care, Visiting Nurse and similar home health agencies are under significant pressure to discharge relatively healthy patients with physical disabilities. People with permanent disabilities who are planning to leave a medical facility may want to take into account that PCA services are not immediate, and approval and billable hours cannot be guaranteed when planning a discharge.

What if the consumer seems to need PCA services but refuses to apply?

Though they have the right to refuse PCA services, and cannot be discharged prematurely, home care with no skilled nursing need will not be offered indefinitely and homemaking is even more difficult to obtain at this time. Home health care is designed to provide care to people with a medical need. The PCA program typically offers more hours of service and more control over those services. Despite some inconvenience of having to recruit and supervise PCAs, many prefer PCA services to minimal home health care or institutional care.

Payment Guidelines – What is the hourly rate for PCAs and how many hours can a PCA user get?

The DMA (MassHealth) allows a set amount of time for each activity of daily living. The total amount of time allowed is based on the particular needs of the consumer. Medicaid approves nighttime attendant hours for persons with severe mobility limitations. One can only bill for the hours for which his/her PCA has worked and time sheets cannot be submitted for hours beyond what has been approved. The hours worked must be submitted (with signatures) to the fiscal intermediary. The current PCA reimbursement amount from Medicaid is $17.80 per hour. If approval is given for might time assistance, PCA users and attendants may opt for a live-in agreement. “Individual Consideration” hours (IC hrs) are approved in some circumstances. IC hours are for people with unusual needs for physical assistance. For instance, a person may develop a need for more assistance due to sudden change in physical condition requiring more awake overnight hands-on care. An increase in PCA hours can be requested if medically necessary.

Problem solving – What happens if problems occur after PCA services have begun?

Though skills training is provided in the beginning to teach people to manage their PCA services, people may request additional assistance if problems arise at a later date. Consumers are encouraged to contact their PCA service provider at any time with questions or concerns.

Protecting  people with disabilities from potential abuse by a PCA

The PCA program has some safeguards and reporting guidelines for employers and employees alike. PCA employees are protected from fraud or exploitation by employers through the SEIU Union #1199. 877-409-7227

Medicaid Fraud suspicions are reported to MassHealth Fraud Hotline 877-437-2830.

Children with disabilities under age 18 are protected from abuse by calling the Department of Children and Families, DCF 24 hour hotline 800-792-5200.

People aged 18-59 are protected from abuse/neglect by a caregiver by the contacting the Disabled Person’s Protection Commission (DPPC) to report suspected abuse/neglect. The DPPC hotline is 800-426-9009.

People over age 60 and over are protected by contacting the Elder Protective Services program. The calls can be made anonymously, but written reports are advised, which may be more difficult to obtain for many. Patients in nursing homes and rehabilitation facilities can also request assistance from the ombudsman program covering that facility.

Elder Abuse Hotline is 800-922-2275

Fact Sheet last updated on: 8/19/2024

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Disclaimer: INDEX is pleased to provide you this information. Please note,  this information is not comprehensive, nor is it intended to take the place of professional advice. We encourage you to check other resources of such information. No endorsement by the University of Massachusetts Chan Medical School, DisabilityInfo.org,  INDEX, or affiliates, should be inferred. We reserve the right to remove, to modify, or to add any information at any time, for any reason, and without notice.