CurrentMass General Brigham Health PlanPolicy 094

Personal Care Attendant and Personal Care Management Agency Services

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Establishes medical necessity and coverage criteria for PCA and PCMA services, primarily for One Care and Senior Care Options members; services are not covered for Medicare Advantage, Mass General Brigham ACO, Commercial, or Qualified Health Plan members.

Policy Summary

PayerMass General Brigham Health Plan

PolicyPersonal Care Attendant and Personal Care Management Agency Services

Policy CodePolicy 094

Change TypeAnnual criteria and code-list updates

Effective DateNov 1, 2026

Last ReviewNov 1, 2026

Next Review DateN/A

Key ActionSubmit prior authorization for One Care and Senior Care Options services.

SourceLink

POLICY UPDATE CHANGES

The policy clarifies that PCMA services are covered for SCO members only and are not a covered benefit for One Care members.

The PCA and PCMA eligibility criteria were updated during the August 2026 annual review.

The code list was updated during the February 2026 ad hoc review.

One Care + SCOPrograms with PCA coverage

SCO only

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CurrentMass General Brigham Health PlanPolicy 094

Personal Care Attendant and Personal Care Management Agency Services

Customize your policy alerts

Sign up for Mass General Brigham Health Plan Policy 094 alerts

Get alerted when Policy 094 changes without checking for updates manually.

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Policy Summary

PayerMass General Brigham Health Plan

PolicyPersonal Care Attendant and Personal Care Management Agency Services

Policy CodePolicy 094

Change TypeAnnual criteria and code-list updates

Effective DateNov 1, 2026

Last ReviewNov 1, 2026

Next Review DateN/A

Key ActionSubmit prior authorization for One Care and Senior Care Options services.

SourceLink

POLICY UPDATE CHANGES

The policy clarifies that PCMA services are covered for SCO members only and are not a covered benefit for One Care members.

The PCA and PCMA eligibility criteria were updated during the August 2026 annual review.

The code list was updated during the February 2026 ad hoc review.

One Care + SCOPrograms with PCA coverage

SCO only

Program eligible for PCMA

2+ ADLsMinimum PCA assistance

7 hr/weekMeal-preparation limit

1 yearAuthorization duration

Not coveredOther listed lines of business

Medical Necessity and Eligibility Criteria

PCA Services

Covered when ALL of the following eligibility criteria are met:

ALL of the following

A representative from the member's individualized care team documented a recommendation for PCA in the integrated care plan.
The member's disability is permanent or chronic in nature and impairs functional ability to perform activities of daily living (ADLs) and instrumental activities of daily living (IADLs) without physical assistance.
The member, as determined by the personal care management agency, requires physical assistance with two or more activities of daily living.

Additional PCA Meal-Preparation Time

Members receiving meal preparation support may be approved for a maximum of 7 hours (420 minutes) per week for meal preparation. To qualify for additional meal preparation time, the member must meet ALL of the following criteria:

ALL of the following

The member has a diagnosis of dysphagia, and clinical documentation supports this diagnosis.
The member requires mechanically altered meals, and clinical documentation supports this requirement.

PCMA Services (SCO Only)

Covered when ALL of the following eligibility criteria are met:

ALL of the following

A recommendation for PCMA is documented in the integrated care plan.
The member requires prompting, cueing, supervision, or physical assistance with at least one ADL.
A representative from the member's Individualized Care Team has conducted an assessment of the member's level of acuity and documented it in the member's record.

Complex Care Services

Medical necessity for Complex Care Services is determined through MassHealth Regulation 130 CMR 422.414(A): Complex Care Authorization Clinical Eligibility.

The member does not meet the applicable eligibility criteria described above.

The member is a resident or inpatient of a hospital, nursing facility, or other inpatient facility, or a resident of a provider-operated residential facility subject to state licensure, such as a group home.

The member has a family member who can provide PCA services.

Any portion of the day that the member is receiving duplicative services as part of a MassHealth-funded community program is excluded.

PCMA services are not a covered benefit for One Care members.

Services and Authorized Codes

Authorized Codesmixed

99456	Work related or medical disability examination by other than the treating physician that includes completion of a medical history commensurate with the patient's condition; performance of an examination commensurate with the patient's condition; formulation of a diagnosis, assessment of capabilities and stability, and calculation of impairment; development of a future medical treatment plan; and completion of necessary documentation/certificates and report.
99509	Home visit for assistance with activities of daily living and personal care.
S5199	Personal care item, not otherwise specified, each; personal care services per 15 minutes, not for an inpatient or resident of a hospital, nursing facility, ICF/MR, or IMD, part of the individualized plan of treatment; personal care services per diem, not for an inpatient or resident of a hospital, nursing facility, ICF/MR, or IMD, part of the individualized plan of treatment.
T1022	Contracted home health agency services, all services provided under contract, per day; screening to determine appropriateness of consideration of an individual for participation in a specified program, project, or treatment protocol, per encounter; case management per month.

PCA ADL assistance

Program applicabilityPCA services are covered for One Care and Senior Care Options (SCO) members who can be appropriately cared for in the home.

Required assistanceThe member must require physical assistance with two or more activities of daily living.

DeterminationThe personal care management agency determines whether the member requires assistance with two or more ADLs.

Standard meal-preparation support

Weekly maximumMeal-preparation support may be approved for a maximum of 7 hours (420 minutes) per week.

Additional timeTime beyond 7 hours (420 minutes) per week requires the member to meet both additional meal-preparation criteria.

Authorization, Documentation, and Exclusions

Prior Authorization

Prior Authorization Required

Prior authorization is required for PCA and PCMA services for One Care and Senior Care Options (SCO) members.

Applies to One Care and SCO services.
Prior Authorization Required: Yes

Note

PCA Authorization Duration

PCA authorizations are generally approved for one year. If the member's status changes during the authorization year, an updated authorization must be submitted for approval; if approved, the new authorization is effective for one year.

Documentation Required

Service Overview

Personal care attendant (PCA) services provide physical assistance with activities of daily living (ADLs) and instrumental activities of daily living (IADLs) for members with chronic or permanent disabilities who can be appropriately cared for at home. Personal care management agency (PCMA) services support eligible SCO members who need prompting, cueing, supervision, or physical assistance with ADLs; the service level is based on the member’s individual needs and required assessment.

Qualifying Activities

Activities of Daily Living (ADLs)

MobilityPhysically assisting a member whose mobility impairment prevents unassisted transferring, walking, or use of prescribed durable medical equipment.

Medications and health-related needsPhysically assisting a member to take medications prescribed by a physician that otherwise would be self-administered.

Bathing or groomingPhysically assisting with bathing, personal hygiene, or grooming.

DressingPhysically assisting a member to dress or undress.

Passive range-of-motion exercisesPhysically assisting a member to perform range-of-motion exercises.

EatingPhysically assisting a member to eat, including assistance with tube-feeding and special nutritional or dietary needs.

Policy Summary

PayerMass General Brigham Health Plan

PolicyPersonal Care Attendant and Personal Care Management Agency Services

Policy CodePolicy 094

Change TypeAnnual criteria and code-list updates

Effective DateNov 1, 2026

Last ReviewNov 1, 2026

Next Review DateN/A

Key ActionSubmit prior authorization for One Care and Senior Care Options services.

SourceLink

On This Page

Service basisMeal-preparation support is provided as part of PCA services for eligible One Care and SCO members.

Additional meal-preparation support

DysphagiaThe member must have a diagnosis of dysphagia supported by clinical documentation.

Mechanically altered mealsThe member must require mechanically altered meals supported by clinical documentation.

Combined requirementBoth criteria are required to qualify for meal-preparation time beyond 7 hours (420 minutes) per week.

PCMA ADL assistance

Program applicabilityPCMA services are covered for Senior Care Options (SCO) members who can be appropriately cared for in the home.

Minimum needThe member must require support with at least one activity of daily living.

Permitted support typesThe required ADL support may consist of prompting, cueing, supervision, or physical assistance.

PCA Eligibility Documentation

PCA services are covered for One Care and SCO members who can be appropriately cared for at home when all eligibility requirements are met.

A representative from the member's individualized care team documents a PCA recommendation in the integrated care plan.
The member has a permanent or chronic disability that impairs the ability to perform activities of daily living (ADLs) and instrumental activities of daily living (IADLs) without physical assistance.
The personal care management agency determines that the member requires physical assistance with two or more ADLs.

Documentation Required

Additional Meal-Preparation Documentation

Meal preparation support may be approved for a maximum of 7 hours (420 minutes) per week. Additional meal-preparation time requires clinical documentation supporting both of the following criteria.

The member has a diagnosis of dysphagia.
The member requires mechanically altered meals.

Documentation Required

PCMA Eligibility Documentation

PCMA services are covered for SCO members who can be appropriately cared for at home when the required eligibility documentation is present.

A recommendation for PCMA is documented in the integrated care plan.
The member requires prompting, cueing, supervision, or physical assistance with at least one ADL.
A representative from the member's Individualized Care Team conducts an assessment of the member's level of acuity and documents it in the member's record.

Prior Authorization

Status-Change Update

When a member's status changes during the authorization year, submit an updated authorization for approval. If approved, the new authorization is effective for one year.

Denial Risk

Exclusion Conditions

Services may be denied or excluded when eligibility or setting requirements are not met, or when another available caregiver or duplicative service applies.

The member does not meet the applicable eligibility criteria.
The member is a resident or inpatient of a hospital, nursing facility, or other inpatient facility, or resides in a provider-operated residential facility subject to state licensure, such as a group home.
A family member is available to provide PCA services.
The requested time overlaps with duplicative services provided through a MassHealth-funded community program.

Denial Risk

Noncovered Lines of Business

PCA and PCMA services are not covered for members in the following lines of business.

Medicare Advantage
Mass General Brigham ACO
Commercial
Qualified Health Plans

Denial Risk

PCMA One Care Exclusion

PCMA services are not a covered benefit for One Care members.

Physically assisting a member with bowel or bladder needs.

Instrumental Activities of Daily Living (IADLs)

Household servicesPhysically assisting with household management tasks incidental to member care, including laundry, shopping, and housekeeping.

Meal preparation and clean-upPhysically assisting a member to prepare meals.

TransportationAccompanying the member to medical providers.

Special needsAssisting with the care and maintenance of wheelchairs and adaptive devices, completing paperwork required to receive PCA services, and other special needs approved by MassHealth as instrumental to the member's health care.