Authorization of Home Health Aide Services with a Personal Care Attendant Prior Authorization
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Temporary MassHealth policy allowing home health agencies to provide home health aide services to members who have an existing prior authorization for Personal Care Attendant (PCA) services when PCA services are disrupted due to COVID-19; applies to MassHealth-participating home health agencies and affected members for the duration of the state of emergency.
No material clinical or coverage changes in this revision.
Coverage Criteria for Temporary Home Health Aide Authorization
Coverage criteria for temporary home health aide authorization
Covered when ALL of the following are met:
ALL of the following
ALL of the following
- Member has an existing MassHealth prior authorization for PCA services
ALL of the following
- Member determines they are experiencing a disruption in receipt of PCA services due to COVID-19
ALL of the following
- Home health aide hours provided may not exceed the weekly hours authorized in the member's PCA prior authorization minus any PCA hours the member continues to receive
ALL of the following
- Home health agency must obtain the member's PCA prior authorization approval and PCA evaluation from the LTSS Provider Service Center
- Home health agency must conduct an initial assessment per 130 CMR 403.000 (may be via telehealth) and determine if skilled nursing needs exist
- If a member is assessed to have skilled nursing needs, the home health agency will not be required to request additional or separate prior authorization from the MassHealth agency for the provision of home health services, skilled or unskilled, provided pursuant to this bulletin
ALL of the following
- Home health agency must comply with 130 CMR 403.000 and 42 CFR 484.00 documentation requirements, including establishing a medical record and plan of care and documenting coordination with any PCA services
Coding and Authorized Hours
Provider Responsibilities and Billing
Use PCA prior authorization to provide home health aide services
Allow members with an existing PCA prior authorization to receive home health aide services from a MassHealth participating home health agency when the member determines they are experiencing a disruption in receipt of PCA services due to COVID-19. This flexibility is effective for the duration of the state of emergency declared via Executive Order No. 591.
Notify members of self-referral and MassOptions support
Personal Care Management agencies must inform members authorized for PCA services that they may self-refer to a MassHealth home health agency for home health aide services or contact MassOptions for assistance if they need home health aide services because of a PCA disruption related to COVID-19.
Obtain PCA documentation, assess, coordinate, and document
Obtain the member's PCA documentation from the LTSS Provider Service Center, perform the initial assessment required by 130 CMR 403.000 (the assessment may be provided via telehealth), determine home health aide and any skilled nursing needs, coordinate services with any ongoing PCA services, and document coordination in the member's plan of care.
- Retrieve PCA documentation from the LTSS Provider Service Center before assessment.
- Conduct initial assessment per 130 CMR 403.000; telehealth assessment is permitted (All Provider Bulletin 289).
- Coordinate home health aide services with any PCA services the member continues to receive.
- If skilled nursing needs are identified, no additional prior authorization is required for home health services provided under this bulletin.
Billing codes, claim listing, and payer instructions
When billing MassHealth for services provided under this bulletin, use the specified service codes (G0299/G0300 U3 for nursing care visits and 99509 for home health aide visits), do not list the PCA prior authorization number on the claim, and bill directly to MassHealth for members enrolled in ACO or MCO plans.
- Use G0299/G0300 U3 for nursing care visits for temporary emergency PCA services.
- Use 99509 for home health aide visits for temporary emergency PCA services.
- Do not list the PCA prior authorization number on the claim.
- Bill services provided pursuant to this bulletin directly to MassHealth for members in Accountable Care Partnership Plans or Managed Care Organizations.
Definitions and Training Requirements
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