MassHealth (Massachusetts Medicaid) Personal Care Attendant (PCA) Program

Last updated: July 13, 2021

 

Overview of the Personal Care Attendant Program

The Massachusetts’ Personal Care Attendant (PCA) Program is intended for permanently or chronically disabled state residents who require assistance with their daily living activities in order to live at home. Frail elderly persons who need help due to the natural progression of aging often meet the program’s functional criteria and are able to receive assistance via this program. PCA provides program participants with hands on assistance with their activities of daily living (ADLs) and instrumental activities of daily living (IADLs). This includes bathing, dressing, mobility, taking medication, using the toilet, meal preparation / cleanup, eating, laundry, and basic housecleaning.

 Family members, such as adult children, grandchildren, nieces, nephews, and siblings, can be paid to be the caregiver of a loved one through the Personal Care Attendant Program.

The PCA Program is a participant-directed program in which the program participant becomes the “employer”. Also called a consumer-directed program, program participants are allotted funds to hire, train, schedule, supervise, and even fire, the personal care attendant (caregiver) of their choosing. While friends and select relatives, such as adult children or grandchildren, can be hired, a spouse cannot be hired as the caregiver. A financial management services agency handles the financial aspects of employment responsibilities, such as processing time sheets, withholding taxes, and issuing caregiver payments. At the time of this writing, a caregiver is paid approximately $18.15 / hour.

Program participants who are unable to self-direct their care, can choose an individual, a “surrogate”, to help manage their care. This person can be anyone the participant wants, including a spouse, with the exception that this person cannot also be hired as the caregiver. Participants must live at home or the home of a loved one. To be clear, persons cannot live in an adult foster care home or an assisted living residence.

The PCA Program is an entitlement, which means meeting the state’s Medicaid eligibility requirements guarantees one will receive benefits. Put differently, there is never a wait list to receive personal care attendant services.

The Personal Care Attendant Program is part of Massachusetts regular Medicaid program. The Medicaid Program in MA is called MassHealth.

 Medicaid Waivers versus State Plan / Regular Medicaid
While home and community based services (HCBS) can be provided via a Medicaid waiver or a state’s regular Medicaid plan, HCBS through Medicaid state plans are an entitlement. Put differently, meeting the program’s eligibility requirements guarantees an applicant will receive benefits. On the other hand, HCBS via Medicaid waivers are not an entitlement. Waivers have a limited number of participant enrollment slots, and once they have been filled, a waitlist for benefits begins. Furthermore, HCBS Medicaid waivers require a program participant require the level of care provided in a nursing home, while state plan HCBS do not always require this level of care.

 

Benefits of the Personal Care Attendant Program

The PCA Program provides physical assistance with daily living activities up to approximately 50 hours a week. The specific amount of assistance, which may include nighttime hours in addition to daytime hours, is based on a functional evaluation. Follows is a list of activities with which one might receive assistance.

– Bathing – includes grooming and personal hygiene
– Dressing / Undressing
– Eating
– Household Tasks – laundry, shopping for essentials, housecleaning
– Meal Preparation – includes cleaning up
– Maintenance of Wheelchairs and Adaptive Equipment
– Medication Administration
– Mobility – includes walking and transferring
– Paperwork – necessary to receive PCA services
– Range of Motion Exercises
– Toileting
– Transportation – to medical appointments

 

Eligibility Requirements for MassHealth Personal Care Attendant Program

The PCA Program is for chronically or permanently disabled MA state residents of any age, given they require assistance with their daily living activities. Additional eligibility criteria are as follows and is relevant for seniors 65+ years of age.

 The American Council on Aging provides a quick and easy MassHealth eligibility test for seniors.

 

Financial Criteria: Income, Assets & Home Ownership

Income
The applicant income limit is equivalent to 133% of the Federal Poverty Level (FPL), which increases on an annual basis in January. As of 2021, the income limit for a single applicant is $1,428 / month. Married couples, regardless of if one or both spouses are applicants, can have a monthly income up to $1,931.

 While many Medicaid programs allow a non-applicant spouse to retain a larger portion of a couple’s income and assets, the Personal Care Attendant Program does not. In contrast, MassHealth’s Frail Elder Waiver (FEW) does allow a non-applicant spouse a monthly maintenance needs allowance from his/her applicant spouse and a community spouse resource allowance.

Assets
In 2021, the asset limit is $2,000 for a single applicant. For married couples, the asset limit is slightly higher at $3,000. This hold true whether one or both spouses are applicants.

Some assets are not counted towards Medicaid’s asset limit. These generally include an applicant’s primary home, household furnishings and appliances, personal effects, and a vehicle.

While there is a 60-month look back rule in which Medicaid checks past asset transfers of those applying for nursing home Medicaid or home and community based services via a Medicaid waiver, this is not relevant for the Personal Care Attendant Program. In other words, the look back period is not applicable.

 To determine if you might have assets over Medicaid’s countable limit, and if so, receive an estimate of the amount, use our spend down calculator.  

Home Ownership
The home is often the highest valued asset a Medicaid applicant owns, and many persons worry that Medicaid will take their home. Fortunately, for eligibility purposes, MA Medicaid / MassHealth considers the home exempt (non-countable) in the following circumstances.

– The applicant lives in the home or has “intent” to return to the home and his / her home equity interest is no greater than $906,000. Home equity interest is the current value of the home minus any outstanding mortgage.
– A spouse lives in the home.
– The applicant has a child under 21 years old living in the home.
– The applicant has a blind or permanently and totally disabled child living in the home.

To learn more about the potential of Medicaid taking the home, click here.

 

Medical Criteria: Functional Need

Unlike with many Medicaid long-term care programs, a nursing facility level of care (NFLOC) is not required. However, applicants must require hands on assistance with a minimum of two of seven of their activities of daily living (ADLs). Areas of consideration are mobility, toileting, bathing/grooming, dressing/undressing, passive range of motion exercises, taking medications, and eating. The functional needs assessment, which is completed by an occupational therapist or registered nurse via a personal care management agency, must be approved and signed by one’s doctor indicating that personal care assistance is required. While it is thought that persons with Alzheimer’s disease or a related dementia, can participate in this program, a diagnosis of dementia in and of itself does not mean one will meet the functional criteria.

 For more information about long-term care Medicaid in Massachusetts, click here.

 

Qualifying When Over the Limits

Having income and / or assets over Medicaid’s limit(s) does not mean an applicant cannot still qualify for MA Medicaid. There are a variety of planning strategies that can be used to help persons who would otherwise be ineligible to become eligible. Some of these strategies are fairly easy to implement, and others, exceedingly complex. Below are the most common.

Massachusetts has a Medically Needy Medicaid Program for Medicaid applicants who have high medical expenses relative to their income. Also known as a spend-down program, applicants are permitted to spend “excess” income on medical expenses and health care premiums, such as Medicare Part B, in order to meet Medicaid’s income limit. The amount that must be “spent down” each month can be thought of as a deductible. Once one’s “deductible” has been met for the spend down period, which is 6-months in MA, the Personal Care Attendant Program will pay for care services.

When persons have assets over the limits, Irrevocable Funeral Trusts (IFTs) are an option. IFTs are pre-paid funeral and burial expense trusts that Medicaid does not count as assets. Persons can also “spend down” assets on home improvements (i.e., updating plumbing, replacing a water heater), home modifications (i.e., adding a first floor bedroom, addition of grab bars), and replacing an older car with a newer one. There are many other options when the applicant has assets exceeding the limit.

Inadequate planning or improperly implementing a Medicaid planning strategy can result in a denial or delay of MassHealth benefits. Professional Medicaid planners are educated in the planning strategies available in Massachusetts to meet Medicaid’s financial eligibility criteria without jeopardizing Medicaid eligibility. Furthermore, while Medicaid’s 60-month look back rule does not apply to the Personal Care Attendant Program, it does apply to nursing home Medicaid and other long-term care Medicaid programs. As more extensive Medicaid-funded care might be required in the future, it is vital that one not violate the look back rule. Medicaid planning strategies should ideally only be implemented with careful planning and well in advance of the need for long-term care. However, there are some workarounds, and Medicaid planners are aware of them. For these reasons, it is highly suggested one consult a Medicaid planner for assistance in qualifying for Medicaid when over the income and / or asset limit(s). Find a Medicaid planner.

 

How to Apply for MassHealth Personal Care Attendant Program

Before You Apply

Prior to submitting an application for the Personal Care Attendant Program, applicants need to ensure they meet the eligibility criteria for MA Medicaid. Applying when over the income and / or asset limit(s) will be cause for denial of benefits. The American Council on Aging offers a free Medicaid eligibility test to determine if one might meet Medicaid’s eligibility criteria. Take the Medicaid eligibility test.

As part of the application process, applicants need to gather documentation for submission. Examples include copies of Social Security and Medicare cards, proof of income, previous bank statements, copies of life insurance policies, property deeds, and pre-need burial contracts. Unfortunately, a common reason applications are held up is required documentation is missing or not submitted in a timely manner.

 

Application Process

To apply for the Personal Care Attendant Program, applicants must be eligible for MA Medicaid / MassHealth. To apply for MassHealth, seniors must complete the Application for Health Coverage for Seniors and People Needing Long-Term Care Services, which can be found here. The completed application can be mailed, faxed, or dropped off at the MassHealth Enrollment Center. The fax number and addresses are on the application.

Persons already enrolled in Medicaid should contact a personal care management (PCM) agency for a functional evaluation. Contact information for PCM agencies can be found here.

For additional information about the Personal Care Attendant Program, click here. Persons can also contact the MassHealth Customer Service Center at 1-800-841-2900.

The Massachusetts’ Executive Office of Health and Human Services (EOHHS) administers the Personal Care Attendant Program in conjunction with personal care management agencies contracted by MassHealth.

 

Approval Process & Timing

The Medicaid application process can take up to 3 months, or even longer, from the beginning of the application process through the receipt of the determination letter indicating approval or denial. Generally, it takes one several weeks to complete the application and gather all of the supportive documentation. If the application is not properly completed, or required documentation is missing, the application process will be delayed even further. In most cases, it takes between 45 and 90 days for the Medicaid agency to review and approve or deny one’s application. Based on law, Medicaid offices have up to 45 days to complete this process (up to 90 days for disability applications). However, despite the law, applications are sometimes delayed even further.

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