What Happens to PCA Hours When You Go Into the Hospital?

MassHealth does not pay for PCA services while you are an inpatient. The regulation at 130 CMR 422.412(E) lists PCA services provided to a member while the member is a resident of a nursing facility or other inpatient facility as noncovered, so nobody can be paid for PCA hours spent with you in a hospital or a rehab bed. Your prior authorization is a separate thing, and nothing in the regulation says an admission cancels it. What you do have to watch are two clocks that keep running while you are lying there.

Can my PCA be paid while I am in the hospital?

No. The PCA program regulations make it a noncovered service at 422.412(E). The thinking behind it is that the facility is already responsible for your personal care while you are in it, and MassHealth will not pay for the same assistance twice.

There is a second provision that closes the obvious workaround. Under 422.412(D), time when a PCA is not providing assistance with activities of daily living or instrumental activities of daily living is noncovered. So a PCA sitting beside your bed, keeping you company and translating for the nurses, is doing something genuinely useful and is still not doing billable work.

Does the same rule apply to rehab or a nursing facility?

Yes. The regulation says nursing facility or other inpatient facility, which takes in an acute hospital admission, a rehabilitation hospital and a skilled nursing stay alike. The same subsection also excludes a member living in a state licensed, provider operated residential facility such as a group home.

One more exclusion surprises people because it has nothing to do with being admitted anywhere. Under 422.412(F), PCA hours are not covered during participation in a MassHealth funded community program such as day habilitation or adult day health. You are home by dinner, but those daytime hours are not PCA hours.

Do I lose my approved hours?

The authorization and the claim are two different things. Your hours were approved for a prior authorization period, and an admission does not reach back and undo that approval. What stops is payment for the days you are not at home. Where people actually get hurt is the paperwork that keeps moving while they are too sick to think about it.

• The authorization clock. Under 422.416(C) the PCM agency must request prior authorization to continue services at least 21 days before the current period expires, and MassHealth may stop payment after expiration if the request comes in late. If your period happens to end during a long stay, somebody still has to file on time.
• The surrogate clock, covered further down this page. It is the one that quietly ends people's services.

Tell your PCM agency you have been admitted, and do it early. Under 422.420(A)(12) the duty sits with the member to report a change in medical condition or living situation that may require an adjustment of hours. An admission is exactly that kind of change. How the hour count is built in the first place is explained in How MassHealth Decides How Many PCA Hours You Get.

My PCA has no income while I am admitted. What can we do?

There is no PCA payment for inpatient days, and the fair thing is to say so to your PCA on day one rather than on the day you are discharged. A good PCA who finds out at the end of three weeks that there is no paycheck often does not come back, and then you are home with no help and a new hiring problem.

Call your fiscal intermediary and your PCM agency and ask what the options are in your particular situation. Many PCAs work for more than one member and can pick up hours elsewhere for a few weeks. What you must not do is let timesheets go in for hours nobody worked in your home. In this program you are the employer, so that exposure is yours as much as theirs, which is the subject of In the PCA Program You Are the Employer.

Can my PCA visit me in the hospital?

Yes, as any other visitor can, under the hospital's own visiting rules. The hours are simply not payable. Plenty of members want their PCA there because that is the one person who knows exactly how they transfer, how they are positioned and how they communicate, and floor staff are often glad of it. Keep the two things separate in your own head: it is a visit, not a shift.

What should I do before discharge day?

Call your PCM agency as soon as a discharge date goes up, rather than waiting for the discharge planner to do it for you. Under 422.416(D)(3) the PCM agency must contact MassHealth or its designee within 24 hours of an inquiry for PCA services for a member being discharged from a nursing facility or other inpatient facility. The 24 hours starts when somebody asks, so the sooner somebody asks, the better.

If you have been in for a while and an evaluation is needed, you do not have to be home first. Under 422.422(C)(2)(b) the evaluation may take place at a hospital or institution where the member has been hospitalized or institutionalized for an extended period. Ask for it to be done before you leave, not after.

Will my hours be reevaluated after a hospital stay?

They can be, in either direction. Under 422.422(D)(1) a reevaluation is required when there is a significant change in the member's physical condition or living situation, and 422.416(B) allows an adjustment request for a change in medical condition, functional status or living situation. A fracture, a stroke, a new amputation or a long stretch of bed rest all count.

The honest version is that most people come home needing more help than they left with, at least for a while, and the hour count should reflect that. Make sure the evaluation captures what you cannot do now rather than what you managed a month ago. If the number comes back lower than you expected, you have an appeal, and the steps are in My PCA Hours Were Cut. How Do I Appeal?

What if my surrogate is unavailable during my stay?

Then a 30 day clock starts, and this is the provision that ends more people's PCA services than any cut ever does. Under 422.422(B)(3), if a surrogate or administrative proxy becomes unavailable at any time during the prior authorization period, the PCM agency must notify the member to find a replacement within 30 days. Under 422.420(B)(2), MassHealth may terminate PCA services if no replacement is identified in that window.

Unavailable covers more than you would think. A surrogate who has moved away, who is unwell themselves, or who is in a hospital bed of their own is unavailable. The time to name a backup is now, while nothing is going wrong, not from a recliner in a rehab unit.

Who covers the first days home if the hours are not in place yet?

That gap is what families call us about. A discharge lands on a Friday, the reevaluation has not happened, the PCA has taken other work for a month, and somebody has to be in the house tonight. Paid home health aide care fills the days until the PCA side catches up, and it can be a handful of hours or a run of nights.

• Home health aide care is $45 an hour, one to eight hours a day. No minimum contract, no assessment fee, and no four hour minimum per visit, which matters when you only need two weeks.
• An overnight is $540 for a twelve hour night. Around the clock care is $1,080 a day.
• Wheelchair accessible transportation is $115 each way, $230 round trip within five miles, then $2 a mile beyond that.
• Stair assistance is $200 a visit, with two trained staff and an electric stair chair. Call us for the chair's rated weight capacity.

Our aides are trained, background checked and insured, and they are not nurses. They do not administer medication, including insulin, they do not change dressings and they do not make clinical judgments. They can be present while you manage your own medication, help if something goes wrong and call for help. If you are coming home with wound care or injections, that is skilled nursing, which is a separate service priced separately.

The front steps are the part nobody plans for on discharge day. Two staff and an electric stair chair solve it in one visit.

Who do I call?

Care Remedy serves eastern and central Massachusetts from offices in Woburn, Springfield and Brockton. For anything about the PCA program or PCM, email pcm@careremedy.com. For aide hours, rides or stair assistance, call 781 957 8076 or email info@careremedyinc.com.

The section numbers on this page come from 130 CMR 422.000, the MassHealth PCA program regulations, which do change. Confirm anything that affects your own hours with MassHealth or your PCM agency, and if services are being terminated or reduced, talk to an attorney or an advocate before the appeal deadline passes.