MassHealth pays the wages, but you are the employer of record. You recruit, interview, check backgrounds, train, schedule, discipline and fire your own attendants. Nobody sends you a caregiver, and nobody manages one for you.

That is the trade in consumer directed care. You get to choose who comes into your home and what they do, and in exchange you take on a real employer's job.

What checks am I supposed to run before hiring?

Three, plus references. These are yours to run, not your agency's.

• CORI, the Massachusetts criminal offender record check.
• SORI, the Sex Offender Registry check.
• The federal exclusion list, known as the LEIE, which shows people barred from working in programs paid by federal health care dollars.

The attendant also has to be legally authorized to work in the United States and has to be able to understand and carry out your instructions. If you skip the checks, the risk lands on you and on whoever lives in your house.

Who cannot be hired as my PCA?

Your spouse, the parent of a minor member including an adoptive or foster parent, any legally responsible relative, and your surrogate. Adult children, siblings, friends and neighbors generally can be hired and paid, which surprises most families, and is often the most practical answer to a staffing problem.

What does the fiscal intermediary actually do?

Payroll and the tax machinery, so you do not have to become a payroll department. Your fiscal intermediary processes timesheets, issues paychecks or direct deposits, files and pays the employer share of state and federal taxes including unemployment, carries workers compensation insurance, and issues the W-2 at the end of the year.

What stays with you: telling them every time you hire somebody and every time you let somebody go, and submitting accurate timesheets on time. Signing a timesheet is a certification that those hours were worked. Treat it that way.

How do timesheets work now?

Most attendants now clock in and out on an app on their own phone or tablet, which is called electronic visit verification and is required by federal law. The app is for the attendant only. You, or your surrogate, review and approve the time in a separate web portal.

If a shift gets missed on the app it can be entered manually in that portal, so a forgotten clock in is a correction rather than a lost paycheck. Two groups are exempt and stay on paper or electronic timesheets: live in attendants, and people who qualify for a safety exemption. The live in exemption has to be recertified every year, and letting it lapse is an avoidable mess.

What am I required to give my PCA?

There is no paid vacation in the program. Beyond that:

• Sick time follows the Massachusetts earned sick time law, the same as any other job in the state.
• Four holidays are paid at time and a half: New Year's Day, July Fourth, Thanksgiving and Christmas. That applies only when the attendant is scheduled and actually works the holiday.
• Jury duty is paid for up to three days when it falls during regularly scheduled hours.

Beyond the required items you set your own house rules, and you should write them down on day one. How much notice you need for a day off, what happens when somebody is going to be late, whether a doctor's note is expected after several sick days. Rules written before a conflict are rules, and rules written during one are an argument.

How do I keep the schedule legal?

Schedule only inside the hours MassHealth approved, and watch the per attendant weekly limit, which is 60 hours and requires an authorization above 50 for one consumer. Those hours add up across every consumer the attendant works for, not just you. We cover the counting on the PCA weekly hour limit and overtime authorization.

What if I cannot manage all of this?

Then you name a surrogate, and that is a normal outcome rather than a failure. A surrogate can take on the parts you find hard while you keep the parts you want. If the assessment says you need one and you do not have one, you get 30 days to name somebody before the program is at risk, so do not let that notice sit on the counter.

Honestly, is hiring and managing an attendant worth it?

For most people yes, because the hours are covered and you choose the person. Where it stops working is when you cannot find anybody to hire, or the management is more than you want to carry. Then the comparison worth doing is honest: PCA hours are free to you but you do the staffing, and agency hours cost money but the staffing is somebody else's problem. Ours are $45 an hour with no minimum contract, and plenty of families run both, using approved PCA hours for the daily routine and buying a few agency hours to cover the weeks nobody can fill.

Who sets this up?

Your personal care management agency does the intake and orientation, the nurse and occupational therapist evaluation, the prior authorization and the skills training that teaches you the employer role. Care Remedy is a PCM agency serving eastern and central Massachusetts from offices in Woburn, Brockton and Springfield. Call 781-957-8076 or email pcm@careremedy.com.

Program requirements change. Confirm current rules with MassHealth, your PCM agency or your fiscal intermediary.