Appealing for more PCA hours

So you didn't get that many PCA hours.

The good news is you can probably get more by firming up your arguments and filing for an appeal.

Filing for an appeal

To appeal the number of PCA hours that MassHealth approved, you send in the attached sheet to the mailing you got from MassHealth with its decision. You can send in any supporting documentation at this time, but also you can send in additional documentation up to 10 calendar days before the appeal. You need to send the appeal in within the timeframe listed on the decision. See here for more information.

Preparing for the appeal

When you received the decision from MassHealth, they should have listed exactly what they modified compared to the requested hours. So if, for example, you requested 5 minutes, 6 times daily, 7 days a week ("5x6x7") for mobility transfers, and they approved you for 3 minutes 6 times daily, that should be listed on the decision.

Compare the decision letter with what was requested. If you don't have the evaluation that was requested, reach out to the PCM that did the evaluation to ask for a copy.

For each item that was modified by MassHealth, write down why you think you should get the minutes you requested. Does it take longer to do that activity? Why? Are you doing it more times per day than they say you are? If the member is a minor, think about how that activity is more time-intensive than it would be for a typically-developing child of the same age. (What you cannot do is request more time than what you initially were evaluated for, just the difference between that and what MassHealth decided. This is why it's important to advocate for lots of time during the evaluation process.)

For items that were blanket denied, consider if a doctor's note would help your case. For example, passive range of motion (stretching) is often denied for young children. Having a PT or doctor write a note explaining medical necessity could get that time approved. But for something that just requires an explanation of why it takes extra time (spasticity, injury, extra things that must be done), just writing it down yourself should be sufficient. Use your best judgement!

For Instrumental Acts of Daily Living (IADLs) like housekeeping, food prep, medical transport, and laundry, MassHealth will generally blanket-deny requested time if the member is a minor. However, the PCA Policies and Procedures handout states that "Special consideration may be given for IADL’s if the documentation supports the reason(s) the parent(s) or legal guardian(s) cannot perform the task(s) or if the task(s) is/are above and beyond what would be expected of a non-disabled child of the same age."

Here is a list of guidelines that MassHealth uses for ADLs and IADLs.

Here is a slightly different document outlining common considerations for assessing time per task.

Here is a graphic showing what activities a child is expected to be able to do independently depending on their age.

Sometimes it's helpful to look at previous hearings and rulings - they are public and searchable. The filters don't work well, but if you scroll to the bottom you can type in a keyword. "PCA" brings up relevant results.

With all of this written down and documented, submit it to the board of hearings at least 10 calendar days in advance as described on the letter you received with the hearing date (after you file for the appeal).

The appeal

Your appeal will likely occur over the phone. They will call you and record the session. A MassHealth representative will attend as well as a hearing officer from the Board of Hearings. The hearing officer is a neutral third-party - they are not a MassHealth employee. The hearing officer will go through each of the ADLs and IADLs individually that were modified or denied from the original request (you won't talk about anything that was approved in full). The MassHealth representative will speak to why they made the denial or modification, and then you will speak as to why you want more time.

The hearing officer may ask clarifying questions or prod the MassHealth representative or you towards a resolution. Hopefully you and the MassHealth representative will agree on each item as you discuss - either leaving the minutes as-is, going up to the amount you requested, or meeting somewhere in the middle. If there is anything that you still disagree with, the hearing officer will provide a written ruling after the appeal call has ended. The written decision will be administered generally within a month or two after the hearing; you can ask when to expect it. The decision will be backdated to when the original MassHealth decision was effective.

Best of luck!