MassHealth work group flags rapid growth in PCA program, recommends overtime cap and fraud controls

Leslie Darcy, chief of MassHealth’s Long Term Services and Supports, told the Mass. Commission on the Status of Persons with Disabilities’ Long Term Services and Supports and Health Equity Subcommittee that a legislative work group met five times between October and February to examine the Personal Care Attendant (PCA) program and reached three consensus recommendations. “The group was able to reach three consensus recommendations,” Darcy said, listing enforcement of an overtime cap, addressing fraudulent activity and removing certain PCA administrative paperwork for members required to use electronic visit verification (EVV).

The recommendations came as work‑group members reviewed data showing rapid spending and utilization growth in the PCA program. Darcy said the program served about 56,000 members in state fiscal year 2024, with roughly 26,000 of those members enrolled in managed care plans. She said PCA program costs rose from about $1.2 billion in fiscal 2020 to $1.6 billion in fiscal 2024 and are projected to reach $2.0 billion by 2027.

Charlie Carr, a commission member who led parts of the discussion, said the group’s charge from the legislature was to “try to see if we could find some level of savings in the PCA program.” Carr said the group identified an estimated savings from enforcing the overtime cap. Darcy reported that MassHealth spent about $71 million on overtime in fiscal 2024 and that enforcing a 66‑hour cap was estimated to save roughly $6.7 million.

Work‑group members also examined how the PCA program compares with other long‑term services and supports (LTSS) programs. Darcy and other presenters noted that PCA is unusual among LTSS services because both rates (wages paid to PCAs) and utilization have increased sharply — 87% rate growth and 51% utilization growth between 2014 and 2026 in presented slides — and that the PCA program draws about 50% federal financial participation (FFP) for eligible categories. The group highlighted that some growth is from serving more people (about 7% utilization growth between 2020 and 2024) and some from wage increases.

The work group reviewed operational changes and tools intended to curb improper payments and administrative burden. Members discussed the federal requirement to adopt electronic visit verification and Darcy said the EVV rollout has been staged over more than a year and “we should be wrapping it up this fall.” One of the group’s consensus recommendations was that MassHealth eliminate certain PCA paperwork and administrative tasks for members who must use EVV and who do not have a live‑in exemption.

The group also analyzed how instrumental activities of daily living (IADLs) — such as shopping, meal preparation and housekeeping — contribute to overall PCA hours. Darcy and other speakers noted a subgroup of fee‑for‑service consumers whose IADL hours exceed hands‑on activity-of-daily-living (ADL) hours; the slides identified 3,359 fee‑for‑service consumers in that category. The panel considered options including tighter correlation of IADL hours to ADL hands‑on needs as one route to potential savings; Darcy presented an illustrative calculation that limiting IADLs to a consumer’s ADL hours could save roughly $19 million in fee‑for‑service spending for the identified group.

Panel members cautioned against measures that would undermine community living or the program’s intent. Charlie Carr said the PCA program’s longevity and the independent‑living philosophy make it popular: “We did our little best to try to find things we could agree to that would save some money,” he said, adding that the group must balance cost control with preserving the program’s purpose.

Committee members asked how the work group would continue its work. Oz Mandahar, a commission member, asked about regular updates and Darcy agreed the group would continue meeting through June and that MassHealth could provide additional data cuts. Darcy also confirmed the work‑group materials and a public report are posted on the group’s website and may be shared by commissioners.

Next steps described in the meeting included continuing work‑group meetings through June to seek additional consensus recommendations, monitoring the EVV rollout, and coordinating with legislators and the administration on budget benchmarks and anticipated federal Medicaid changes.

Votes and formal actions taken during the commission meeting not tied to the work group included a voice vote to approve the meeting minutes (motion made by Oz Mandahar) and a subsequent adjournment motion; the minutes approval and adjournment were carried by voice vote and counts were not specified on the record.

The work group’s materials, including slides and the public report Darcy referenced, are available on the commission’s website, and the commission scheduled an informational hearing on health equity for people with disabilities at the State House on May 19. The subcommittee said it will request periodic updates from Darcy or MassHealth on progress toward the recommendations.