reglab/statecodes huggingface dataset:
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 415.000 - Acute Inpatient Hospital Services › Section 415.404 - Provider Eligibility

Current through Register 1525, July 5, 2024
Payment for the services described in
				130 CMR 415.000 is made
				only to acute inpatient hospitals participating in MassHealth as of the date of
				service.
(A)
In-state
. To participate in MassHealth, an acute
			 inpatient hospital located in Massachusetts must
(1) be licensed as a hospital by the
			 Massachusetts Department of Public Health;
(2) have a signed provider agreement that
			 specifies a payment methodology with the MassHealth agency; and
(3) participate in the Medicare
			 program.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 415.000 - Acute Inpatient Hospital Services › Section 415.405 - Utilization Management Program

Current through Register 1525, July 5, 2024
The MassHealth agency pays for medical procedures and related
				hospital stays that are subject to the Utilization Management Program only if
				the requirements of the program, as described in
				130
				CMR 450.207:
Utilization Management
				Program for Acute Inpatient Hospitals
through 450.209:
Utilization Management: Prepayment Review for Acute Inpatient
				Hospitals
, are satisfied. Appendix E of the
Acute Inpatient
				Hospital Manual
describes the information that must be provided as
				part of the review process.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 415.000 - Acute Inpatient Hospital Services › Section 415.406 - Payment Methodology

Current through Register 1525, July 5, 2024
Payments to acute inpatient hospitals in Massachusetts for
				services provided to MassHealth members equals the rate established in the
				signed provider agreement with the MassHealth agency.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 415.000 - Acute Inpatient Hospital Services › Section 415.407 - Covered Administrative Days: Payment Methodology

Current through Register 1525, July 5, 2024
Payment for covered administrative days provided on or after
				October 1, 1991, is made in accordance with the methodology established by the
				signed provider agreement with the MassHealth agency. The
per diem
rate must be accepted by the hospital as payment in full for all days
				determined to be administratively necessary, in accordance with
				130 CMR
				415.414.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 415.000 - Acute Inpatient Hospital Services › Section 415.408 - Nonpayable Services

Current through Register 1525, July 5, 2024
The following are not payable:
(A) drugs and durable medical equipment
			 prescribed for take-home use that are readily available from pharmacies or
			 medical providers;
(B) the cost of
			 any treatment or testing provided to a member who is an inpatient at another
			 hospital, whether of the member or of a specimen from the member. Payment will
			 be made to the hospital where the member is an inpatient and not to the
			 provider where this treatment or testing occurs;
(C) leaves of absence;
(D) research or the provision of
			 experimental, unproven, cosmetic, or otherwise medically unnecessary procedures
			 or treatments;
(E) cosmetic
			 surgery;
(F) the provision of whole
			 blood (however, administrative and processing costs associated with the
			 provision of blood and its derivatives are reimbursable);
(G) private hospital rooms, except when the
			 member is being treated for an infectious disease that requires a private room,
			 or in other circumstances in which a private room would be medically necessary;
			 and
(H) the treatment of male or
			 female infertility (including, but not limited to, laboratory tests, drugs, and
			 procedures associated with such treatment); however, MassHealth does pay for
			 the diagnosis of male or female infertility.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 415.000 - Acute Inpatient Hospital Services › Section 415.409 - Sterilization Services: Introduction

Current through Register 1525, July 5, 2024
(A)
Covered Services
. The MassHealth agency pays for
			 sterilization services performed by a licensed physician in an acute inpatient
			 hospital for a member only if all of the following conditions are met.
(1) The member has voluntarily given informed
			 consent for the sterilization procedure in the manner and at the time described
			 in
			 130 CMR
			 415.410, and such consent is documented in
			 the manner described in
			 130 CMR
			 415.411.
(2) The member is 18 years of age or older at
			 the time consent is obtained.
(3)
			 The member is not a mentally incompetent individual or an institutionalized
			 individual.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 415.000 - Acute Inpatient Hospital Services › Section 415.410 - Sterilization Services: Informed Consent

Current through Register 1525, July 5, 2024
A member's consent for sterilization will be considered
				informed and voluntary only if such consent is obtained in accordance with the
				requirements specified in 130 CMR 415.410(A) and (B), and such consent is
				documented as specified in
				130 CMR
				415.411.
(A)
Informed Consent
			 Requirements
.
(1) The person who
			 obtains consent (a physician, nurse, or counselor, for example) must orally
			 provide all of the following information and advice to the member requesting
			 sterilization:
(a) advice that the member is
			 free to withhold or withdraw consent for the procedure at any time before the
			 sterilization without affecting the right to future care or treatment and
			 without loss of any federal- or state-funded program benefits to which the
			 member otherwise might be entitled;
(b) a description of available alternative
			 methods of family planning and birth control;
(c) advice that the sterilization procedure
			 is considered irreversible;
(d) a
			 thorough explanation of the specific sterilization procedure to be
			 performed;
(e) a full description
			 of the discomforts and risks that may accompany or follow the procedure,
			 including an explanation of the type and possible effects of any anesthetic to
			 be used;
(f) a full description of
			 the benefits or advantages that may be expected as a result of the
			 sterilization; and
(g) advice that
			 the sterilization will not be performed for at least 30 days, except under the
			 circumstances specified in 130 CMR 415.410(B)(1).
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 415.000 - Acute Inpatient Hospital Services › Section 415.411 - Sterilization Services: Consent Form Requirements

Current through Register 1525, July 5, 2024
Informed consent for sterilization must be documented by the
				completion of the MassHealth Consent for Sterilization form in accordance with
				the following requirements. (Instructions for obtaining the Consent for
				Sterilization forms are located in Subchapter 5 of the
Acute Inpatient
				Hospital Manual
.)
(A)
Required Consent Form
.
(1) One of the following Consent for
			 Sterilization forms must be used:
(a) CS-18 -
			 for members 18 through 20 years of age; or
(b) CS-21 - for members 21 years of age or
			 older.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 415.000 - Acute Inpatient Hospital Services › Section 415.412 - Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Services

Current through Register 1525, July 5, 2024
The MassHealth agency pays for all medically necessary acute
				inpatient hospital services for EPSDT-eligible members in accordance with
				130
				CMR 450.140:
Early and Periodic
				Screening, Diagnosis and Treatment (EPSDT) Services: Introduction
through 450.149:
EPSDT Services: Recordkeeping
				Requirements
, without regard to service limitations described in
				130 CMR 415.000, and with
				prior authorization.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 415.000 - Acute Inpatient Hospital Services › Section 415.413 - Hysterectomy Services

Current through Register 1525, July 5, 2024
(A)
Nonpayable Services
. The MassHealth agency does not
			 pay for a hysterectomy provided to a member under the following conditions.
(1) The hysterectomy was performed solely for
			 the purpose of sterilizing the member.
(2) If there was more than one purpose for
			 the procedure, the hysterectomy would not have been performed but for the
			 purpose of sterilizing the member.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 415.000 - Acute Inpatient Hospital Services › Section 415.414 - Utilization Review

Current through Register 1525, July 5, 2024
(A) All inpatient
			 services must be provided in accordance with
			 130 CMR
			 450.204:
Medical Necessity
or
			 130 CMR
			 415.415, and are subject, among other things,
			 to utilization review under
			 130
			 CMR 450.207:
Utilization Management
			 Program for Acute Inpatient Hospital
through 450.209:
Utilization Management: Prepayment Review for Acute Inpatient Hospitals
and to requirements governing overpayments under
			 130 CMR
			 450.235(B):
Overpayments
and 450.237:
Overpayments:
			 Determination
.
(B)
(1) The MassHealth agency (or its agent) will
			 review inpatient services provided to members to determine the medical
			 necessity, pursuant to
			 130 CMR
			 450.204:
Medical Necessity
,
			 or administrative necessity and appropriateness, pursuant to
			 130 CMR
			 415.415, of such services. Any such review
			 may be conducted prior to, concurrently, or retrospectively following the
			 member's inpatient admission. Reviewers consider the medical-record
			 documentation of clinical information available to the admitting provider at
			 the time the decision to admit was made. Reviewers do not deny admissions based
			 on what happened to the member after the admission. However, if an admission
			 was not medically necessary at the time of the decision to admit, but the
			 medical record indicates that an inpatient admission later became medically
			 necessary, the admission will be approved as long as all other MassHealth
			 requirements are met.
(2) If,
			 pursuant to any review, the Division concludes that the inpatient admission was
			 not medically or administratively necessary, the Division will deny payment for
			 the inpatient admission.
(3) If the
			 Division issues a denial notice for an acute inpatient hospital admission
			 pursuant to 130 CMR 415.414 and
			 450.204:
Medical Necessity
as well as either
			 130
			 CMR 450.209:
Utilization Management:
			 Prepayment Review for Acute Inpatient Hospitals
or 450.237:
Overpayments: Determination
, the hospital may rebill the claim
			 as an outpatient service, as long as the Division has determined the service
			 would have been appropriately provided in an outpatient setting. In order for
			 the hospital to receive payment under 130 CMR 415.414(B)(3), the outpatient
			 claim and a copy of the denial notice must be received by the Division within
			 90 days from the date of the denial notice and must comply with all applicable
			 Division requirements.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 415.000 - Acute Inpatient Hospital Services › Section 415.415 - Reimbursable Administrative Days

Current through Register 1525, July 5, 2024
(A)
			 Administrative days as defined in
			 130 CMR 415.402 are
			 reimbursable if the following conditions are met:
(1) the recipient requires an admission to a
			 hospital or a continued stay in a hospital for reasons other than the need for
			 services that can only be provided in an acute inpatient hospital as defined in
			 130 CMR 415.402
			 (
see
130 CMR 415.415(B) for examples); and
(2) a hospital is making regular efforts to
			 discharge the recipient to the appropriate setting. These efforts must be
			 documented according to the procedures described in
			 130 CMR
			 450.205:
Recordkeeping and
			 Disclosure
. The regulations covering discharge-planning standards
			 described in
			 130 CMR
			 415.419 must be followed, but they do not
			 preclude additional, effective discharge-planning activities.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 415.000 - Acute Inpatient Hospital Services › Section 415.416 - Nonreimbursable Administrative Days

Current through Register 1525, July 5, 2024
Administrative days are not reimbursable when:
(A) a hospitalized recipient is awaiting an
			 appropriate placement or services that are currently available but the hospital
			 has not transferred or discharged the recipient because of the hospital's
			 administrative or operational delays;
(B) the Division or its agent determines that
			 appropriate noninstitutional or institutional placement or services are
			 available within a reasonable distance of the recipient's noninstitutional
			 (customary) residence and the recipient, the recipient's family, or any person
			 legally responsible for the recipient refuses the placement or services;
			 or
(C) the Division or its agent
			 determines that appropriate noninstitutional or institutional placement or
			 services are available within a reasonable distance of the recipient's
			 noninstitutional (customary) residence and advises the hospital of the
			 determination, and the hospital or the physician refuses or neglects to
			 discharge the recipient.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 415.000 - Acute Inpatient Hospital Services › Section 415.418 - Accident Victims

Current through Register 1525, July 5, 2024
When a member is admitted to an acute inpatient hospital as the
				result of an accident, it is the hospital's responsibility to notify the
				member's local office so that assignment may be taken of the member's right to
				third-party coverage of claims or possible recovery of claims as the result of
				tort action.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 415.000 - Acute Inpatient Hospital Services › Section 415.419 - Discharge-planning Standards

Current through Register 1525, July 5, 2024
(A)
Staff
.
(1) The
			 hospital must assign in writing the responsibility for all patient discharge
			 planning to one appropriate department (such as social services or continuing
			 care). That department in turn must designate specific staff members whose
			 primary duties are discharge-planning.
(2) The discharge-planning staff must include
			 either a registered nurse or a social worker who is licensed or eligible and
			 applying for licensure in Massachusetts, and is under the supervision of, or in
			 consultation with, a licensed graduate-level nurse or social worker.
(3) Unless permitted a lower ratio by the
			 MassHealth agency, the hospital must employ one discharge planner or full-time
			 equivalent for every 60 licensed beds, excluding maternity and special-care
			 units. Visiting Nurse Association (VNA) or home health staff who are not
			 employed by the hospital, but who regularly perform discharge-planning
			 activities there, may be included in this ratio.
(4) The hospital must demonstrate to the
			 MassHealth agency that it provides formal in-service training programs and
			 regular case conferences for all discharge-planning staff and all other
			 personnel who affect the discharge-planning process.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 415.000 - Acute Inpatient Hospital Services › Section 415.420 - Child and Adolescent Needs and Strengths (CANS) Certification

Current through Register 1525, July 5, 2024
The following clinicians are eligible to administer the Child
				and Adolescent Needs and Strengths (CANS) in acute inpatient hospitals and must
				be certified every two years according to the process established by the
				Executive Office of Health and Human Services (EOHHS):
(A) psychiatrists and psychiatric
			 residents;
(B) psychiatric nurse
			 mental-health clinical specialists;
(C) psychologists who have a specialization
			 in clinical or counseling psychology;
(D) social workers who have a master's degree
			 in social work from an accredited educational institution; and
(E) counselors who hold a master's degree in
			 counseling education, counseling psychology, or rehabilitation psychology from
			 an accredited educational institution.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 415.000 - Acute Inpatient Hospital Services › Section 415.421 - Child and Adolescent Needs and Strengths (CANS) Data Reporting

Current through Register 1525, July 5, 2024
For each Child and Adolescent Needs and Strengths (CANS)
				conducted, the hospital must report data collected during the assessment to the
				MassHealth agency, in the manner and format specified by the MassHealth
				agency.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 415.000 - Acute Inpatient Hospital Services › Section 415.425 - Medical Leave-of-absence: Responsibilities of the Hospital for the Transfer of a Recipient who is a Resident of a Nursing Facility

Current through Register 1525, July 5, 2024
(A) Effective for dates of service on or
			 after July 1, 2000, the Division will pay a nursing facility to reserve a bed
			 during a member's medical leave-of-absence in accordance with the terms and
			 conditions of 130 CMR 415.425(B).
(B) Whenever a member is admitted to a
			 hospital from a nursing facility, the hospital must comply with the following
			 requirements.
(1) Not later than the second
			 working day of the member's hospital stay, the hospital must:
(a) review the member's medical record to
			 determine the member's estimated length of stay; and
(b) notify the nursing facility by telephone
			 of the estimated number of days of the stay and document in the member's
			 medical record the date of such telephone notification to the nursing
			 facility.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 416.000 - Hearing Instrument Specialist Services › Section 416.401 - Introduction

Current through Register 1525, July 5, 2024
130 CMR 416.000 governs
				services provided by hearing instrument specialist under MassHealth. A hearing
				instrument specialist who complies with
				130 CMR
				416.404, dispenses hearing aids or
				instruments, and provides services related to the care and maintenance of
				hearing aids or instruments is eligible to become a MassHealth provider. All
				hearing instrument specialists participating in MassHealth must comply with
				MassHealth regulations, including but not limited to those set forth in
				130 CMR 416.000 and
				450.000:
Administrative and Billing Regulations
.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 416.000 - Hearing Instrument Specialist Services › Section 416.403 - Eligible Members

Current through Register 1525, July 5, 2024
(A)
(1)
MassHealth
			 Members
. MassHealth covers hearing aid services only when provided
			 to eligible MassHealth members, subject to the restrictions and limitations
			 described in MassHealth's regulations. MassHealth's regulations at
			 130 CMR 450.105:
Coverage Types
specifically state, for each MassHealth
			 coverage type, which services are covered and which members are eligible to
			 receive those services.
(2)
Recipients of the Emergency Aid to the Elderly, Disabled and
			 Children Program
. For information on covered services for
			 recipients of the Emergency Aid to the Elderly, Disabled and Children Program,
see
130 CMR
			 450.106:
Emergency Aid to the
			 Elderly, Disabled and Children Program
.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 416.000 - Hearing Instrument Specialist Services › Section 416.404 - Provider Eligibility

Current through Register 1525, July 5, 2024
(A)
In-state
. The following requirements apply when the
			 practice is located in Massachusetts.
(1)
Independent Hearing Instrument Specialist
. An
			 independent hearing instrument specialist engaged in private practice in
			 Massachusetts is eligible to participate in MassHealth only if the individual
			 is licensed by the Commonwealth of Massachusetts, Division of Professional
			 Licensure, Board of Registration of Hearing Instrument Specialists.
(2)
Acute Hospital Outpatient
			 Department, Hospital-licensed Health Center, or Other Satellite
			 Clinic
. An acute hospital's outpatient department,
			 hospital-licensed health center, or other satellite clinic that participates in
			 MassHealth pursuant to the Executive Office of Health and Human Services
			 (EOHHS) Acute Hospital Request for Applications (RFA) and contract is eligible
			 to provide services designated as hearing aid services in Subchapter 6 of the
			 MassHealth
Hearing Instrument Specialist Manual
for providers
			 under
			 130 CMR 416.000.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 416.000 - Hearing Instrument Specialist Services › Section 416.405 - Out-of-state Services

Current through Register 1525, July 5, 2024
The MassHealth agency pays out-of-state hearing instrument
				specialists in accordance with
				130 CMR
				450.109:
Out-of-state
				Services
.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 416.000 - Hearing Instrument Specialist Services › Section 416.406 - Maximum Allowable Fees

Current through Register 1525, July 5, 2024
The MassHealth agency pays the lower of the following for
				hearing aids and related services:
(A)
			 the hearing instrument specialist's usual and customary fee; or
(B) the maximum fee listed in the applicable
			 fee schedule of the Massachusetts Division of Health Care Finance and
			 Policy.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 416.000 - Hearing Instrument Specialist Services › Section 416.407 - Individual Consideration

Current through Register 1525, July 5, 2024
Services designated "I.C." in the list of service codes and
				descriptions in Subchapter 6 of the
Hearing Instrument Specialist
				Manual
are given individual consideration by the MassHealth agency to
				determine the amount of payment to be made to the hearing instrument
				specialist. The MassHealth agency determines the amount of payment using the
				following criteria:
(A) the time
			 required to perform the procedure;
(B) the degree of skill required to perform
			 the procedure;
(C) the severity or
			 complexity of the member's hearing disorder or disability;
(D) the policies, procedures, and practices
			 of other third-party purchasers of health care; and
(E) the reasonable and customary practices of
			 hearing instrument specialists.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 416.000 - Hearing Instrument Specialist Services › Section 416.408 - Prior Authorization

Current through Register 1525, July 5, 2024
(A) Services
			 designated "P.A." in the list of service codes and descriptions in Subchapter 6
			 of the
Hearing Instrument Specialist Manual
require prior
			 authorization from the MassHealth agency. The MassHealth agency requires prior
			 authorization for:
(1) any hearing aid that
			 costs more than the amount indicated in the applicable service description in
			 Subchapter 6 of the
Hearing Instrument Specialist
			 Manual
;
(2) the
			 replacement of a hearing aid consistent with the provisions of
			 130 CMR
			 416.418, regardless of the cost of the
			 hearing aid, due to:
(a) a medical
			 change;
(b) loss of the hearing
			 aid; or
(c) damage beyond repair to
			 the hearing aid; and
(3)
			 certain hearing aid related services as specified in Subchapter 6 of the
Hearing Instrument Specialist Manual
.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 416.000 - Hearing Instrument Specialist Services › Section 416.409 - Separate Procedures

Current through Register 1525, July 5, 2024
Some procedures are commonly carried out as an integral part of
				a total service, and as such do not warrant a separate identification. When,
				however, such a procedure is performed independently of, and is not immediately
				related to, other services, it is designated as a "separate procedure" or
				"S.P." in the list of service codes and descriptions in Subchapter 6 of the
Hearing Instrument Specialist Manual
. Thus, when a procedure
				is performed alone for a specific purpose, it must be considered a separate
				procedure.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 416.000 - Hearing Instrument Specialist Services › Section 416.410 - Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Services

Current through Register 1525, July 5, 2024
The MassHealth agency pays for all medically necessary hearing
				instrument specialist services for EPSDT-eligible members in accordance with
				130
				CMR 450.140
et seq
., without
				regard to service limitations described in
				130 CMR 416.000, and with
				prior authorization.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 416.000 - Hearing Instrument Specialist Services › Section 416.414 - Dispensing Requirements

Current through Register 1525, July 5, 2024
A hearing instrument specialist may dispense a hearing aid only
				after receiving the following documentation.
(A)
Complete Audiological
			 Evaluation
. A complete audiological evaluation includes air and
			 bone conduction, spondee thresholds, and word discrimination testing.
(1) The hearing instrument specialist must
			 have received a complete audiological evaluation (air and bone conduction,
			 spondee thresholds, and word discrimination testing) performed by one of the
			 following:
(a) an independent audiologist who
			 personally performed and completed the audiological evaluation;
(b) a licensed audiologist who is employed at
			 a speech and hearing clinic and who personally performed and completed the
			 audiological evaluation;
(c) a
			 licensed audiologist who is employed by a physician, or an acute hospital's
			 outpatient department, hospital-licensed health center or other satellite
			 clinic;
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 416.000 - Hearing Instrument Specialist Services › Section 416.415 - Conditions of Payment

Current through Register 1525, July 5, 2024
All claims must be submitted in accordance with the
				administrative and billing instructions in Subchapter 5 of the
Hearing
				Instrument Specialist Manual
.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 416.000 - Hearing Instrument Specialist Services › Section 416.416 - Reimbursable Services

Current through Register 1525, July 5, 2024
(A)
Audiological Evaluation/Testing Services
. Payment for
			 an audiological evaluation will be made only if the evaluation is recommended
			 by a physician.
(B)
Hearing Aid Purchase
. Payment for a hearing-aid
			 purchase includes the following:
(1) the
			 hearing aid and standard accessories/options required for the proper operation
			 of the hearing aid;
(2) the proper
			 fitting and instruction in the use, care, and maintenance of the hearing
			 aid;
(3) maintenance, minor repair,
			 and servicing of the hearing aid that is furnished free of charge to
			 non-MassHealth members;
(4) the
			 initial manufacturer's warranty against loss or damage; and
(5) the loan of a hearing aid to the member
			 by the hearing instrument specialist, when necessary.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 416.000 - Hearing Instrument Specialist Services › Section 416.417 - Nonreimbursable Services

Current through Register 1525, July 5, 2024
MassHealth does not pay for any of the following
				services:
(A) the rental of hearing
			 aids;
(B) hearing aids that are
			 completely in the ear canal (CIC);
(C) personal FM systems; or
(D) assistive technology devices provided
			 under
			 34 CFR
			 300.308, where such devices are maintained at
			 the school facility for the general use of disabled students, and assistive
			 technology services provided under
			 34 CFR
			 300.308 relating to the use of such
			 devices.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 416.000 - Hearing Instrument Specialist Services › Section 416.418 - Service Limitations

Current through Register 1525, July 5, 2024
(A) The MassHealth
			 agency does not pay for more than one hearing aid per ear per member in a
			 60-month period without prior authorization in accordance with
			 130 CMR
			 416.408. One hearing aid per ear consists of
			 either one binaural hearing-aid fitting, or two monaural hearing aids dispensed
			 more than six months apart, with one aid dispensed for the left ear and the
			 other dispensed for the right ear.
(B) Two monaural fittings dispensed within a
			 six-month period, with one aid dispensed for the left ear and the other for the
			 right ear, are defined as a single binaural fitting. The MassHealth agency does
			 not pay two monaural dispensing fees for this service. MassHealth pays only one
			 binaural dispensing fee for this service.
(C) The MassHealth agency will pay for the
			 hearing tests listed in Subchapter 6 of the
Hearing Instrument
			 Specialist Manual
only when provided for the sole purpose of hearing
			 aid fitting and dispensing to an eligible member 18 years of age or older. The
			 MassHealth agency will not pay for services for which the provider does not
			 customarily charge non-MassHealth members.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 416.000 - Hearing Instrument Specialist Services › Section 416.419 - Recordkeeping Requirements

Current through Register 1525, July 5, 2024
A hearing instrument specialist must maintain a medical record
				for each member for a period of at least as long as the minimum period required
				by
				130 CMR
				450.205(G). The MassHealth
				agency does not pay a provider for services if the provider does not have
				adequate documentation to substantiate the provision of services payable under
				MassHealth. The medical record must contain all pertinent information about the
				services provided, including the date of service and the dates on which
				materials were ordered and dispensed. In no instance does the completion of the
				appropriate MassHealth claim form, the maintenance of a copy of such a claim,
				or the simple notation of service codes constitute sufficient documentation for
				the purposes of 130 CMR 416.419. The recordkeeping requirements are specific to
				each type of service and are described as follows.
(A)
Earmolds
. The
			 hearing instrument specialist must maintain the manufacturer's invoice, in the
			 member's medical record indicating the actual acquisition cost for the
			 earmold.
(B)
Hearing
			 Aids
. The hearing instrument specialist must maintain the
			 following information in the member's medical record:
(1) a history of the member's hearing loss
			 and use of hearing aids. The history must contain the following information:
(a) the etiology and chronology of the
			 member's hearing loss, including the member's age at the onset of the loss and
			 an indication of whether the hearing loss is progressive;
(b) the make, model number, type, and date of
			 purchase of each hearing aid previously worn by the member;
(c) a description of any speech and hearing
			 therapy received by the member; and
(d) a description of any medical condition
			 that the member has that may impair vision or affect hearing aid use;
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 417.000 - Psychiatric Day Treatment Program Manual › Section 417.401 - Introduction

Current through Register 1525, July 5, 2024
All psychiatric day treatment programs participating in
				MassHealth must comply with the regulations of the MassHealth agency governing
				MassHealth including, but not limited to, 130 CMR 417.000 and 130 CMR 450.000:
Administrative and Billing Regulations.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 417.000 - Psychiatric Day Treatment Program Manual › Section 417.403 - Eligible Members

Current through Register 1525, July 5, 2024
(A)
(1) MassHealth Members. The MassHealth agency
			 covers psychiatric day treatment program services only when provided to
			 eligible MassHealth members, subject to the restrictions and limitations
			 described in the MassHealth agency's regulations. The MassHealth agency's
			 regulations at
			 130 CMR 450.105:
Coverage Types
specifically state, for each MassHealth
			 coverage type, which services are covered and which members are eligible to
			 receive those services.
(2)
Recipients of the Emergency Aid to the Elderly, Disabled and
			 Children Program
. For information on covered services for
			 recipients of the Emergency Aid to the Elderly, Disabled and Children Program,
see
130 CMR
			 450.106:
Emergency Aid to the
			 Elderly, Disabled and Children Program.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 417.000 - Psychiatric Day Treatment Program Manual › Section 417.404 - Provider Eligibility

Current through Register 1525, July 5, 2024
(A)
In
			 State
. In order to qualify for participation in MassHealth as an
			 in state psychiatric day treatment program, a psychiatric day treatment program
			 must be located in Massachusetts and:
(1)
			 Operate under a valid clinic license to provide mental health services issued
			 by the Massachusetts Department of Public Health;
(2) Be in operation at least five days a week
			 and provide services to members at least six hours per day but fewer than 24
			 hours on each of those days; and
(3) Meet all provider participation
			 requirements as specified in 130 CMR 417.400 and 450.000:
Administrative and Billing Regulations.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 417.000 - Psychiatric Day Treatment Program Manual › Section 417.406 - In-state Providers: Reporting Requirements

Current through Register 1525, July 5, 2024
All psychiatric day treatment programs must complete and submit
				a Uniform Financial Report annually to the Division according to the Centers
				for Health Information and Analysis and comply with all other applicable
				reporting requirements as specified in 957 CMR 6.00:
Cost Reporting
				Requirements.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 417.000 - Psychiatric Day Treatment Program Manual › Section 417.409 - Out-of-state Providers: Maximum Allowable Fees

Current through Register 1525, July 5, 2024
Payment to an out-of-state psychiatric day treatment program is
				in accordance with the applicable rate schedule of its state's Medicaid Program
				or its equivalent, and is always subject to the applicable conditions,
				exclusions, and limitations set forth in 130 CMR 417.000.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 417.000 - Psychiatric Day Treatment Program Manual › Section 417.410 - Nonreimbursable Services

Current through Register 1525, July 5, 2024
The MassHealth agency does not pay psychiatric day treatment
				providers for:
(A)
Vocational Rehabilitative Services
. The MassHealth
			 agency does not pay for any vocational rehabilitative services that may
			 include, but are not limited to, activities which have a primary focus of
			 producing goods or performing services. However, certain prevocational
			 activities, such as time management groups and career planning groups to
			 prepare members for less intensive services, may be considered part of the
			 hourly rate.
(B)
Educational Services
. The MassHealth agency does not
			 pay for educational services, such as traditional academic and special
			 classroom services.
(C)
Functional Maintenance Programs
. The MassHealth agency
			 does not pay for functional maintenance programs.
(D)
Research and Experimental
			 Treatment
. The MassHealth agency does not pay for research or
			 experimental treatment.
(E)
Meals
. The MassHealth agency does not pay for meals as
			 part of psychiatric day treatment.
(F)
Services Included as Part of
			 Treatment Sessions
. The MassHealth agency does not pay for the
			 following services separately, since the fee for treatment sessions includes
			 the cost of these services:
(1) telephone
			 contacts of any duration with or related to members;
(2) any consultations about members with
			 outside agencies;
(3) information
			 and referral;
(4) patient
			 registration;
(5)
			 recordkeeping;
(6) individual
			 service planning; or
(7) case
			 management.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 417.000 - Psychiatric Day Treatment Program Manual › Section 417.411 - Treatment Response

Current through Register 1525, July 5, 2024
(A) Each
			 psychiatric day treatment program must assess the member's recovery status at
			 intake into the program, and assess treatment response every 90 days that the
			 member remains in the program, and at discharge from the program. These
			 assessments must be completed using instruments, subject to review by the
			 MassHealth agency, for measuring an individual member's treatment response.
			 Results of the assessments of treatment response must be kept in the member's
			 medical record
(B) The MassHealth
			 agency may decide to review a member's treatment if examination of the member's
			 treatment response review indicates that one or more of the following applies:
(1) no progress has been made for four
			 months;
(2) the member has
			 regressed in their recovery; or
(3)
			 another reason deemed appropriate by the MassHealth agency.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 417.000 - Psychiatric Day Treatment Program Manual › Section 417.412 - Scope of Services

Current through Register 1525, July 5, 2024
A psychiatric day treatment program must ensure the
				availability of a sufficient variety of professional and special services to
				meet the needs of its member population. These services may be provided by the
				program itself or through referral to other agencies, as set forth in
				130 CMR 417.414.
				Professional and special services that meet the needs of a psychiatric day
				treatment program that are all inclusive include: diagnostic, bio-psychosocial
				evaluation, self care, case management; group therapy; skills building and
				other recovery-oriented services; psycho-education; crisis planning and
				management; individualized treatment and recovery planning; multidisciplinary
				treatment review team; and discharge and aftercare planning, including relapse
				prevention planning. Programs refer for psychiatric and nursing assessment as
				indicated.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 417.000 - Psychiatric Day Treatment Program Manual › Section 417.413 - Psychiatric Day Treatment Program Services Provided to Institutionalized Members

Current through Register 1525, July 5, 2024
The MassHealth agency pays a psychiatric day treatment program
				for the following services only when such services are not provided during a
				psychiatric day treatment program session:
(A) a preadmission evaluation visit of at
			 least one hour that consists of a comprehensive evaluation to determine the
			 need for psychiatric day treatment program services and to design a treatment
			 plan; and
(B) a face-to-face
			 individual or group session lasting at least one hour with the member's family
			 or other involved persons to interpret accumulated data and to advise them on
			 how to assist the member.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 417.000 - Psychiatric Day Treatment Program Manual › Section 417.414 - Referrals

Current through Register 1525, July 5, 2024
(A) To ensure that members receive services
			 not available from the program, but required by their comprehensive treatment
			 plan or aftercare plan, a psychiatric day treatment program must have effective
			 methods to promptly and efficiently refer these members to community resources.
			 This requires that the staff know the resources available in the community,
			 maintain a file of appropriate addresses, telephone numbers, and contact
			 persons, have standing agreements with these resources as necessary, and
			 prepare for and follow up on referrals through case conferences, written
			 communications, and other less formal procedures.
(1)
Emergency Service
			 Team
. The program, or parent corporation, must maintain a
			 member-specific crisis plan and have established communication and referral
			 protocols with the local emergency services program (ESP) to ensure expeditious
			 access to emergency psychiatric care and hospitalization when
			 necessary.
(2)
Ambulatory Health Care Provider
. The program must
			 establish and maintain a transfer agreement with a MassHealth-participating
			 ambulatory care provider to provide screening, diagnosis, and treatment
			 services.
(3)
Massachusetts Rehabilitation Commission
. The program
			 must establish and maintain a documented affiliation agreement with the local
			 office of the Massachusetts Rehabilitation Commission to provide evaluation and
			 rehabilitation services to members approaching discharge from the program. The
			 agreement may allow for placement of a Massachusetts Rehabilitation Commission
			 employee on site in the psychiatric day treatment program.
(4)
Other Resources
.
			 The program must document the establishment of effective methods for providing
			 its members with housing, employment, recreation, transportation, education,
			 social services, health care, and legal services through referral to
			 appropriate community agencies.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 417.000 - Psychiatric Day Treatment Program Manual › Section 417.421 - Staffing Requirements

Current through Register 1525, July 5, 2024
(A)
Minimum Staffing Requirements
. A psychiatric day
			 treatment program must provide an adequate number of qualified personnel to
			 fulfill the program's objective.
(B)
Composition of the Treatment
			 Team
. The treatment team must contain multi-disciplinary staff
			 available as appropriate for the needs of the participants. The treatment team
			 must be comprised of mental health professionals who meet the requirements set
			 forth under
			 105 CMR 140.530(C)
			  or expressive therapy or allied health. The
			 treatment team may also include other related mental health professionals
			 necessary for the provision of intake, evaluation, diagnostic and treatment
			 services.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 417.000 - Psychiatric Day Treatment Program Manual › Section 417.422 - Organizational Structure

Current through Register 1525, July 5, 2024
(A)
Program Director
.
(1)
			 A psychiatric day treatment program must designate a full-time professional as
			 overall administrator and clinical director to be responsible for the program
			 and charged with day-today responsibility over it.
(2) The program director must have the
			 following educational and work experience.
(a)
Educational Requirements
. A program director must have
			 one of the following college degrees:
1. a
			 master's degree in one of the disciplines set forth in
			 105 CMR
			 140.530(C):
Personnel Qualifications:
2. a master's degree in a related health
			 field (such as health administration or public health); or
3. a bachelor's degree in nursing (to become
			 a registered nurse) or in occupational therapy, unless the basic preparation
			 took place at a master's degree level.
(b)
Experience
			 Requirements
. A program director must have five years of
			 full-time, supervised clinical experience in a multidisciplinary team treatment
			 setting, and a familiarity with the principles of the rehabilitation and
			 recovery model. Two years of this experience must be attained after the degree
			 required in
			 130 CMR 417.422(A)(3)(a)
			  has been received, except for registered
			 nurses and occupational therapists with a bachelor's degree who must have the
			 required five years of experience subsequent to receiving their degrees.
			 Occupational therapists with a bachelor's degree in occupational therapy and a
			 master's degree in a related health field, as described in
			 130 CMR
			 417.422(A)(3)(a)2., must
			 have two years of experience subsequent to receiving their master's degree.
			 Experience should be broken down as follows:
1. two years of work with a participant
			 population similar to that of receiving psychiatric day treatment program
			 services;
2. one year (which may be
			 concurrent with one of the foregoing two years) in another day treatment
			 program; and
3. two years in an
			 administrative/supervisory category.
(3)
Responsibilities
. The program director's
			 responsibilities include:
(a) hiring and
			 firing of clinical staff;
(b)
			 establishing and implementing a supervision protocol in consultation with the
			 medical director and/or clinic director;
(c) establishing policies and procedures for
			 participant treatment;
(d)
			 accountability for adequacy and appropriateness of participant
			 treatment;
(e) coordinating staff
			 activities to meet program objectives;
(f) program evaluation; and
(g) establishing and supervising in-service
			 training and education.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 417.000 - Psychiatric Day Treatment Program Manual › Section 417.423 - Qualifications of Licensed and Unlicensed Professional Staff

Current through Register 1525, July 5, 2024
A psychiatric day treatment program's professional staff must
				meet the qualifications for their respective disciplines set forth in
				130 CMR
				417.423(A) through (K), and
				must demonstrate a familiarity with the principles of rehabilitation and
				recovery. All licensed and unlicensed professional staff must be supervised
				according to the supervisory protocol described at
				130 CMR
				417.422(A)(3)(b).
(A)
Psychiatrist
.
(1) At least one psychiatrist employed by a
			 psychiatric day treatment program, whether full time or as a consultant, must
			 either currently be certified by the American Board of Psychiatry and
			 Neurology, or the American Osteopathic Board of Neurology and Psychiatry, or be
			 eligible applying for such certification.
(2) Any additional psychiatrists must be at
			 least licensed physicians in their second year of a psychiatric residency
			 program accredited by the Council on Medical Education of the American Medical
			 Association. Such physicians must be under the direct supervision of a fully
			 qualified psychiatrist.
(3) All
			 clinics where psychiatric day treatment is provided must comply with
			 105 CMR 140.530(C)(1)(a)
			  Mental Health regulation
			 requirements.