Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 403.000 - Home Health Agency › Section 403.409 - Clinical Eligibility Criteria for Home Health Services

Current through Register 1525, July 5, 2024
(A)
Member Must Be under the Care
			 of a Physician or Ordering Non-physician Practitioner
. The
			 MassHealth agency pays for home health services only if the member's physician
			 or ordering non-physician practitioner certifies the medical necessity for such
			 services and establishes an individual plan of care in accordance with
			 130 CMR
			 403.420. A member may receive home health
			 services only if he or she is under the care of a physician or ordering
			 non-physician practitioner. (A podiatrist may be considered a physician for the
			 purposes of meeting 130 CMR 403.409(A).) The physician or ordering
			 non-physician practitioner providing the certification of medical necessity and
			 submitting the plan of care for home health services must not be a physician or
			 ordering non-physician practitioner on the staff of, or under contract with,
			 the home health agency.
(B)
Limitations on Covered Services
. The MassHealth agency
			 pays for home health services to a member who resides in a non-institutional
			 setting, which may include, without limitation, a homeless shelter or other
			 temporary residence or a community setting. In accordance with
			 42 CFR
			 440.70(c), the MassHealth
			 agency does not pay for home health services provided in a hospital, nursing
			 facility, intermediate care facility for the intellectually or developmentally
			 disabled, or any other institutional facility providing medical, nursing,
			 rehabilitative, or related care.
(C)
Medical Necessity
			 Requirement
. In accordance with
			 130 CMR
			 450.204:
Medical Necessity
,
			 and MassHealth Guidelines for Medical Necessity Determination for Home Health
			 Services, the MassHealth agency pays for only those home health services that
			 are medically necessary. Home health services are not to be used for homemaker,
			 respite, or heavy cleaning or household repair.
(D)
Availability of Other
			 Caregivers
. When a family member or other caregiver is providing
			 services, including nursing services, that adequately meet the member's needs,
			 it is not medically necessary for the home health agency to provide such
			 services.
(E)
Least
			 Costly Form of Care
. The MassHealth agency pays for home health
			 agency services only when services are no more costly than medically comparable
			 care in an appropriate institution and the least costly form of comparable care
			 available in the community.
(F)
Safe Maintenance in the Community
. The member's
			 physician or ordering non-physician practitioner and home health agency must
			 determine that the member can be maintained safely in the community.
(G)
Prior
			 Authorization
. Home health services require prior authorization.
See
130
			 CMR 403.413 for requirements.
(H)
Continuous Skilled Nursing
			 (CSN) Services
. For clinical eligibility criteria for CSN
			 services,
see
130 CMR 438.000:
Continuous Skilled
			 Nursing Agency
.
(1) the member meets
			 the criteria for nursing services as stated in
			 130 CMR
			 403.420;
(2) there is a clearly identifiable specific
			 medical need for a nursing visit of more than two continuous hours;
			 and
(3) prior authorization for CSN
			 services has been obtained from the MassHealth agency or its designee, in
			 accordance with
			 130 CMR
			 403.410.