reglab/statecodes huggingface dataset:
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 456.000 - Long Term Care Services › Section 456.420 - Case-mix Classification

Current through Register 1525, July 5, 2024
(A) MassHealth
			 pays for nursing facility services based on
per diem
rates
			 that correspond to the nursing care needs of members in a facility using a
			 case-mix classification system.
(B)
			 To determine the member's nursing care needs, a nursing facility must complete
			 a case-mix classification assessment to be specified by EOHHS and in accordance
			 with sub-regulatory guidance. Based on the assessment, each member is assigned
			 a case-mix classification rating, which corresponds to a rate of payment
			 established by MassHealth.
(C)
			 MassHealth or its designee may periodically audit medical records to ensure
			 that the nursing facility's documentation supports the
per
			 diem
case-mix classification rating. MassHealth or its designee must
			 be permitted access to the facility's records and the facility's premises for
			 an audit pursuant to
			 130
			 CMR 456.420(C).
(D) As part of the review under
			 130
			 CMR 456.420(C), if it is
			 determined that the case-mix classification rating is not supported, MassHealth
			 or its designee will notify the nursing facility of any re-classification by
			 MassHealth through the issuance of audit findings. If MassHealth's case-mix
			 classification rating differs from that of the nursing facility, MassHealth's
			 case-mix classification rating will supersede the facility's and the facility
			 must bill for the member's payment cycle at the MassHealth audited case-mix
			 classification
per diem
rate.
(E) If in the course of conducting audits
			 MassHealth determines that any of the regulations, rules, instructions, or
			 procedures of MassHealth have been violated by the nursing facility, MassHealth
			 may implement an overpayment action and/or impose sanctions against the nursing
			 facility in accordance with MassHealth's administrative and billing regulations
			 at 130 CMR
			 450.000:
Administrative and Billing
			 Regulations
.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 456.000 - Long Term Care Services › Section 456.421 - Reconsideration of MassHealth-assigned Case-mix Classification Rating

Current through Register 1525, July 5, 2024
(A) A nursing facility may request
			 reconsideration of MassHealth's audit findings and of the case-mix
			 classification rating assigned by MassHealth. All requests must state the
			 facility's justification for the request for reconsideration and must contain
			 documentation justifying the request for reconsideration. All documentation
			 must be specific to the individual whose case-mix classification rating is
			 under review. The request for reconsideration must be received by MassHealth
			 within 30 days from the date that the nursing facility receives the audit
			 findings from MassHealth.
(B) If
			 the nursing facility does not submit a request for reconsideration, the audit
			 findings issued pursuant to
			 130
			 CMR 456.420(C) will
			 constitute MassHealth's final action. If the nursing facility requests
			 reconsideration but does not comply with the requirements of
			 130
			 CMR 456.421(A), then
			 MassHealth will deny the request for reconsideration for failure to make a
			 timely request. In either case, MassHealth's audit findings will constitute
			 MassHealth's final agency action and the nursing facility will have no right to
			 an adjudicatory hearing pursuant to
			 130
			 CMR 456.421(C) because of
			 its failure to exhaust its administrative remedies.
(C) MassHealth will review a request for
			 reconsideration, the accompanying documentation submitted in compliance with
			 the requirements of
			 130
			 CMR 456.421(A), and any
			 other documents MassHealth deems relevant and issue a final decision based on
			 its review. The decision by MassHealth will be a determination of whether the
			 nursing facility has met all the criteria for the case-mix classification item
			 or items that are the subject of the reconsideration. The determination will be
			 in writing, state the reasons for the determination, and inform the nursing
			 facility of its right to file a Claim for Adjudicatory Hearing in accordance
			 with 130 CMR 450.241:
Hearings: Claim for an Adjudicatory Hearing
. The Board of
			 Hearings will decide the claim in accordance with
			 130
			 CMR 450.248:
Medicaid Director's
			 Decision
.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 456.000 - Long Term Care Services › Section 456.422 - Hospice Services in Nursing Facilities

Current through Register 1525, July 5, 2024
A resident of a nursing facility may elect hospice services and
				continue to reside in the facility, if the facility is serviced by a hospice
				provider. When a member elects hospice in accordance with
				130 CMR
				437.000:
Hospice Services
, MassHealth
				will not pay for nursing facility services and will not pay the nursing
				facility for medical leaves of absence while the election is in effect.
				MassHealth will pay the hospice for room and board and medical leave of absence
				while the election is in effect and the member remains in the nursing facility.
				MassHealth may recoup any payment made by MassHealth to the facility for
				services to the member while a hospice election is in effect.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 456.000 - Long Term Care Services › Section 456.423 - Patient-paid Amount

Current through Register 1525, July 5, 2024
(A) If the
			 MassHealth agency determines that a member is financially eligible for nursing
			 facility services, the MassHealth agency will issue a notice that contains the
			 effective date of coverage and the patient-paid amount.
(B) The patient-paid amount is applied to the
			 nursing facility's
per diem
rate for the member. If the member
			 is discharged from the facility or transferred to another nursing facility, the
			 patient-paid amount is applied up to the last full day of the member's stay and
			 the nursing facility must do the following.
(1) If the member is transferred from one
			 facility to another, the first facility must notify the second facility of the
			 disposition of the patient-paid amount. If the first facility receives a
			 patient-paid amount in excess of the
per diem
rate for the
			 number of days the member was in the facility, then the first facility must
			 issue a check to the second facility for the amount of the balance. The first
			 facility must submit a claim for the member's stay up to, but not including,
			 the day of transfer, even if the claim will not result in any payment by
			 MassHealth to the facility. Submission of this claim is necessary to ensure
			 that the second facility is correctly paid.
(2) If the member is discharged to the
			 community and the facility received a patient-paid amount in excess of the
per diem
rate for the number of days the member was in the
			 facility, then the facility must return the balance of the patient-paid amount
			 to the member.
(3) If the patient
			 dies and the facility has received a patient-paid amount in excess of the
per diem
rate for the number of days the member was in the
			 facility, then the facility must deposit the balance into the member's personal
			 needs account or return the balance to the party who paid the patient-paid
			 amount.
See
130
			 CMR 456.614 for the disposition of the
			 personal needs allowance account when a member dies.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 456.000 - Long Term Care Services › Section 456.424 - Limitations on Charges to Members

Current through Register 1525, July 5, 2024
(A) A
			 nursing facility may only charge members for items requested by the member.
			 Before charging the member, the facility must inform the member of the cost of
			 the requested item. The facility must not charge a member for any item or
			 service covered by MassHealth or Medicare.
(B) Items for which the nursing facility must
			 not charge the member, include, but are not limited to, the following:
(1) group activities or entertainment that
			 occur within the facility;
(2)
			 parties organized by the facility;
(3) medically necessary drugs, medical
			 supplies, or medical services;
(4)
			 funeral expenses;
(5) room and
			 board to the facility;
(6)
			 wheelchair purchase, rental, or repair;
(7) transportation to obtain necessary
			 medical treatment; and
(8) service
			 charges for maintaining the member's personal needs allowance (PNA)
			 account.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 456.000 - Long Term Care Services › Section 456.425 - Medical Leave of Absence (MLOA): Introduction

Current through Register 1525, July 5, 2024
(A) MassHealth pays a nursing facility to
			 reserve a bed for up to 20 consecutive days for a member who is on a medical
			 leave of absence from the nursing facility, if all the conditions of
			 130
			 CMR 456.426 and
			 456.427 are met.
(B) In accordance with federal law, nursing
			 facilities must establish and follow a written policy regarding their bed-hold
			 periods, which must be consistent with the MassHealth bed-hold
			 policy.
(C) Following a medical
			 leave of absence of 20 days or fewer, the nursing facility must allow the
			 member to return to the nursing facility and resume residence unless the member
			 no longer requires the services provided by the nursing facility.
(D) When a member's hospitalization exceeds
			 20 days or does not meet the requirements of
			 130
			 CMR 456.426, the nursing facility must
			 immediately readmit the member to the facility, to the next available bed in a
			 semiprivate room, unless the member no longer requires the services provided by
			 the nursing facility.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 456.000 - Long Term Care Services › Section 456.426 - Medical Leave of Absence: Conditions of Payment

Current through Register 1525, July 5, 2024
(A) When a member is transferred from a
			 nursing facility to a hospital, the nursing facility must (1) provide the
			 member and the member's authorized or legal representative with notice of the
			 facility's bed-hold policy, including the member's right to return and resume
			 residence in the facility;
(2) provide the
			 member and the member's authorized or legal representative with notice of the
			 transfer that complies with the requirements set forth in
			 130
			 CMR 456.701 and
			 456.702;
(3) document the date and time of the
			 transfer in the member's record;
(4) automatically reserve the same bed and
			 room occupied by the member at the time the absence began for the member until
			 the close of business on the second working day of the member's hospital
			 stay;
(5) contact the admitting
			 hospital and obtain the estimated length of stay by the close of business on
			 the second working day of the member's hospital stay and document the estimated
			 length of stay in the member's medical record;
(6) if the estimated length of stay is 20
			 consecutive days or fewer, reserve the same bed and room occupied by the member
			 at the time the absence began for the balance of the actual length of stay not
			 to exceed 20 consecutive days from the date of admission to the
			 hospital;
(7) ensure that for each
			 day that a bed is reserved the bed is not occupied; and
(8) if the hospital advises the nursing
			 facility that the estimated length of stay exceeds 20 consecutive days, the
			 nursing facility cannot bill MassHealth for a medical leave of absence from the
			 date of such notification by the hospital.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 456.000 - Long Term Care Services › Section 456.427 - Medical Leave of Absence: Payment

Current through Register 1525, July 5, 2024
(A) For
			 billing and payment purposes, the day on which a member is transferred from a
			 nursing facility to a hospital for an inpatient or observation stay is the
			 first day of the medical leave of absence from the nursing facility. The day on
			 which a member is transferred back to a nursing facility or is discharged from
			 the hospital to a noninstitutional setting is not a medical leave of absence
			 day.
(B) MassHealth will only pay a
			 nursing facility for medical leave of absence days at the the leave of absence
			 rate specified by
			 101
			 CMR 206.06:
Adjustments to Standard
			 Nursing Facility Rates et seq
.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 456.000 - Long Term Care Services › Section 456.428 - Medical Leave of Absence: Readmission

Current through Register 1525, July 5, 2024
Members who have been authorized for payment of nursing
				facility services who are admitted to a hospital from a nursing facility may be
				readmitted to the same facility without a new authorization except when a
				hospitalization exceeds six months. When a hospitalization exceeds six months,
				the nursing facility must request a new authorization for nursing facility
				services before readmitting the member pursuant to
				130
				CMR 456.407.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 456.000 - Long Term Care Services › Section 456.429 - Medical Leave of Absence: Failure to Readmit

Current through Register 1525, July 5, 2024
(A) When a nursing facility is notified that
			 the member is ready to return to the facility, the nursing facility must
			 readmit the member following a medical leave of absence. If the nursing
			 facility does not allow the member to be readmitted following hospitalization
			 or other medical leave of absence, the nursing facility's failure to readmit
			 the member is deemed a transfer or discharge. If the nursing facility does not
			 readmit, it must provide the member and the member's authorized or legal
			 representative with a notice explaining its decision not to readmit the member
			 at the time such determination is made. The notice must comply with the
			 requirements set forth in
			 130
			 CMR 456.701.
(B) A nursing facility that fails to readmit
			 a member who requires nursing facility services or otherwise violates these
			 provisions may be subject to overpayment or sanction action under
			 130 CMR
			 450.000:
Administrative and Billing
			 Regulations
.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 456.000 - Long Term Care Services › Section 456.430 - Nonmedical Leave of Absence (NMLOA): Introduction

Current through Register 1525, July 5, 2024
MassHealth seeks the fullest integration possible of members
				into the community. Wherever possible, coordinated support services will be
				arranged so a member may return to the community. To prevent members from
				becoming isolated in nursing facilities, MassHealth will pay the nursing
				facility to reserve a bed for a member when the member is temporarily absent
				from the facility for nonmedical reasons subject to the requirements set forth
				in 130 CMR 456.431 and
				456.432.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 456.000 - Long Term Care Services › Section 456.431 - Nonmedical Leave of Absence: Limitations

Current through Register 1525, July 5, 2024
MassHealth pays for temporary absences for nonmedical leave for
				members in nursing facilities for up to a total of ten days per 12-month period
				starting with the first day of the nonmedical leave. For the purpose of NMLOA,
				a day is defined as a continuous 24-hour period. Absences from the nursing
				facility of less than 24 hours do not constitute a day of
				absence.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 456.000 - Long Term Care Services › Section 456.432 - Nonmedical Leave of Absence: Conditions for Payment

Current through Register 1525, July 5, 2024
(A) For the facility to obtain payment for a
			 nonmedical absence, the following conditions must be met.
(1) The member must request the nonmedical
			 leave.
(2) A written authorization
			 from the attending physician or PCP must be on file in the member's medical
			 record.
(3) During the period of
			 absence, the nursing facility must hold the same bed and room occupied by the
			 member at the time the absence began and must not admit any other resident in
			 the member's place.
(4) The
			 member's medical record maintained by the facility must document
(a) the home address, telephone number, and
			 relationship of the person responsible for the member while the member is
			 absent from the facility;
(b) the
			 duration of absence;
(c) the
			 physician or PCP's authorization for the absence; and
(d) the member's condition before and after
			 the absence from the facility.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 456.000 - Long Term Care Services › Section 456.433 - Nonmedical Leave of Absence: Payment

Current through Register 1525, July 5, 2024
MassHealth will only pay the nursing facility for nonmedical
				leave of absence days at the leave of absence rate specified by
				101
				CMR 206.06:
Adjustments to Standard
				Nursing Facility Rates et seq
.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 456.000 - Long Term Care Services › Section 456.451 - Withdrawal by Nursing Facilities from MassHealth: Introduction

Current through Register 1525, July 5, 2024
A nursing facility participating in MassHealth may cease to
				participate only in the manner detailed in
				130
				CMR 456.452 through
				456.455.
				130
				CMR 456.452 through
				456.455 continue apply even
				if the facility is continuing to operate as a nursing facility, is converting
				to a residential program (including, but not limited to, assisted living), or
				is closing.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 456.000 - Long Term Care Services › Section 456.452 - Notice of Withdrawal

Current through Register 1525, July 5, 2024
(A) A nursing
			 facility electing to withdraw from MassHealth must give written notice of its
			 intention to withdraw to MassHealth, unless such withdrawal results from an
			 emergency situation beyond the control of the provider such as fire or an act
			 of God. In the instance of alleged emergency withdrawal, the burden of proof
			 will be on the facility. The facility must send the withdrawal notice by
			 certified or registered mail (with return receipt requested) or email to
			 MassHealth's Office of Long-term Services and Supports not less than 90 days
			 before the effective date of withdrawal.
(B) When a decision has been made to close a
			 facility, the nursing facility must promptly complete a Relocation Assessment
			 Form for each member. The forms must be sent to MassHealth's designated nurse
			 reviewer. MassHealth will notify the facility of the results of the
			 assessment.
(C) A facility must not
			 admit any new MassHealth members after the date on which the withdrawal notice
			 was sent to MassHealth. Residents of the facility who become eligible for
			 MassHealth after the notice of withdrawal, MassHealth members who are
			 hospitalized when the notice was sent, and members who are on nonmedical leaves
			 of absence at the time the notice was sent are not considered new
			 admissions.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 456.000 - Long Term Care Services › Section 456.453 - Withdrawal Requirements

Current through Register 1525, July 5, 2024
(A) On the same
			 date on which the nursing facility sends a withdrawal notice to MassHealth, the
			 facility must give notice, in hand, to all its residents and the residents'
			 authorized or legal representatives, including those residents who have been
			 transferred to hospitals, or who are on nonmedical leave of absence. The notice
			 must advise that any resident who is eligible for MassHealth on the effective
			 date of the withdrawal must relocate to a facility participating in MassHealth
			 to ensure continuation of MassHealth payment of nursing facility services and
			 must also be determined eligible to continue to receive the services.
(B) The notice will also state that the
			 facility will work promptly and diligently to arrange for the relocation of
			 members to MassHealth-participating facilities or, if appropriate, to the
			 community. The nursing facility must give a similar notice to applicants for
			 admission during the period between the date in which the facility sent the
			 withdrawal notice to MassHealth and the effective date of the
			 withdrawal.
(C) After giving notice
			 of intent to withdraw, the facility must promptly begin and diligently sustain
			 efforts to arrange for the relocation of members to facilities participating in
			 MassHealth or to the community.
(D)
			 When it has been determined where a member is to be transferred to, the
			 facility must give the member written notice including the name of the facility
			 to which the member will be transferred and notification of the member's right
			 to appeal such a transfer as provided for in
			 130
			 CMR 456.701 and
			 456.702.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 456.000 - Long Term Care Services › Section 456.454 - Administrative Action Regarding Withdrawals

Current through Register 1525, July 5, 2024
A nursing facility that withdraws from MassHealth must continue
				to provide services to members until the members are relocated. If the facility
				fails to provide medical services to a member, the facility is subject to a
				fine of $1000 for each violation.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 456.000 - Long Term Care Services › Section 456.455 - Limitation of Provider Participation

Current through Register 1525, July 5, 2024
A nursing facility provider that voluntarily withdraws from
				MassHealth and continues to operate as a nursing facility may not participate
				as a MassHealth nursing facility provider for up to five years after the date
				of notice of the intent to withdraw, except to the extent, as determined by
				MassHealth, that the facility's participation in MassHealth is necessary for
				the health, welfare, and safety of members. If on the date that the withdrawal
				was to be effective, the nursing facility is still providing services to
				MassHealth members, then the facility will continue to be a MassHealth provider
				with regard to those members but will otherwise be considered withdrawn from
				the program. In such circumstances, the facility must notify MassHealth of its
				need to keep its MassHealth provider number.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 456.000 - Long Term Care Services › Section 456.601 - Personal Needs Allowance (PNA) Account

Current through Register 1525, July 5, 2024
MassHealth members have the right to manage their own financial
				affairs and the nursing facility must not require residents to deposit their
				personal funds with the facility. However, upon written request by a member,
				the facility must hold, safeguard, and manage an account for the member's
				personal funds deposited with the facility as specified in
				130
				CMR 456.601 through
				456.615.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 456.000 - Long Term Care Services › Section 456.602 - Management of the PNA Account

Current through Register 1525, July 5, 2024
If requested by the member, a facility must assume
				responsibility, that is, become a trustee, for the PNA funds of a member. To do
				so, the facility must obtain and maintain on file a statement of authorization
				signed by the member or the member's authorized or legal representative. The
				authorized or legal representative must not be an employee of the facility or
				related to an employee of the facility. Once a facility becomes trustee of a
				member's PNA account, the facility is responsible for the safekeeping of the
				PNA money and must repay the member for any lost or stolen funds or for any
				money that cannot be accurately accounted for.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 456.000 - Long Term Care Services › Section 456.603 - Autonomy of PNA Account

Current through Register 1525, July 5, 2024
(A) If the facility
			 assumes responsibility for a member's funds, the facility must deposit funds in
			 excess of $50 into a PNA account, that is, an interest-bearing trustee account
			 separate from any of the facility's operating accounts. A fee may not be
			 charged to the account.
(B) The
			 facility must ensure that a member's PNA funds are not available for any
			 purpose except the personal needs of that member. The funds must not be lent or
			 be used as collateral for a loan for anyone including the facility and may not
			 be less than a zero balance.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 456.000 - Long Term Care Services › Section 456.605 - Petty Cash in the Facility

Current through Register 1525, July 5, 2024
The facility may, if it chooses, maintain a petty cash fund in
				order to make direct cash distributions to residents. The total of this petty
				cash fund must not exceed an amount equal to $5 per member for whom the
				facility manages a PNA account; however, a maximum of $250 is allowable
				regardless of the number of residents.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 456.000 - Long Term Care Services › Section 456.606 - Assurance of Financial Security

Current through Register 1525, July 5, 2024
The facility must purchase a surety bond to assure the security
				of all personal funds of members deposited with the facility. The facility must
				keep this bond at the facility.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 456.000 - Long Term Care Services › Section 456.607 - Availability of PNA Records to MassHealth or it's Designee's Personnel

Current through Register 1525, July 5, 2024
All PNA records must be kept in the facility at all times and
				must be available to MassHealth or its designee's personnel upon
				request.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 456.000 - Long Term Care Services › Section 456.608 - Member Signature

Current through Register 1525, July 5, 2024
If the member cannot sign his or her own name, a staff member
				or business employee of the facility may sign as witness that the member has
				received cash from the member's PNA account.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 456.000 - Long Term Care Services › Section 456.609 - Notification of Account Balance

Current through Register 1525, July 5, 2024
(A) The
			 facility must notify each member for whom it has established a PNA account, and
			 his or her authorized or legal representatives, when the balance reaches a
			 total of $1,800, which is $200 less than the maximum countable assets allowed
			 per member. The notification must state that, if the member's countable assets
			 exceed the maximum allowable amount of $2,000, the member may lose MassHealth
			 eligibility.
(B) If the member's
			 balance exceeds the maximum allowable amount, the member may apply the excess
			 to the cost of care in the facility.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 456.000 - Long Term Care Services › Section 456.610 - Availability of PNA Records to Members

Current through Register 1525, July 5, 2024
The facility must, within one working day of a request, allow
				the member or the member's authorized or legal representative to examine the
				PNA records of the member.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 456.000 - Long Term Care Services › Section 456.611 - PNA Funds of a Member Transferred to Another Facility

Current through Register 1525, July 5, 2024
If a member is transferred to another nursing facility, all of
				the member's funds held in trust by the facility must be sent to the new
				facility within ten days of the transfer date.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 456.000 - Long Term Care Services › Section 456.612 - PNA Funds of a Member Discharged to the Community

Current through Register 1525, July 5, 2024
If a member has been discharged from the facility to the
				community, the member must receive his or her personal ledger or bank book back
				from the facility and must receive a check for the balance of the member's PNA
				account. The amount of the check must reflect both the cash held on behalf of
				the member by the facility and the bank balance.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 456.000 - Long Term Care Services › Section 456.613 - Member Is Transferred to a Hospital and Does Not Return to the Facility

Current through Register 1525, July 5, 2024
If a member is transferred to a hospital and does not return to
				the facility, the balance of the PNA account must be sent to the member at his
				or her new address within ten days after the member leaves the
				hospital.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 456.000 - Long Term Care Services › Section 456.614 - Death of a Member

Current through Register 1525, July 5, 2024
(A) Upon the death
			 of a MassHealth member, the nursing facility must
(1) render an accounting of the member's PNA
			 funds. The funds must remain at the facility for 30 days after the death of a
			 member to allow for the appointment of an administrator or executor of the
			 estate and for the payment of burial expenses; and
(2) notify the next of kin or the member's
			 authorized or legal representative of any remaining funds, determine whether an
			 executor or administrator has been or will be appointed, and explain to the
			 next of kin or the member's authorized or legal representative how to obtain
			 the funds from the facility.
(a) If there is
			 an outstanding balance due on a funeral bill, the funeral home may submit an
			 itemized funeral bill to the nursing facility and the nursing facility may pay
			 the bill from the PNA funds.
(b) If
			 an executor or administrator is appointed within 30 days after the death of a
			 member, the facility must send the balance of the PNA account and a final
			 accounting of the member's account to the administrator or executor of the
			 member's estate. If any payment has been made to the funeral home under
			 130
			 CMR 456.614(A)(2)(a), the
			 final accounting must reflect that payment.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 456.000 - Long Term Care Services › Section 456.615 - Annual Accounting to MassHealth of the PNA Balance

Current through Register 1525, July 5, 2024
(A) An accounting must be made to MassHealth
			 of the balance of each PNA account annually, by June
			 1st of each year. If the facility is not a trustee
			 for any member's money, it must report this fact by each June
			 1st to MassHealth. The accounting to MassHealth must
			 be submitted on the Statement of MassHealth Member's Personal Needs Account
			 (PNA-1) and must be dated and signed under the pains and penalty of perjury by
			 the administrator of the facility and mailed to MassHealth.
(B) The accounting must at a minimum consist
			 of the following, as well as any additional information requested by
			 MassHealth:
(1) the member's name;
(2) the member's MassHealth ID
			 number;
(3) the amount of petty
			 cash held in the facility for the member;
(4) the balance held in any individual bank
			 account for the member;
(5) the
			 balance held in the trustee account for the member;
(6) any other money being held by the
			 facility for the member; and
(7) if
			 funds are held in an aggregate trustee bank account, then a copy of the bank
			 statement for that account must be submitted with the accounting.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 456.000 - Long Term Care Services › Section 456.621 - Return of Unused Unit-Dose Drugs

Current through Register 1525, July 5, 2024
(A)
Returnable Drugs.
(1)
Requirement
. The nursing facility must return to the
			 dispensing pharmacy unused drugs in unit-dose packaging that are listed in
			 Appendix F of the
Nursing Facility Manual
and that were
			 dispensed to a MassHealth member, when the use of the drug for that member is
			 discontinued. Such returns allow the pharmacy to credit the Division for unused
			 doses, which reduces pharmaceutical waste. The nursing facility must return
			 such drugs that meet the requirements of 130 CMR 456.621(A)(2), unless they are
			 excluded under 130 CMR 456.621(B). The nursing facility must return such drugs
			 as soon as possible, but no later than 30 days after the date that the drug is
			 discontinued for the member, and no less than 90 days before the earliest
			 expiration date printed on the drug's label.
(2)
Returnable
			 Drugs
. Drug products that are returned must comply with all
			 applicable state and federal requirements, including those related to the
			 safety, labeling, handling, and storage of drugs.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 456.000 - Long Term Care Services › Section 456.701 - Notice Requirements for Transfers and Discharges Initiated by a Nursing Facility

Current through Register 1525, July 5, 2024
(A) A resident may
			 be transferred or discharged from a nursing facility only when
(1) the transfer or discharge is necessary
			 for the resident's welfare and the resident's needs cannot be met in the
			 nursing facility;
(2) the transfer
			 or discharge is appropriate because the resident's health has improved
			 sufficiently so that the resident no longer needs the services provided by the
			 nursing facility; (3) the safety of individuals in the nursing facility is
			 endangered;
(4) the health of
			 individuals in the nursing facility would otherwise be endangered;
(5) the resident has failed, after reasonable
			 and appropriate notice, to pay for (or failed to have MassHealth or Medicare
			 pay for) a stay at the nursing facility; or
(6) the nursing facility ceases to
			 operate.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 456.000 - Long Term Care Services › Section 456.702 - Time Frames for Notices Issued by Nursing Facilities

Current through Register 1525, July 5, 2024
(A) The notice of discharge or transfer
			 required under
			 130
			 CMR 456.701(C)  must be made
			 by the nursing facility at least 30 days prior to the date the resident is to
			 be discharged or transferred, except as provided for under
			 130
			 CMR 456.702(B).
(B) In
lieu
of the
			 30-day-notice requirement set forth in
			 130
			 CMR 456.702(A), the notice
			 of discharge or transfer required under
			 130
			 CMR 456.701(C)  must be made
			 as soon as practicable before the discharge or transfer in any of the following
			 circumstances.
(1) The health or safety of
			 individuals in the nursing facility would be endangered and this is documented
			 in the resident's record by a physician or PCP.
(2) The resident's health improves
			 sufficiently to allow a more immediate transfer or discharge and the resident's
			 attending physician or PCP documents this in the resident's record.
(3) An immediate transfer or discharge is
			 required by the resident's urgent medical needs and this is documented in the
			 medical record by the resident's attending physician or PCP.
(4) The resident has not resided in the
			 nursing facility for 30 days immediately prior to receipt of the
			 notice.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 456.000 - Long Term Care Services › Section 456.703 - Time Frames for Submission of Requests for Fair Hearings

Current through Register 1525, July 5, 2024
(A) Appeals of discharges and transfers will
			 be handled by MassHealth's Board of Hearings (BOH) pursuant to
			 130 CMR
			 610.000:
MassHealth: Fair Hearing
			 Rules
.
(B)
Time Limitation on the Right of Appeal
. The date of
			 request for a fair hearing is the date on which BOH receives such a request in
			 writing. BOH must receive the request for a fair hearing within the following
			 time limits:
(1) 30 days after a resident
			 receives written notice of a discharge or transfer pursuant to
			 130
			 CMR 456.702(A); or
(2) 30 days after a nursing facility
			 initiates a transfer or discharge or fails to readmit and fails to give the
			 resident notice; or
(3) 14 days
			 after a resident receives written notice of an emergency discharge or emergency
			 transfer pursuant to
			 130
			 CMR 456.702(B); or
(4) 14 days after a resident receives written
			 notice of a transfer or discharge that is the result of a nursing facility's
			 failure to readmit a resident following hospitalization or other medical leave
			 of absence.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 456.000 - Long Term Care Services › Section 456.704 - Stay of a Transfer or Discharge from a Nursing Facility Pending Appeal

Current through Register 1525, July 5, 2024
(A) If a request for a hearing regarding a
			 discharge or transfer from a nursing facility is received by the Board of
			 Hearings during the notice period described in
			 130
			 CMR 456.703(B)(1), the
			 nursing facility must stay the planned discharge or transfer until 30 days
			 after the decision is rendered. While this stay is in effect, the resident must
			 not be transferred or discharged from the nursing facility.
(B) If a hearing is requested, in accordance
			 with 130 CMR
			 456.703(B)(2), and the
			 request is received prior to the discharge or transfer, then the nursing
			 facility must stay the planned transfer or discharge until five days after the
			 hearing decision.
(C) If the
			 request for a hearing, in accordance with
			 130
			 CMR 456.703(B)(2), is
			 received within the applicable time frame but after the transfer, the nursing
			 facility must, upon receipt of an appeal decision favorable to the resident,
			 promptly readmit the resident to the next available bed in the
			 facility.
(D) In the case of a
			 transfer or discharge that is the result of a nursing facility's failure to
			 readmit a resident following hospitalization or other medical leave of absence,
			 if the request for a hearing is received within the applicable time period as
			 described in
			 130
			 CMR 456.703(B)(3), the
			 nursing facility must, upon receipt of an appeal decision favorable to the
			 resident, promptly readmit the resident to the next available bed in the
			 facility.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 456.000 - Long Term Care Services › Section 456.705 - Scheduling by the Board of Hearings

Current through Register 1525, July 5, 2024
(A) Upon
			 receipt of a request for a fair hearing, BOH will register the appeal, set a
			 date for a hearing, and so notify the appellant and the nursing
			 facility.
(B) In accordance with
			 130
			 CMR 610.015(F):
Expedited Appeals for Discharges and Transfers from a Nursing Facility
			 under
			 130
			 CMR 610.029(B) or
			 (C)
, a resident may request an
			 expedited appeal when a nursing facility notifies a resident of a discharge or
			 transfer under the time frames in
			 130
			 CMR 456.702(B) or
			 (C).
(C) BOH will designate a site for the hearing
			 accessible to the appellant. If the appellant has a handicap or disability that
			 reasonably prevents his or her appearance at the designated site, he or she may
			 request that the hearing be held by telephone or video conferencing, or at an
			 accessible location.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 457.000 - Freestanding Birth Center Services › Section 457.401 - Introduction

Current through Register 1525, July 5, 2024
130 CMR
				457.000 establishes the requirements for the provision
				and payment of freestanding birth center (FBC) services under MassHealth. All
				freestanding birth centers participating in MassHealth must comply with
				MassHealth regulations including, but not limited to,
				130 CMR
				457.000 and
				130 CMR
				450.000:
Administrative and Billing
				Regulations
. FBCs must render services in accordance with all
				applicable statutes and regulations, including DPH regulations at
				105 CMR
				140.000:
Licensure of Clinics
, and
				all applicable regulations cited therein.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 457.000 - Freestanding Birth Center Services › Section 457.402 - Definitions

Current through Register 1525, July 5, 2024
The following terms used in
				130 CMR
				457.000 have the meanings given in 130 CMR 457.402
				unless the context clearly requires a different meaning. The reimbursability of
				services defined in
				130 CMR
				457.000 is not determined by these definitions, but by
				application of
				130 CMR
				457.000 and
				130 CMR
				450.000:
Administrative and Billing
				Regulations
.
Freestanding Birth Center (FBC)
. A
				health facility not operated under a hospital license that is licensed by the
				Department of Public Health (DPH) as a birth center, pursuant to
				105 CMR
				140.000:
Licensure of Clinics
. A
				freestanding birth center does not include individual or group-practice
				offices.
Low-risk Pregnancy
. A normal,
				uncomplicated prenatal course as determined by documentation of adequate
				prenatal care and the anticipation of a normal, uncomplicated labor and birth,
				as defined by reasonable and generally accepted criteria adopted by
				professional groups for maternal, fetal, and neonatal health
				care.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 457.000 - Freestanding Birth Center Services › Section 457.403 - Eligible Members

Current through Register 1525, July 5, 2024
(A)
(1)
MassHealth
			 Members
. The MassHealth agency pays for freestanding birth center
			 services only when provided to eligible MassHealth members, subject to the
			 restrictions and limitations described in MassHealth regulations.
			 130
			 CMR 450.105:
Coverage Types
specifically states, for each 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 457.000 - Freestanding Birth Center Services › Section 457.404 - Provider Eligibility

Current through Register 1525, July 5, 2024
The MassHealth agency pays only freestanding birth centers who
				are participating in MassHealth on the date of service. Freestanding birth
				centers must meet the following eligibility requirements.
(A)
In-state
			 Providers
. To be eligible for participation as a MassHealth FBC
			 provider, the applicant must meet the MassHealth and DPH requirements specified
			 as follows:
(1) for each service location,
			 complete and submit the application for enrollment to MassHealth on the form
			 provided for this purpose by MassHealth;
(2) be located and legally doing business in
			 the Commonwealth of Massachusetts;
(3) operate under an FBC clinic license
			 issued by DPH, in accordance with
			 105 CMR
			 140.000:
Licensure of
			 Clinics
;
(4) be accredited
			 by the Commission for the Accreditation of Birth Centers (CABC).
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 457.000 - Freestanding Birth Center Services › Section 457.405 - Maximum Allowable Fees

Current through Register 1525, July 5, 2024
The Executive Office of Health and Human Services (EOHHS)
				determines the payment rate for freestanding birth center services in
				accordance with
				101 CMR
				355.00:
Rates for Freestanding Birth Center
				Services
. Payment is subject to the conditions, exclusions, and
				limitations set forth in
				130 CMR
				457.000 and
				130 CMR
				450.000:
Administrative and Billing
				Regulations
.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 457.000 - Freestanding Birth Center Services › Section 457.406 - Early and Periodic Screening, Diagnostic and Treatment (EPSDT) Services

Current through Register 1525, July 5, 2024
The MassHealth agency pays for all medically necessary
				freestanding birth center services for EPSDT-eligible members in accordance
				with 130 CMR 450.140:
Early and Periodic Screening, Diagnostic and Treatment (EPSDT)
				Services
:
Introduction
, without regard to service
				limitations described in
				130 CMR
				457.000, and with prior
				authorization.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 457.000 - Freestanding Birth Center Services › Section 457.407 - Covered Services

Current through Register 1525, July 5, 2024
The MassHealth agency pays for medically necessary FBC
				services, including the following:
(A)
			 prenatal visits;
(B)
			 ultrasound;
(C) low-risk labor and
			 delivery;
(D) postpartum
			 visit(s);
(E) newborn care
			 services; and
(F) labor care prior
			 to hospital transfer.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 457.000 - Freestanding Birth Center Services › Section 457.408 - Noncovered Services

Current through Register 1525, July 5, 2024
The MassHealth agency does not pay FBCs for the following
				services:
(A) surgical procedures such
			 as forceps delivery, tubal ligation, abortion, or cesarean section;
(B) services that are not provided by a
			 licensed provider within the scope of their practice and authorized under state
			 law or regulation;
(C) home births;
			 or
(D) general or regional
			 anesthesia.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 457.000 - Freestanding Birth Center Services › Section 457.409 - Service Limitations

Current through Register 1525, July 5, 2024
Surgical procedures must be limited to those normally provided
				during an uncomplicated birth, including episiotomy and repair. Local
				anesthesia may be administered when performed within the scope of practice of
				the health care provider. Members who are participating in the Primary Care
				Clinician (PCC) plan do not require a referral for FBC
				services.