Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 405.000 - Community Health Center Services › Section 405.477 - CARES Program Services

Current through Register 1525, July 5, 2024
(A)
Introduction
. The MassHealth Coordinating Aligned,
			 Relationship-centered, Enhanced Support for Kids program (CARES program) is a
			 Targeted Case Management (TCM) service rendered by CARES program providers
			 certified in accordance with
			 130
			 CMR 405.477(D)  to members
			 younger than 21 years old who satisfy the eligibility criteria in
			 130
			 CMR 405.477(C). The
			 MassHealth agency pays for CARES program services provided by CARES program
			 providers subject to restrictions and limitations in
			 130
			 CMR 405.477(A)  through
			 405.477(H) 
			 and Appendix M of the
Physician Manual
.
(B)
Definitions
. The
			 following terms used in
			 130
			 CMR 405.477(A)  through
			 405.477(H) 
			 have the meanings given in
			 130
			 CMR 405.477(B)  unless the
			 context clearly requires a different meaning.
Comprehensive Assessment
- a
				systematic, timely, and clearly documented screening process that provides the
				foundation for care coordination and the individual care plan. The assessment
				includes information and data from multiple sources and reflects key
				information about the member and their parent/guardian's needs and
				priorities.
Individual Care Plan (ICP)
- a plan
				that specifies the goals and actions to address the medical, educational,
				social, behavioral, or other services needed by the member and their
				parent/guardian.
Local Education Agency
- a public
				authority legally constituted by the state as an administrative agency to
				provide control of and direction for kindergarten through grade 12 public
				educational institutions.
Medical Complexity
- a combination of
				multiorgan system involvement from chronic health condition(s) that often
				result in functional limitations, ongoing use of medical technology, and high
				resource need and use.
Natural Supports
- include family,
				friends, neighbors, and self-help groups intentionally identified to support
				the member. This support system is an active component of the ICP to support
				the member and their parent/guardian.
Subspecialist
- a provider who
				specializes in a narrow field of professional knowledge/skills within a medical
				specialty, such as pediatric congenital heart disease within the broad
				specialty of cardiology.
(C)
Clinical Eligibility
			 Criteria
. To receive CARES program services, a member must:
(1) be younger than 21 years old;
(2) not reside in a nursing facility or other
			 inpatient facility for longer than six consecutive months at the time of
			 seeking CARES program services; and
(3) satisfy:
(a) all of the eligibility criteria in
			 130
			 CMR 405.477(C)(3)(b)(1);
			 and
(b) all of the eligibility
			 criteria in either
			 130
			 CMR 405.477(C)(3)(b)(2)  or
			 130
			 CMR 405.477(C)(3)(b)(3), as
			 follows:
1. The member is a child with special
			 health needs who requires ongoing medical management by at least two pediatric
			 subspecialists At least one of the specialists must treat a medical condition
			 that results in all of the following:
a.
			 functional impairment (
e.g.
, need for assistance with
			 activities of daily living) that substantially interferes with or limits the
			 member's role/functioning in family, school, and community activities.
			 Functional impairment is defined as difficulties that substantially interfere
			 with or limit the member in achieving or maintaining developmentally
			 appropriate, social, behavioral, cognitive, communicative, or adaptive skills.
			 Functional impairments of episodic, recurrent, and continuous duration are
			 included unless they are temporary and expected responses to stressful events
			 in the environment.
b. at least one
			 condition must be:
(i) progressive, associated
			 with persistent deteriorating health; or
(ii) a chronic medical condition, expected to
			 last at least a year and expected to be episodically or continuously
			 debilitating and require ongoing treatment for control of the condition that
			 will use health care resources above the level of a healthy child; or
(iii) a progressive or metastatic
			 malignancy.
2. At the time the member begins receiving
			 CARES program services, the member is at high risk for adverse health outcomes
			 due to both of the following:
a. Demonstrated
			 inability to coordinate multiple medical, social, and other services impacting
			 medical condition, as evidenced by:
i. two or
			 more unplanned emergency department visits within the past 180 days; or
ii. a documented pattern of
			 multiple missed primary care physician (PCP) or subspecialty appointments; or
iii. chronic absenteeism from
			 school directly related to the member's medical conditions.
b. Demonstrated health-related
			 social needs impacting the management of the member's medical condition. Social
			 complexity/health-related social needs are defined by at least one of the
			 following:
i. experiencing homelessness or
			 housing insecurity;
ii.
			 experiencing food insecurity;
iii.
			 parent/caregiver experiencing employment instability;
iv. lacking access to basic resources such as
			 heat, electricity, internet, transportation, education, and social connections;
			 or
v. living in unsafe or violent
			 conditions.
3.
			 The member requires more than two continuous hours of skilled nursing services
			 to remain safely at home.