Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 456.000 - Long Term Care Services › Section 456.409 - Clinical Eligibility Criteria

Current through Register 1525, July 5, 2024
To be considered clinically eligible for nursing facility
				services, a member or MassHealth applicant must require one skilled service
				listed in
				130
				CMR 456.409(A)  daily, or
				the member must have a medical or mental condition requiring a combination of
				at least three services from
				130
				CMR 456.409(B) and (C),
				including at least one of the nursing services listed in
				130
				CMR 456.409(C).
				Additionally, to be considered clinically eligible for nursing facility
				services, a member or MassHealth applicant younger than 22 years old must also
				meet criteria as determined by the multi-disciplinary medical review team
				coordinated by the Department of Public Health.
(A)
Skilled
			 Services
. Skilled services must be performed by or under the
			 supervision of a registered nurse or therapist. Skilled services consist of the
			 following:
(1) intravenous, intramuscular, or
			 subcutaneous injection, or intravenous feeding;
(2) nasogastric-tube, gastrostomy, or
			 jejunostomy feeding;
(3)
			 nasopharyngeal aspiration and tracheostomy care, however, long-term care of a
			 tracheotomy tube does not, in itself, indicate the need for skilled
			 services;
(4) treatment and/or
			 application of dressings when the physician or PCP has prescribed irrigation,
			 the application of medication, or sterile dressings of deep decubitus ulcers,
			 other widespread skin disorders, or care of wounds, when the skills of a
			 registered nurse are needed to provide safe and effective services (including,
			 but not limited to, ulcers, burns, open surgical sites, fistulas, tube sites,
			 and tumor erosions);
(5)
			 administration of oxygen on a regular and continuing basis when the member's
			 medical condition warrants skilled observation (for example, when the member
			 has chronic obstructive pulmonary disease or pulmonary edema);
(6) skilled nursing observation and
			 evaluation of an unstable medical condition (observation must, however, be
			 needed at frequent intervals throughout the 24 hours; for example, for
			 arteriosclerotic heart disease with congestive heart failure);
(7) skilled nursing for management and
			 evaluation of the member's care plan when underlying conditions or
			 complications require that only a registered nurse can ensure that essential
			 unskilled care is achieving its purpose. The complexity of the unskilled
			 services that are a necessary part of the medical treatment must require the
			 involvement of skilled nursing personnel to promote the member's recovery and
			 safety;
(8) insertion, sterile
			 irrigation, and replacement of catheters, care of a suprapubic catheter, or, in
			 selected residents, a urethral catheter (a urethral catheter, particularly one
			 placed for convenience or for control of incontinence, does not justify a need
			 for skilled nursing care). However, the insertion and maintenance of a urethral
			 catheter as an adjunct to the active treatment of disease of the urinary tract
			 may justify a need for skilled nursing care. In such instances, the need for a
			 urethral catheter must be documented and justified in the member's medical
			 record (for example, cancer of the bladder or a resistant bladder
			 infection);
(9) gait evaluation and
			 training administered or supervised by a registered physical therapist at least
			 five days a week for members whose ability to walk has recently been impaired
			 by a neurological, muscular, or skeletal abnormality following an acute
			 condition (for example, fracture or stroke). The plan must be designed to
			 achieve specific goals within a specific time frame. The member must require
			 these services in an institutional setting;
(10) certain range-of-motion exercises may
			 constitute skilled physical therapy only if they are part of an active
			 treatment plan for a specific state of a disease that has resulted in
			 restriction of mobility (physical therapy notes showing the degree of motion
			 lost and the degree to be restored must be documented in the member's medical
			 record);
(11) hot pack,
			 hydrocollator, paraffin bath, or whirlpool treatment will be considered skilled
			 services only when the member's condition is complicated by a circulatory
			 deficiency, areas of desensitization, open wounds, fractures, or other
			 complications; and
(12) physical,
			 speech/language, occupational, or other therapy that is provided as part of a
			 planned program that is designed, established, and directed by a qualified
			 therapist. The findings of an initial evaluation and periodic reassessments
			 must be documented in the member's medical record. Skilled therapeutic services
			 must be ordered by a physician or PCP and be designed to achieve specific goals
			 within a given time frame.