reglab/statecodes huggingface dataset:
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 408.000 - Adult Foster Care Services › Section 408.438 - Withdrawal by an Adult Foster Care Provider from MassHealth

Current through Register 1525, July 5, 2024
An AFC provider that intends to withdraw from MassHealth must
				satisfy all of the following obligations.
(A)
MassHealth
			 Notification
.
(1) An AFC provider
			 electing to withdraw from participation in MassHealth must send written notice
			 to the MassHealth agency, or its designee, of the provider's intention to
			 withdraw from the AFC program. The AFC provider must send the withdrawal notice
			 by certified or registered mail (return receipt requested) to the MassHealth
			 agency or its designee, no fewer than 90 days before the effective date of
			 withdrawal.
(2) In the instance of
			 alleged emergency withdrawal, the AFC provider must contact the MassHealth
			 agency, or its designee, within one business day of the emergency withdrawal
			 and follow up in writing within three business days, informing the MassHealth
			 agency or its designee of the reasoning for such emergency withdrawal, and must
			 provide proof in documentation or other form as the MassHealth agency may
			 require. The AFC provider must also notify all members and the MassHealth
			 agency about the status of all members and any plans for relocation under
			 130
			 CMR 408.432.
(3) The AFC provider must forward a list of
			 all members currently receiving AFC. The AFC provider must notify the
			 MassHealth agency in writing as members are placed in other programs or begin
			 to receive alternative services, including the name of the new program or
			 service and the members' start date in the new program or service.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 408.000 - Adult Foster Care Services › Section 408.503 - GAFC Eligible Members

Current through Register 1525, July 5, 2024
(A)
MassHealth Members
. MassHealth eligible members 22
			 years of age or older may receive GAFC, subject to the restrictions and
			 limitations described in
			 130
			 CMR 450.105:
Coverage Types
that specifies, for each MassHealth coverage type, which services are covered
			 and which members are eligible to receive those services.
(B)
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
.
(C)
Reference
. For
			 information on verifying MassHealth member eligibility and coverage type,
see
130
			 CMR 450.107:
Eligible Members and the
			 MassHealth Card
.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 408.000 - Adult Foster Care Services › Section 408.506 - GAFC Clinical Eligibility Criteria

Current through Register 1525, July 5, 2024
A member must meet the following clinical eligibility criteria
				for receipt of GAFC:
(A) GAFC has been
			 ordered by the member's PCP; and
(B) The member has a medical or mental
			 condition that requires daily assistance with at least one of the ADLs
			 described at
			 130
			 CMR 408.506(C). Such
			 assistance must be either:
(1) hands-on
			 (physical) assistance, or
(2)
			 cueing and supervision throughout the entire ADL.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 408.000 - Adult Foster Care Services › Section 408.507 - GAFC Clinical Assessment and Prior Authorization

Current through Register 1525, July 5, 2024
(A)
Clinical
			 Assessment
. As part of the prior authorization process, members
			 seeking GAFC must undergo a clinical assessment to assess the member's clinical
			 status and need for GAFC. Completed clinical assessment documentation must be
			 submitted to the MassHealth agency, or its designee, in the form and format
			 requested by the MassHealth agency. A new clinical assessment is required
			 annually and upon significant change. The MassHealth agency reserves the right
			 to conduct the clinical assessment.
(B)
Prior
			 Authorization
.
(1) As a
			 prerequisite for payment of GAFC, the GAFC provider must obtain prior
			 authorization from the MassHealth agency or its designee before the first date
			 of service delivery and annually thereafter, and upon significant
			 change.
(2) Prior authorization
			 determines the medical necessity for GAFC as described under
			 130
			 CMR 408.507 and in accordance with
			 130
			 CMR 450.204:
Medical
			 Necessity
.
(3) Prior
			 authorization may specify the service amount for payment for the
			 service.
(4) Prior authorization
			 does not establish or waive any other prerequisites for payment such as the
			 member's financial eligibility described in
			 130
			 CMR 503.007:
Potential Sources of
			 Health Care
and
			 130
			 CMR 517.008:
Potential Sources of
			 Health Care
.
(5) When
			 submitting a request for prior authorization for payment of GAFC to the
			 MassHealth agency, or its designee, the GAFC provider must submit requests in
			 the form and format required by the MassHealth agency. The GAFC provider must
			 include all required information including, but not limited to, documentation
			 of the completed clinical assessment conducted by the MassHealth agency or its
			 designee; other nursing, medical or psychosocial evaluations or assessments;
			 and any other documentation that the MassHealth agency, or its designee,
			 requests in order to complete the review and determination of prior
			 authorization.
(6) In making its
			 prior authorization determination, the MassHealth agency or its designee, may
			 require additional assessments of the member or require other necessary
			 information in support of the request for prior authorization.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 408.000 - Adult Foster Care Services › Section 408.508 - GAFC Quality Management

Current through Register 1525, July 5, 2024
Providers must participate in any quality management and
				program integrity processes established by the MassHealth agency, including
				making any necessary data available and access to visit the provider's place of
				business upon request by the MassHealth agency or its
				designee.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 408.000 - Adult Foster Care Services › Section 408.509 - GAFC Conditions for Payment

Current through Register 1525, July 5, 2024
(A) The MassHealth
			 agency pays a GAFC provider for GAFC in accordance with the applicable payment
			 methodology and rate schedule established by the EOHHS. Rates of payment for
			 GAFC do not cover or include any amount for room and board.
(B) Payment for GAFC is subject to the
			 conditions, exclusions, and limitations set forth in
			 130 CMR
			 408.000 and
			 130 CMR 450.000:
Administrative and Billing Regulations
.
(C) The MassHealth agency pays a GAFC
			 provider for GAFC only if
(1) the member
			 receiving GAFC is eligible under 130 CMR 408.503;
(2) the member meets the clinical eligibility
			 criteria for GAFC in accordance with 130 CMR 408.506;
(3) the GAFC provider has obtained prior
			 authorization for GAFC in accordance with 130 CMR 408.507;
(4) the GAFC provider bills for GAFC provided
			 by direct care aides with the use of electronic visit verification (EVV) in the
			 form and format as required by EOHHS; and
(5) the GAFC provider is not billing for days
			 that are non-covered days under 130 CMR 408.526.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 408.000 - Adult Foster Care Services › Section 408.521 - GAFC Provider Responsibilities

Current through Register 1525, July 5, 2024
(A)
Policies and Procedures Manual
. Each GAFC provider
			 must develop, maintain, annually review, and update a comprehensive policies
			 and procedures manual governing the delivery of GAFC services. Each manual at a
			 minimum must contain a mission statement; the goals and objectives of the
			 program; an organizational chart describing the lines of authority and
			 communication needed to manage the GAFC program, including the lines of
			 authority for delegation of responsibility down to the member care level; job
			 descriptions that include titles, reporting authority, qualifications and
			 responsibilities; and a description of the governing body. Additionally, each
			 policy and procedure manual must contain the following:
(1) administrative policies and procedures
			 including, but not limited to:
(a) human
			 resource and personnel;
(b) staff
			 and staffing requirements;
(c)
			 backup staff in the event coverage is required due to illness, vacation, or
			 other reasons;
(d) staff education
			 and training;
(e) GAFC provider
			 staff evaluation and monitoring;
(f) emergencies, including fire, safety and
			 disasters, including notifying the fire department and police in emergencies,
			 relocating members during an emergency, and coordinating alternative GAFC
			 providers when a member is relocated;
(g) MassHealth basics and member
			 rights;
(h) human rights and
			 nondiscrimination;
(i) incident and
			 accident reporting;
(j) staff and
			 member grievances;
(k) cultural
			 competency;
(l) quality assurance
			 and improvement;
(m) direct care
			 aide training;
(n) emergency
			 services and plans;
(o) first aid
			 and cardiopulmonary resuscitation requirements;
(p) Health Insurance Portability and
			 Accountability Act (HIPAA);
(q)
			 coordination of GAFC with other services the member is receiving; and
(r) procedures to be followed if a member is
			 missing or lost; and
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 408.000 - Adult Foster Care Services › Section 408.522 - GAFC Preadmission and Admission Procedures

Current through Register 1525, July 5, 2024
Before admitting a member in GAFC, the GAFC provider must
				perform all of the activities in
				130
				CMR 408.522(A)(2). Intake
				and assessment services are provided to members seeking admission to GAFC, but
				who may have not yet received prior authorization by the MassHealth agency or
				its designee for GAFC.
(A)
Preadmission Procedures and Activities
(1)
Preadmission
			 Procedures
. Before admitting a member in GAFC the GAFC provider
			 must conduct a preadmission meeting with the member, and if applicable or
			 requested, the member's family, other informal caregivers, and any other health
			 or social service provider involved in the member's care. The nurse must
			 determine that the GAFC provider is able to meet the ADL and IADL needs of the
			 member prior to admitting the member to GAFC, as well as use the meeting to
			 obtain information about the member's overall health characteristics,
			 psychosocial condition, nutrition habits, financial and health insurance
			 information, housing situation, formal and informal supports in place, and
			 ethnic and cultural background. The GAFC provider must also use this meeting to
			 inform the member and the member's family about the scope of GAFC to be
			 provided and any other relevant information;
(2)
Preadmission
			 Activities
. Prior to admitting the member, the GAFC provider must
			 perform the following intake and assessment services:
(a) conduct clinical evaluations of the need
			 for GAFC;
(b) instruct members on
			 the rules, policies, and procedures of the GAFC program; and
(c) provide information on the member's
			 rights and responsibilities when receiving GAFC services.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 408.000 - Adult Foster Care Services › Section 408.523 - GAFC Discharge Procedures

Current through Register 1525, July 5, 2024
(A) A member must be
			 discharged by the GAFC provider upon the member's request, or if the member
			 ceases to benefit from GAFC, including the following circumstances:
(1) the member no longer meets the clinical
			 eligibility criteria for GAFC;
(2)
			 the member demonstrates behavioral or other problems that may endanger the
			 member or GAFC provider staff;
(3)
			 the member's clinical needs are beyond the scope of GAFC;
(4) the member's needs cannot be met by the
			 GAFC provider;
(5) the member
			 selects another service which is duplicative of GAFC; or
(6) the member transitions to another GAFC
			 provider.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 408.000 - Adult Foster Care Services › Section 408.524 - GAFC Staff Qualifications and Responsibilities

Current through Register 1525, July 5, 2024
All staff directly employed by the GAFC provider, as well as
				any contract staff,
per diem
staff, backup staff, or anyone
				providing GAFC on behalf of the GAFC provider to members must meet the
				following requirements.
(A)
General Staff Requirements
.
(1) Prior to hiring or contracting with any
			 staff the GAFC provider must:
(a) check the
			 candidate's references and job history and ensure that the candidate meets all
			 of the required experience, education, and qualifications before
			 hiring;
(b) conduct a Criminal
			 Offender Records Information (CORI) check and determine whether any offender
			 records may disqualify the individual for employment;
(c) conduct a Sex Offender Registry
			 Information (SORI) check;
(d)
			 conduct Office of Inspector General (OIG) check;
(e) conduct licenses and certification checks
			 and validate that the candidate has obtained all necessary licenses and
			 certifications and that all licenses and certifications are current;
(f) ensure that each GAFC staff person is not
			 related to or legally responsible for the member receiving GAFC; and
(g) ensure that each GAFC direct care aide,
			 registered nurse, licensed practical nurse, and care manager has received a
			 tuberculosis screening within the previous 12 months.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 408.000 - Adult Foster Care Services › Section 408.525 - GAFC Emergency Services and Plans

Current through Register 1525, July 5, 2024
The GAFC provider must establish written plans for medical and
				other emergencies. Emergency plans must include, at a minimum, the
				following:
(A) a written disaster plan
			 for notifying the MassHealth agency of relocation of the member and ensuring
			 the continuity of GAFC service delivery in the event of a fire, flood, or other
			 natural or unnatural disaster, an easily accessible emergency plan for each
			 member listing the member's name, telephone number of the member's physician,
			 special medical needs, including treatments and medications, and emergency
			 phone numbers as specified in
			 130
			 CMR 408.521(C)(6) for
			 notification of the family or legal guardian, if identified, and a primary
			 contact person who is able to address the member's needs and available if an
			 unforeseen event occurs that prevents the member's GAFC provider from providing
			 services;
(B) a written plan for
			 emergency staff coverage;
(C) a
			 written plan for emergency care and service in the event a member is displaced
			 for any reason; and
(D) a written
			 Continuity of Operations Plan that follows the guidelines from the Department
			 of Public Health.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 408.000 - Adult Foster Care Services › Section 408.526 - GAFC Non-covered Days

Current through Register 1525, July 5, 2024
The MassHealth agency does not pay a GAFC provider when:
(A) the member is receiving any other
			 personal care services including, but not limited to, personal care services
			 under 130 CMR 422.000:
Personal Care Attendant
			 Services
;
(B) the member
			 receives home health aide services provided by a home health agency under 130
			 CMR 403.000:
Home Health Agency
;
(C) the member is a resident or inpatient of
			 a hospital, nursing facility, ICF/IID, or other provider-operated residential
			 facility subject to state licensure such as group homes licensed by the
			 Department of Developmental Services (DDS) or the Department of Mental Health
			 (DMH), or other facility that provides the member's medically necessary
			 personal care; or
(D) the GAFC
			 provider has not received prior authorization from the MassHealth
			 agency.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 408.000 - Adult Foster Care Services › Section 408.527 - Withdrawal by a GAFC Provider from MassHealth

Current through Register 1525, July 5, 2024
A GAFC provider that intends to withdraw from MassHealth must
				satisfy all of the following obligations:
(A)
MassHealth
			 Notification
.
(1) A GAFC provider
			 electing to withdraw from participation in MassHealth must send written notice
			 to the MassHealth agency or its designee, of the provider's intention to
			 withdraw from the GAFC program. The GAFC provider must send the withdrawal
			 notice by certified or registered mail (return receipt requested) to the
			 MassHealth agency or its designee, no fewer than 90 days before the effective
			 date of withdrawal.
(2) In the
			 instance of alleged emergency withdrawal, the GAFC provider must contact the
			 MassHealth agency, or its designee, within one business day of the emergency
			 withdrawal and follow-up, in writing, within three business days informing the
			 MassHealth agency, or its designee, of the reasoning for such emergency
			 withdrawal, and must provide proof in documentation or other form as the
			 MassHealth agency may require. The GAFC provider must also notify all members
			 and the MassHealth agency about the status of all members and any plans for
			 relocation under
			 130
			 CMR 408.523.
(3) The GAFC provider must forward a list of
			 all members currently receiving GAFC. The GAFC provider must notify the
			 MassHealth agency in writing as members are placed in other programs or begin
			 to receive alternative services, including the name of the new program or
			 service and the members' start date in the new program or service.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 409.000 - Durable Medical Equipment Services › Section 409.401 - Introduction

Current through Register 1525, July 5, 2024
130 CMR 409.000 describes
				the requirements for the purchase, rental, and repair of durable medical
				equipment, and for the purchase of medical supplies under MassHealth. All
				durable medical equipment and supplies (DME) must be non-experimental,
				non-investigational, of proven quality and dependability, and must conform to
				all applicable federal and state product standards. All DME providers
				participating in MassHealth must comply with
				130 CMR 409.000, and
				130 CMR 450.000:
Administrative and Billing Regulations
. The MassHealth agency
				may deny enrollment to an applicant or terminate participation of a MassHealth
				DME provider if the applicant or DME provider does not meet one or more of the
				requirements in
				130 CMR
				409.000.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 409.000 - Durable Medical Equipment Services › Section 409.403 - Eligible Members

Current through Register 1525, July 5, 2024
(A)
MassHealth Members
. MassHealth covers DME provided to
			 eligible MassHealth members, subject to the restrictions and limitations
			 described in
			 130 CMR
			 409.000 and
			 130 CMR
			 450.000:
Administrative and Billing
			 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.
(B)
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
.
(C)
Verification of Member
			 Eligibility
. For information about verifying member eligibility
			 and coverage type,
see
130
			 CMR 450.107:
Eligible Members and the
			 MassHealth Card
.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 409.000 - Durable Medical Equipment Services › Section 409.404 - Provider Eligibility

Current through Register 1525, July 5, 2024
(A)
Provider Participation Requirements
. Payment for
			 services described in
			 130 CMR
			 409.000 is made to DME providers who, as of the date
			 of service, are participating in MassHealth; to providers also enrolled as
			 MassHealth-participating OXY providers, orthotic services providers, or
			 prosthetic services providers and who meet all program-specific requirements;
			 and to MassHealth-enrolled pharmacy providers who have been assigned a DME
			 specialty in accordance with
			 130
			 CMR 409.404(C)  as of the
			 date of service. Applicants must meet the requirements in
			 130 CMR
			 450.000:
Administrative and Billing
			 Regulations
as well as the requirements in
			 130 CMR
			 409.000. Participating DME providers must continue to
			 meet provider eligibility participation requirements throughout the period of
			 their provider contract with the MassHealth agency.
(B)
General
			 Qualifications
. To qualify as a MassHealth DME provider, all
			 applicants and providers must enter into a provider contract or agreement with
			 MassHealth, and:
(1) have a service facility
			 that
(a) is open a minimum of 30 hours per
			 week;
(b) is staffed with an
			 employee during posted business hours;
(c) is available to members during regular,
			 posted business hours;
(d) has
			 available inventory for all products for which the DME provider has been
			 accredited by an Accrediting Body, and for which the DME provider is enrolled
			 in MassHealth, with the exception of items provided by
			 subcontractors;
(e) is accessible
			 to all members, including members with disabilities;
(f) has clear access and space for
			 individualized ordering, returns, repair, and storing of business
			 records;
(g) has a sign visible
			 from outside the facility identifying the business name and hours that the
			 service facility is open. If the DME provider's place of business is located
			 within a building complex, the sign must be visible at the main entrance of the
			 building where the service facility is located;
(h) has a primary business telephone number
			 listed in the name of the business with a local toll-free telephone number that
			 is answered by customer service staff during business hours, and that has TTY
			 transmission and reception capability. During business hours, this number
			 cannot be a pager, answering service, or voice message system; and
(i) during off hours, must maintain a voice
			 message system and/or answering service;
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 409.000 - Durable Medical Equipment Services › Section 409.407 - Early and Periodic Screening, Diagnostic and Treatment (EPSDT) Services

Current through Register 1525, July 5, 2024
The MassHealth agency pays for all medically necessary DME
				services for EPSDT-eligible members in accordance with
				130 CMR
				450.144:
EPSDT Services: Diagnosis
				and Treatment
, without regard to service limitations described in
				130 CMR 409.000, and with
				prior authorization pursuant to
				130 CMR
				409.418.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 409.000 - Durable Medical Equipment Services › Section 409.412 - MassHealth Procurements and Subcontracted Services

Current through Register 1525, July 5, 2024
(A) The MassHealth agency, in accordance with
			 M.G.L. c. 118E, § 12, may issue procurements seeking qualified DME
			 providers or suppliers to submit applications for consideration, in accordance
			 with policies set by EOHHS.
(B)
Subcontracted Services
. A DME provider may subcontract
			 with other entities to provide DME. The DME provider continues to be
			 responsible for complying with
			 130 CMR 450.000:
Administrative and Billing Regulations
and
			 130 CMR 409.000, when
			 activities are performed by a subcontractor. The subcontract must be in writing
			 and must contain, at a minimum, the following:
(1) names, addresses, phone numbers, and
			 contact names for both companies;
(2) the contract term (begin and end
			 dates);
(3) a description of the
			 DME covered under the subcontract, including the cost of each item;
(4) signatures of both parties, including
			 signature dates and position titles;
(5) an established credit limit that is
			 reasonable, based on the value of the products and services to be provided by
			 the contractor. Collect on delivery (COD) terms are not acceptable;
			 and
(6) provisions requiring the
			 subcontractor to meet all applicable requirements specified in
			 130 CMR
			 409.404 and
			 409.405.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 409.000 - Durable Medical Equipment Services › Section 409.413 - Covered Services

Current through Register 1525, July 5, 2024
(A) MassHealth
			 covers medically necessary DME that can be appropriately used in the member's
			 home or setting in which normal life activities take place, and in certain
			 circumstances described in
			 130 CMR
			 409.415 for use in facilities. All DME must
			 be approved for community use by the federal Food and Drug Administration
			 (FDA). DME that is appropriate for use in the member's home may also be used in
			 the community.
(B) MassHealth
			 covers the DME listed in Subchapter 6 of the Durable Medical Equipment Manual,
			 the DME and Oxygen Payment and Coverage Guideline Tool, and any successor
			 guidance issued by the MassHealth agency or its designee. Providers may request
			 prior authorization for medically necessary DME if the corresponding service
			 code is not listed in Subchapter 6 or the DME and Oxygen Payment and Coverage
			 Guideline Tool. Covered DME includes, but is not limited to
(1) absorbent products;
(2) ambulatory equipment, such as crutches
			 and canes;
(3) compression
			 devices;
(4) augmentative and
			 alternative communication devices;
(5) enteral and parenteral
			 nutrition;
(6) nutritional
			 supplements;
(7) home infusion
			 equipment and supplies (pharmacy providers with DME specialty only);
(8) glucose monitors and diabetic
			 supplies;
(9) mobility equipment
			 and seating systems;
(10) personal
			 emergency response systems (PERS);
(11) ostomy supplies;
(12) support surfaces;
(13) hospital beds and accessories;
(14) patient lifts; and
(15) bath and toilet equipment and supplies
			 (including, but not limited to, commodes, grab bars, and tub
			 benches).
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 409.000 - Durable Medical Equipment Services › Section 409.414 - Non-covered Services

Current through Register 1525, July 5, 2024
The MassHealth agency does not pay for the following:
(A) DME that is experimental or
			 investigational in nature;
(B) DME
			 that is determined by the MassHealth agency not to be medically necessary
			 pursuant to
			 130 CMR 409.000, and
			 130 CMR
			 450.204:
Medical Necessity
.
			 This includes, but is not limited to, items that:
(1) cannot reasonably be expected to make a
			 meaningful contribution to the treatment of a member's illness, disability, or
			 injury;
(2) are more costly than
			 medically appropriate and feasible alternative pieces of equipment;
			 or
(3) serve the same purpose as
			 DME already in use by the member, with the exception of the devices described
			 in
			 130 CMR
			 409.413(D);
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 409.000 - Durable Medical Equipment Services › Section 409.415 - Durable Medical Equipment Provided to Members in Facilities

Current through Register 1525, July 5, 2024
(A)
MassHealth Members Residing
			 in Nursing Facilities
.
(1) The
			 MassHealth agency pays for the following services for members residing in
			 nursing facilities.
(a)
Mobility
			 Systems for Members in Nursing Facilities with No Written Discharge
			 Plan
. The MassHealth agency pays DME providers for the purchase,
			 rental, or repair of medically necessary mobility systems, positioning seating
			 systems and add-ons, subject to all limitations and conditions of payment in
			 130 CMR 409.000, and
			 130 CMR 450.000:
Administrative and Billing Regulations
, when purchased solely
			 for the full-time use of the member while residing in a nursing facility, with
			 the exception of equipment described under 130 CMR 409.415(A)(2). The nursing
			 facility in which the member resides is responsible for payment to the DME
			 provider for $500 toward the purchase of the mobility system, unless the member
			 has a written discharge plan in accordance with 130 CMR 409.415(A)(1)(b). If a
			 MassHealth member needs a custom positioning seating system the nursing
			 facility must check its existing inventory for a wheelchair base that can be
			 used for a customized seating system for the sole use of a member. If the
			 facility provides a base, the nursing facility is not responsible for the
			 $500.00 toward the purchase of a customized positioning/seating
			 system.
(b)
Mobility
			 Systems for Members in Nursing Facilities Who Have a Written Discharge
			 Plan
. The MassHealth agency pays DME providers for the purchase,
			 rental, or repair of medically necessary mobility systems, positioning seating
			 systems, and add-ons, subject to all limitations and conditions of payment in
			 130 CMR 409.000, and
			 130 CMR 450.000:
Administrative and Billing Regulations
, when purchased solely
			 for the full-time use of the member while residing in a nursing facility, with
			 the exception of equipment described under 130 CMR 409.415(A)(2). The DME
			 provider may deliver equipment to a nursing facility up to ten business days
			 prior to the member's scheduled discharge date, for the purpose of teaching the
			 member how to use the equipment, taking measurements, or adjusting equipment to
			 be used in the member's home. The DME provider must document the member's
			 discharge plan and discharge date in the member's record before the equipment
			 is delivered to the nursing facility, and provide such documentation to the
			 MassHealth agency upon request. For equipment delivered to a nursing facility
			 for use by a member after discharge from the facility, the date of service is
			 the date of discharge.
(c)
Support Surfaces
. The MassHealth agency pays DME
			 providers for the rental or purchase of support surfaces for the exclusive
			 full-time use of a member residing in a nursing facility.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 409.000 - Durable Medical Equipment Services › Section 409.416 - Requirements for Prescriptions or Letters of Medical Necessity Completed by the Ordering Practitioner

Current through Register 1525, July 5, 2024
(A)
LOMN and Prescriptions
. The DME provider must obtain
			 either a prescription or letter of medical necessity (LOMN), or a combination
			 of a prescription and LOMN for the purchase or rental of DME. The prescription,
			 LOMN, or a combination of a prescription and LOMN that meets the requirements
			 of 130 CMR 409.416, must be in writing, signed by the ordering practitioner,
			 and dated prior to the date the claim is submitted to the MassHealth agency.
			 For certain DME that requires a prescription by specified medical
			 professionals, the prescription or LOMN must be signed by such medical
			 professionals. If the DME requires prior authorization, the prescription or
			 LOMN must be dated prior to the date the prior authorization request is
			 submitted to the MassHealth agency.
(B)
Required Prescription or LOMN
			 Information
. The initial and subsequent prescriptions or the LOMN
			 must contain the following information as applicable with the exception of item
			 (5), which may be provided in additional supporting documentation.
(1) the member's name;
(2) the date of the prescription;
(3) the name and quantity of the prescribed
			 item and the number of refills (if appropriate);
(4) the name, NPI number, and signature of
			 the ordering practitioner and date signed;
(5) medical justification for the item(s)
			 being requested, including diagnosis or ICD-10 code;
(6) the equipment settings, hours to be used
			 per day, options, or additional features, as they pertain to the
			 equipment;
(7) length of
			 need;
(8) the expected outcome and
			 therapeutic benefit of providing the requested item(s) or treatment, when
			 requested; and
(9) a summary of any
			 previous treatment plan, including outcomes, that was used to treat the
			 diagnosed condition for which the prescribed treatment is being recommended,
			 upon request.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 409.000 - Durable Medical Equipment Services › Section 409.417 - Medical Necessity Criteria

Current through Register 1525, July 5, 2024
(A) All
			 DME covered by MassHealth must meet the medical necessity requirements set
			 forth in
			 130 CMR 409.000 and in
			 130 CMR
			 450.204:
Medical Necessity
,
			 and any applicable medical necessity guidelines for specific DME published on
			 the MassHealth website.
(B) For
			 items covered by MassHealth for which there is no MassHealth item-specific
			 medical necessity guideline, and for which there is a Medicare Local Coverage
			 Determination (LCD) indicating Medicare coverage of the item under at least
			 some circumstances, the provider must demonstrate medical necessity of the item
			 consistent with the Medicare LCD. However, if the provider believes the durable
			 medical equipment is medically necessary even though it does not meet the
			 criteria established by the local coverage determination, the provider must
			 demonstrate medical necessity under
			 130 CMR
			 450.204:
Medical
			 Necessity
.
(C) For an item
			 covered by MassHealth for which there is no MassHealth item-specific medical
			 necessity guideline, and for which there is a Medicare LCD indicating that the
			 item is not covered by Medicare under any circumstance, the provider must
			 demonstrate medical necessity under
			 130 CMR
			 450.204:
Medical
			 Necessity
.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 409.000 - Durable Medical Equipment Services › Section 409.418 - Prior Authorization

Current through Register 1525, July 5, 2024
(A)
Prior Authorization
. The DME provider must obtain
			 prior authorization from the MassHealth agency or its designee as a
			 prerequisite for payment of DME identified in the DME and Oxygen Payment and
			 Coverage Guideline Tool or other guidance specified by the MassHealth agency or
			 its designee as requiring prior authorization, or pursuant to
			 130 CMR
			 409.413(B), for service
			 codes not listed in Subchapter 6 or in the DME and Oxygen Payment and Coverage
			 Guideline Tool.
(B)
Prior Authorization for MassHealth Covered Services
.
			 Prior authorization for MassHealth-covered services is a determination of
			 medical necessity only and does not establish or waive any other prerequisites
			 for payment, such as member eligibility or requirements to seek payment from
			 other liable parties, including Medicare.
(C)
Documentation of Medical
			 Necessity
.
Prior authorization requests submitted by the provider for DME
				must include
(1) a completed
			 MassHealth Prior Authorization Request (PA-1) form (if request is submitted on
			 paper);
(2) a prescription or
			 letter of medical necessity that meets the requirements of
			 130
			 CMR 409.416, including any additional
			 documentation as required by
			 42 CFR
			 440.70 or other state or federal law;
			 and
(3) if diagnostic test results
			 are used as a means to document medical necessity, the test results must be
			 interpreted, signed, and dated by a physician, or include documentation that
			 supports the need for DME from an appropriate health care professional other
			 than the DME provider including, but not limited to, physical therapists,
			 speech language pathologists, nurses, respiratory therapists, and occupational
			 therapists who have expertise in the applicable area.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 409.000 - Durable Medical Equipment Services › Section 409.419 - Delivery of Durable Medical Equipment

Current through Register 1525, July 5, 2024
(A)
Delivery of Durable Medical Equipment to a Member's
			 Home
.
(1) The DME provider must
			 ensure that DME orders are delivered within a reasonable time after DME
			 provider receipt of a prescription or LOMN and any required documentation or
			 prior approval for the item. Providers must make alternate arrangements such as
			 contracting with subcontractors, or referring the member to another DME
			 provider, when timely delivery cannot be made by the DME provider. The
			 MassHealth agency, reserves the right to issue additional subregulatory
			 guidance on reasonableness of delivery times for specific DME.
(2) Except as provided in 130 CMR 409.419(D),
			 the DME provider must maintain in the member's record a copy of its delivery
			 slip signed by the member or the member's designee accepting delivery on behalf
			 of the member, and dated at the time of delivery. The date of the signature on
			 the delivery slip must be the same as the date of delivery.
(3) The MassHealth agency accepts the
			 member's mark or a signature stamp as proof of delivery on behalf of a member
			 whose disability inhibits the member's ability to write. A signature stamp may
			 be used only by the member or the member's designee. A signature stamp may not
			 be used by anyone associated with either the provider or the delivery
			 service.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 409.000 - Durable Medical Equipment Services › Section 409.426 - Quality Management

Current through Register 1525, July 5, 2024
DME providers must participate in any quality management and
				program integrity processes established by the MassHealth agency including
				making any necessary data including, but not limited to, member complaint data
				under
				130 CMR 409.405(N) and
				(S), available and providing access to the
				provider's place of business upon request by the MassHealth agency or its
				designee, within the time frame designated by the MassHealth
				agency.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 409.000 - Durable Medical Equipment Services › Section 409.427 - Payment for Durable Medical Equipment

Current through Register 1525, July 5, 2024
(A)
			 MassHealth pays for DME for eligible members as required by
			 130 CMR
			 450.231:
General Conditions of
			 Payment
and in accordance with the applicable payment methodology and
			 rate schedule established by EOHHS at
			 101 CMR 322.00:
Durable Medical Equipment, Oxygen and Respiratory Therapy
			 Equipment
.
(B) Payments
			 are subject to the conditions, exclusions, and limitations set forth in
			 130 CMR 409.000, and
			 130 CMR 450.000:
Administrative and Billing Regulations
.
(C) MassHealth pays for DME only if:
(1) medically necessary and, if subject to
			 PA, the MassHealth agency or its designee determines that the DME is medically
			 necessary;
(2) the member meets
			 applicable clinical eligibility criteria for the DME;
(3) the provider has obtained a prescription
			 or letter of medical necessity for the purchase or rental of DME in accordance
			 with
			 130
			 CMR 409.416; and, if necessary, prior
			 authorization for purchase, rental or repair of DME in accordance with the
			 requirements set forth in
			 130 CMR
			 409.418; and
(4) provider has diligently sought payment
			 from all other liable parties in accordance with
			 130 CMR
			 409.418(D), and
			 130 CMR
			 450.316:
Third-party Liability:
			 Requirements
.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 409.000 - Durable Medical Equipment Services › Section 409.428 - Augmentative and Alternative Communication Devices and Speech Generation Devices (AAC)

Current through Register 1525, July 5, 2024
(A)
Covered Services
. AAC devices are defined in
			 130 CMR 409.402. An
			 AAC device must be a dedicated speech device, used solely by the member who has
			 severe expressive communication impairment. Examples of AAC devices are
(1) communication boards or books;
(2) electro larynxes;
(3) speech/voice amplifiers;
(4) electronic devices that produce speech or
			 written output; and
(5)
			 communication software and applications.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 409.000 - Durable Medical Equipment Services › Section 409.429 - Personal Emergency Response System (PERS)

Current through Register 1525, July 5, 2024
(A)
Requirements for
			 Coverage
. PERS is indicated for the personal use of a member with
			 medical conditions that cause significant functional limitations or
			 incapacitation and prevents the member from using other methods of summoning
			 assistance in an emergency. The member must
(1) have a functioning landline phone that
			 can accommodate a PERS;
(2) live
			 alone or be routinely alone for extended periods of time such that the member's
			 safety would be compromised without the availability of a PERS unit in the
			 home;
(3) be able to independently
			 use the PERS to summon help;
(4)
			 understand when and how to appropriately use the PERS; and
(5) be at risk of moving to a more structured
			 residential setting, or be at significant risk for falls or other medical
			 complications that may result in an emergency situation.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 409.000 - Durable Medical Equipment Services › Section 409.430 - Recordkeeping Requirements

Current through Register 1525, July 5, 2024
The DME provider must keep a record, either paper or
				electronic, at the service facility for each member. The record must include
				all purchases, rentals, and repairs of DME provided for each member in
				accordance with the recordkeeping requirements set forth in
				130 CMR
				450.205:
Recordkeeping and
				Disclosure
. The DME provider must make all records retained in
				accordance with 130 CMR 409.430 and
				450.205
				available to the MassHealth agency, or its designee upon request. Payment for
				services is conditioned upon the complete documentation in the member's record.
				In addition to fulfilling the requirements of
				130 CMR
				450.205, the DME provider must ensure that
				each member's record includes the following, except where noted that the record
				must be available upon request:
(A) a
			 completed, signed, and dated prescription and letter of medical necessity that
			 meets the requirements set forth in
			 130
			 CMR 409.416, and
			 42 CFR
			 440.70, and any other applicable state or
			 federal law or regulation;
(B) a
			 copy of the prior-authorization request submitted to the MassHealth agency, or
			 its designee, including a copy of the MassHealth agency decision;
(C) the face-to-face encounter related to the
			 primary reason the member requires DME must be documented in the member's
			 record either on the plan of care or in other medical notes sufficient to make
			 the link between the member's health conditions, the DME ordered, and an
			 appropriate face-to-face encounter that occurred within six months of the start
			 of services of DME consistent with
			 42 CFR
			 440.70. This documentation must include the
			 name of the practitioner and date of the encounter;
(D) if the member has third-party liability,
			 including Medicare, the DME provider must also maintain a copy of all
			 documentation of their efforts to diligently seek prior authorization and
			 payment from other liable parties;
(E) a copy of all documentation submitted
			 with a member's prior authorization request, including any MassHealth agency or
			 its designee's correspondence and decisions related to such requests;
(F) written confirmation of receipt of the
			 prescribed DME, including refills, signed by the member or the member's
			 designee, except as permitted by
			 130 CMR
			 409.419(D)  regarding signed
			 delivery tickets, that includes
(1) the date
			 the equipment or medical supplies were delivered to the member;
(2) the manufacturer, brand name, model
			 number, and, if applicable, the serial number of the equipment or medical
			 supplies; and
(3) if the delivery
			 slip is signed by the member's designee, an explanation of the designee's
			 relationship to the member. This individual cannot be associated with either
			 the DME provider or the delivery service.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 409.000 - Durable Medical Equipment Services › Section 409.431 - Prohibited Marketing Activities

Current through Register 1525, July 5, 2024
A DME provider must not:
(A) with the knowledge that a member is
			 enrolled in a MassHealth capitated program, engage in any practice that would
			 reasonably be expected to have the effect of steering or encouraging the member
			 to disenroll from the MassHealth capitated program in order to retain the
			 provider to provide services on a fee-for-service basis;
(B) offer to a member, or his or her family
			 or caregivers, in-person or through marketing, any inducement to retain the
			 provider to provide DME services, such as a financial incentive, reward, gift,
			 meal, discount, rebate, giveaway, or special opportunity;
(C) pay a "finder's fee" to any third-party
			 in exchange for referring a member to the orthotic provider; or
(D) engage in any unfair or deceptive acts or
			 practices in connection with any marketing.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 410.000 - Outpatient hospital services › Section 410.401 - Introduction

Current through Register 1525, July 5, 2024
130 CMR
				410.000 establishes the requirements for the provision
				of services by hospital outpatient departments, hospital-licensed health
				centers, and other hospital satellite clinics under MassHealth. For the
				purposes of
				130 CMR
				410.000, "hospital outpatient department" may also
				refer to hospital-licensed health centers, and other hospital satellite
				clinics. MassHealth pays for outpatient hospital visits and ancillary services
				(such as radiographic views, laboratory tests, medical supplies, and drugs)
				that are medically necessary and appropriately provided, as defined in
				130
				CMR 450.204:
Medical
				Necessity
. The quality of such services must meet professionally
				recognized standards of care.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 410.000 - Outpatient hospital services › Section 410.403 - Eligible Members

Current through Register 1525, July 5, 2024
(A)
(1)
MassHealth
			 Members
. MassHealth covers outpatient hospital 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 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
.