reglab/statecodes huggingface dataset:
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 403.000 - Home Health Agency › Section 403.408 - Administrative Requirements

Current through Register 1525, July 5, 2024
Whether services are provided by the home health agency
				directly or through contractual arrangements made by the agency, the agency
				must
(A) accept the member for
			 treatment in accordance with its admission policies;
(B) maintain a complete medical record as
			 defined at
			 130 CMR 403.402
			 relating to all services provided in accordance with
			 130 CMR
			 403.419(C)(3)(b);
(C) obtain from the physician or ordering
			 non-physician practitioner the required certifications and recertifications of
			 the plan of care in accordance with
			 130 CMR
			 403.420(C); and
(D) ensure that the home health agency's
			 staff or designated review group review the medical necessity of services and
			 the physician and ordering non-physician practitioner certification on a
			 regular basis.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 403.000 - Home Health Agency › Section 403.410 - Prior Authorization Requirements

Current through Register 1525, July 5, 2024
(A)
General Terms
.
(1)
			 Prior authorization must be obtained from the MassHealth agency or its designee
			 as a prerequisite to payment after certain limits are reached, as described in
			 130 CMR 403.410. Without such prior authorization, the MassHealth agency will
			 not pay providers for these services.
(2) Prior authorization determines only the
			 medical necessity of the authorized service, and does not establish or waive
			 any other prerequisites for payment such as member eligibility or resort to
			 health insurance payment.
(3)
			 Approvals for prior authorization specify the number of hours, visits, or units
			 for each service that are medically necessary and payable each calendar week
			 and the duration of the prior authorization period. The authorization is issued
			 in the member's name and specifies frequency and duration of care for each
			 service approved per calendar week.
(4) The home health agency must submit all
			 prior authorization requests in accordance with the MassHealth agency's
			 administrative and billing regulations and instructions and must submit each
			 such request to the appropriate addresses listed in Appendix A of the Home
			 Health Agency Manual.
(5) In
			 conducting prior authorization review, the MassHealth agency or its designee
			 may refer the member for an independent clinical assessment to inform the
			 determination of medical necessity for home health services.
(6) If authorized services need to be
			 adjusted because the member's medical needs have changed, the home health
			 agency must submit an adjustment request to the MassHealth agency or its
			 designee.
(7) MassHealth only pays
			 for services up to the amount authorized in the PA.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 403.000 - Home Health Agency › Section 403.411 - Notice of Approval or Denial of Prior Authorization

Current through Register 1525, July 5, 2024
(A)
Notice of
			 Approval
. For all approved prior authorization requests for home
			 health services, the MassHealth agency or its designee sends written notice to
			 the member and the home health agency about the frequency, duration, and
			 intensity of care authorized, and the effective date of the
			 authorization.
(B)
Notice of Denial or Modification and Right of Appeal
.
(1) For all denied or modified prior
			 authorization requests, the MassHealth agency or its designee notifies both the
			 member and the home health agency of the denial or modification, and the
			 reason. In addition, the member will receive information about the member's
			 right to appeal, and appeal procedure.
(2) A member may request a fair hearing if
			 the MassHealth agency or its designee denies or modifies a prior authorization
			 request. The member must request a fair hearing in writing within 30 days after
			 the date of receipt of the notice of denial or modification. The Office of
			 Medicaid Board of Hearings conducts the hearing in accordance with
			 130 CMR 610.000:
MassHealth: Fair Hearing Rules
.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 403.000 - Home Health Agency › Section 403.412 - Scope of Home Health Services

Current through Register 1525, July 5, 2024
The MassHealth agency pays for the following home health
				services for eligible MassHealth members, subject to the restrictions and
				limitations described in
				130 CMR
				403.000 and
				450.000:
Administrative and Billing Regulations
:
(A) nursing;
(B) home health aide; and
(C) physical, occupational, and
			 speech/language therapy.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 403.000 - Home Health Agency › Section 403.413 - Early and Periodic Screening, Diagnostic and Treatment (EPSDT) Services

Current through Register 1525, July 5, 2024
The MassHealth agency pays for all medically necessary home
				health agency services for EPSDT-eligible members in accordance with
				130
				CMR 450.140:
Early and Periodic
				Screening, Diagnostic and Treatment (EPSDT) Services: Introduction
with prior authorization.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 403.000 - Home Health Agency › Section 403.415 - Nursing Services

Current through Register 1525, July 5, 2024
(A)
Conditions of Payment
. Nursing services are payable
			 only if all of the following conditions are met:
(1) there is a clearly identifiable, specific
			 medical need for nursing services;
(2) the services are ordered by the member's
			 physician or ordering non-physician practitioner and are included in the plan
			 of care;
(3) the services require
			 the skills of a registered nurse or of a licensed practical nurse under the
			 supervision of a registered nurse, in accordance with 130 CMR
			 403.415(B);
(4) the services are
			 medically necessary to treat an illness or injury in accordance with
			 130 CMR
			 403.409(C); and
(5) prior authorization is obtained where
			 required in compliance with
			 130 CMR
			 403.410.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 403.000 - Home Health Agency › Section 403.416 - Home Health Aide Services

Current through Register 1525, July 5, 2024
(A)
Conditions of Payment
. Home health aide services are
			 payable only if all of the following conditions are met:
(1) home health aide services are medically
			 necessary to
(a) directly support curative,
			 rehabilitative, or preventative aspects of nursing or therapy services provided
			 by the home health agency; and/or
(b) provide hands-on assistance throughout
			 the task or until completion, with at least two activities of daily living
			 (ADLs) defined as: bathing, grooming, dressing, toileting/ continence,
			 transferring/ambulation, and eating.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 403.000 - Home Health Agency › Section 403.417 - Physical, Occupational, and Speech/Language Therapy

Current through Register 1525, July 5, 2024
(A)
Physical
			 Therapy
. The MassHealth agency pays for up to 20 visits within a
			 calendar year for physical therapy without prior authorization when provided to
			 an eligible MassHealth member, if the services are
(1) prescribed by a physician or an ordering
			 non-physician practitioner;
(2)
			 directly and specifically related to an active treatment regimen;
(3) of such a level of complexity and
			 sophistication that the judgment, knowledge, and skills of a licensed physical
			 therapist are required;
(4)
			 performed by a licensed physical therapist, or by a licensed physical therapy
			 assistant under the supervision of a licensed physical therapist;
(5) considered under accepted standards of
			 medical practice to be a specific and effective treatment for the member's
			 condition;
(6) medically necessary
			 for treatment of the member's condition. Services related to activities for the
			 general good and welfare of members (for example, general exercises to promote
			 overall fitness and flexibility, and activities to provide diversion or general
			 motivation) do not constitute physical therapy services for purposes of
			 MassHealth payment; and
(7)
			 certified by the physician or an ordering non-physician practitioner every 60
			 days.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 403.000 - Home Health Agency › Section 403.418 - Medical Supplies

Current through Register 1525, July 5, 2024
Home health agencies must submit prescriptions and orders for
				medical supplies only to vendors who are participating in MassHealth. Medical
				supplies, equipment, and appliances must be prescribed or ordered by the
				member's physician or non-physician practitioner and must be provided and
				claimed directly by appropriate vendors in accordance with MassHealth
				regulations governing drugs, restorative therapy services, rehabilitative
				services, and durable medical equipment.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 403.000 - Home Health Agency › Section 403.419 - Provider Responsibilities

Current through Register 1525, July 5, 2024
In addition to meeting all of the qualifications set forth in
				130 CMR
				403.000 and
				450.000:
Administrative and Billing Regulations
, home health agencies
				must meet all of the following requirements.
(A)
Policies and
			 Procedures
. Each home health agency must develop, maintain,
			 review, update, and comply with comprehensive policies and procedures governing
			 the delivery of home health services which at a minimum must contain the
			 following as applicable for the services the agency delivers:
(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) home health
			 agency staff evaluation and supervision;
(f) emergencies including fire, safety and
			 disasters, including notifying the fire department and police in
			 emergencies;
(g) member
			 rights;
(h) human rights and
			 nondiscrimination;
(i) incident and
			 accident reporting;
(j) staff and
			 member grievances;
(k) staff
			 cultural competency;
(l) quality
			 assurance and improvement;
(m) home
			 health aide training;
(n) emergency
			 services and plans;
(o) recognizing
			 and reporting abuse (physical, sexual, emotional, psychological), neglect,
			 self-neglect and financial exploitation;
(p) Health Insurance Portability and
			 Accountability Act (HIPAA); and
(q)
			 procedures to be followed if a member is missing or lost.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 403.000 - Home Health Agency › Section 403.420 - Plan-of-care Requirements

Current through Register 1525, July 5, 2024
All home health services must be provided under a plan of care
				established individually for the member.
(A)
Providers Qualified to
			 Establish a Plan of Care
.
(1) The
			 member's physician or ordering non-physician practitioner must establish a
			 written plan of care in consultation with the home health agency. The physician
			 or ordering non-physician practitioner must review, sign and date the plan of
			 care and revise it, as applicable:
(a) no less
			 than every 60 days from the start of home health services;
(b) more frequently as the member's condition
			 or needs require. The plan of care or other medical notes in the member record
			 must document that a face-to-face encounter related to the primary reason the
			 member requires home health services occurred no more than 90 days before or 30
			 days after the start of home health services.
See
130 CMR
			 403.420(E).
(c) in accordance with
			 verbal order requirements described in 130 CMR 403.420(D).
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 403.000 - Home Health Agency › Section 403.421 - Quality Management and Utilization Review

Current through Register 1525, July 5, 2024
(A) A home health agency must participate in
			 any quality management and program integrity processes as required by the
			 MassHealth agency including making any necessary data available and providing
			 access to visit the home health agency's place of business upon request by
			 MassHealth or its designee.
(B) A
			 home health agency must submit requested documentation to the MassHealth agency
			 or its designee for purposes of utilization review and provider review and
			 audit, within the MassHealth agency's or its designee's time specifications.
			 The MassHealth agency or its designee may periodically review a member's plan
			 of care and other records to determine if services are medically necessary in
			 accordance with
			 130 CMR
			 403.409(C). The home health
			 agency must provide the MassHealth agency or its designee with any supporting
			 documentation the MassHealth agency or its designee requests, in accordance
			 with M.G.L. c. 118E, § 38, and
			 130 CMR 450.000:
Administrative and Billing Regulations
.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 403.000 - Home Health Agency › Section 403.422 - Transfers and Discharge Planning

Current through Register 1525, July 5, 2024
(A)
Discharge Procedures
.
(1) A member shall be discharged by the home
			 health agency provider under the following conditions:
(a) upon the member's request;
(b) if the member ceases to benefit from home
			 health services;
(c) if the member
			 no longer meets the clinical eligibility for home health services;
(d) if the member selects another MassHealth
			 service that is duplicative of the home health the member is receiving,
			 including MassHealth services that provide assistance with personal
			 care;
(e) if the member transitions
			 completely to another home health provider or CSN provider or combination of
			 providers; or
(f) if the home
			 health agency ceases operations.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 403.000 - Home Health Agency › Section 403.423 - Conditions of Payment

Current through Register 1525, July 5, 2024
The following conditions for payment apply to all home health
				services, in addition to conditions of payment described throughout
				130 CMR
				403.000.
(A)
			 The MassHealth agency pays for home health in accordance with the applicable
			 payment methodology and rate schedule established by EOHHS.
(B) The home health provider must review each
			 member in its care to ensure that the clinical eligibility criteria for home
			 health continue to be met. A home health provider may not bill and the
			 MassHealth agency will not pay for any member who does not meet the clinical
			 criteria for home health.
(C)
Initial Patient Assessments
. The MassHealth agency
			 pays for one initial member assessment visit by a home health agency with a
			 physician or ordering non-physician practitioner's order. The MassHealth agency
			 does not pay for any subsequent services provided to the member unless the
			 physician or ordering non-physician practitioner has ordered the service prior
			 to the continuation of care and includes them in the written plan of
			 care.
(D)
Observation
			 and Evaluation Visits
. The MassHealth agency pays for observation
			 and evaluation (or reevaluation) visits when they are made by a registered
			 nurse or physical, occupational, or speech/language therapist ordered by the
			 physician or ordering non-physician practitioner, for the purpose of evaluating
			 the member's condition and his or her continuing need for home health
			 services.
(E)
Supervisory Visits
. The MassHealth agency does not pay
			 for a supervisory visit made by a nurse or physical and occupational therapist
			 for the purpose of evaluating the specific personal-care needs of the member,
			 or reviewing the manner in which the personal-care needs of the member are
			 being met by the home health aide. These visits are administrative and are,
			 therefore, not payable.
(F)
Nursing Visits for Members Receiving Home Health Services after 30
			 Calendar Days
. The MassHealth agency pays a reduced rate for any
			 additional nursing visit provided to the member on or after the
			 31st calendar day of the member's first home health
			 service, even if some or all of those services were provided by a different
			 home health agency or paid by a third-party insurer other than MassHealth. When
			 billing the MassHealth agency for any nursing visit on or after the
			 31st calendar day, the service code and modifier
			 must reflect the nursing visit. The MassHealth agency resumes the full nursing
			 visit rate of one through 30 calendar days under the following conditions:
(1) Admission to a hospital for at least one
			 overnight.
(2) Admission to a
			 Crises Stabilization Unit of at least one overnight.
(3) Admission to a skilled nursing facility
			 of at least three nights.
(4)
			 Following a break in home health services of 60 days or more.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 403.000 - Home Health Agency › Section 403.424 - Intermittent or Part-time Requirement

Current through Register 1525, July 5, 2024
The MassHealth agency pays for nursing visits and home health
				aide services provided pursuant to a need for skilled nursing services only on
				an intermittent or part-time basis, and only as described in 130 CMR
				403.424(A), except as provided in 130 CMR 403.424(B). Services described in
				this section are paid for subject to any applicable prior authorization
				requirements as described at
				130 CMR
				403.410.
(A)
Intermittent and Part-time
			 Services
.
(1) Services are
			 intermittent if up to eight hours per day of medically necessary nursing visits
			 and home health aide services, combined, are provided seven days per calendar
			 week for temporary periods of up to 30 days.
(2) Services are part-time if the combination
			 of medically necessary nursing visits and home health aide services does not
			 exceed 35 hours per calendar week, and those services are provided on a
			 less-than-daily basis.
(3) To
			 receive intermittent or part-time nursing care, the member must have a
			 medically predictable recurring need for skilled nursing services at least once
			 every 60 days, or the member must meet the conditions in 130 CMR
			 403.424(A)(4).
(4) In certain
			 circumstances, the member needs infrequent, yet intermittent, nursing services.
			 The following are nonexclusive examples of such services, which are payable.
(a) The member has an indwelling silicone
			 catheter and generally needs a catheter change only at 90-day
			 intervals.
(b) The member
			 experiences a fecal impaction due to the normal aging process (that is, loss of
			 bowel tone, restrictive mobility, and a breakdown in good health habits) and
			 must be manually disimpacted. Although these impactions are likely to recur, it
			 is not possible to predict a specific time frame.
(c) The member is diabetic and visually
			 impaired. He or she self-injects insulin, and has a medically predictable
			 recurring need for a nursing visit at least every 90 days. These nursing
			 visits, which supplement the physician's contacts with the member, are
			 necessary to observe and determine the need for changes in the level and type
			 of care that have been prescribed.
(d) The need for intermittent or part-time
			 nursing is medically predictable, but a situation arises after the first
			 nursing visit that makes additional visits unnecessary (for example, the member
			 becomes institutionalized or dies, or a primary caregiver has been trained to
			 provide care). In this situation, the one nursing visit is payable.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 403.000 - Home Health Agency › Section 403.428 - Maximum Allowable Fees

Current through Register 1525, July 5, 2024
Home health agencies must accept MassHealth payment in full for
				home health services according to the rates and regulations established by
				EOHHS as set forth in
				101 CMR 350.00:
Rates for Home Health Services
. Payments are subject to the
				conditions, exclusions, and limitations set forth in
				130 CMR
				403.000 and
				130 CMR 450.000:
Administrative and Billing Regulations
.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 403.000 - Home Health Agency › Section 403.429 - Denial of Services and Administrative Review

Current through Register 1525, July 5, 2024
(A) A failure or refusal by a home health
			 agency to provide services that have been ordered by the member's attending
			 physician and that are within the range of payable services is not an action by
			 the MassHealth agency or its designee that a member may appeal; but such
			 failure or refusal constitutes a violation of these regulations for which
			 administrative sanctions may be imposed, with the exception of instances where
			 the home health agency does not reasonably have staffing availability or cannot
			 reasonably procure staffing to provide services. The MassHealth agency receives
			 and acts upon complaints from physicians and ordering non-physician
			 practitioners, continuing-care coordinators, and other social-services
			 agencies, as well as from members and their families. A failure or refusal by a
			 physician or ordering non-physician practitioner to order services or to
			 certify their medical necessity is not an action by the MassHealth agency or
			 its designee that a member may appeal.
(B) When a home health agency believes that
			 services ordered by the physician or ordering non-physician practitioner are
			 not payable under
			 130 CMR
			 403.000, the agency must refer the matter to the
			 MassHealth agency for a payment decision. If and to the extent the MassHealth
			 agency determines that the ordered services are payable, the agency must
			 provide those services.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 403.000 - Home Health Agency › Section 403.430 - Prohibited Marketing Activities

Current through Register 1525, July 5, 2024
A Home Health Agency provider must not:
(A) with the knowledge that a member is
			 enrolled in a 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 Capitated Program in order to retain the home health agency
			 provider to provide home health 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
			 home health agency provider to provide home health 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 home health
			 agency 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 404.000 - Adult Day Health Services › Section 404.401 - Statement of Purpose

Current through Register 1525, July 5, 2024
130 CMR 404.000 establishes MassHealth requirements for
				providers of adult day health services. All providers participating in
				MassHealth must comply with all MassHealth regulations including, but not
				limited to, 130 CMR 404.000 and 130 CMR 450.000:
Administrative and
				Billing Regulations
.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 404.000 - Adult Day Health Services › Section 404.403 - Eligible Members

Current through Register 1525, July 5, 2024
(A)
MassHealth Members
. MassHealth-eligible members 18
			 years of age or older, are 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 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) For information on verifying MassHealth
			 member eligibility and coverage type,
see
130 CMR
			 450.107:
Eligible Members and
			 MassHealth Card.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 404.000 - Adult Day Health Services › Section 404.404 - Provider Eligibility

Current through Register 1525, July 5, 2024
(A) An organization
			 seeking to participate in MassHealth as an ADH provider must
(1) enter into a provider contract with the
			 MassHealth agency;
(2) be licensed
			 by the Department of Public Health under 105 CMR 158.00
Licensure of
			 Adult Day Health Programs;
(3) accept MassHealth payments as payment in
			 full for all ADH;
(4) establish,
			 maintain, and comply with written policies and procedures to comply with 130
			 CMR 404.000;
(5) agree to periodic
			 inspections, by the MassHealth agency or its designee, that assess the quality
			 of member care and ensure compliance with 130 CMR 404.000;
(6) agree to comply with all the provisions
			 of 130 CMR 404.000, 450.000:
Administrative and Billing
			 Regulations,
and all other applicable MassHealth rules, regulations,
			 and sub-regulatory guidance; and
(7) participate in any ADH provider
			 orientation required by EOHHS.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 404.000 - Adult Day Health Services › Section 404.405 - Clinical Eligibility Criteria

Current through Register 1525, July 5, 2024
(A) The
			 MassHealth agency pays for ADH provided to members who meet all of the
			 following clinical eligibility criteria:
(1)
			 ADH has been ordered by the member's PCP;
(2) The member has one or more chronic or
			 post-acute medical, cognitive, or mental health condition(s) identified by the
			 member's PCP that require active monitoring, treatment or intervention and
			 ongoing observation and assessment by a nurse, without which the member's
			 condition will likely deteriorate;
(3) The member requires one or both of the
			 following be provided by the ADH program:
(a)
			 at least one skilled service listed in 130 CMR 404.405(B); or
(b) at least daily or on a regular basis
			 hands-on (physical) assistance or cueing and supervision, throughout the entire
			 activity, with one or more qualifying ADLs listed in 130 CMR 404.405(C) when
			 required at the ADH program as determined clinically appropriate by the
			 ordering PCP and the ADH program nurse developing the plan of care.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 404.000 - Adult Day Health Services › Section 404.406 - Clinical Assessment and Prior Authorization

Current through Register 1525, July 5, 2024
(A)
Clinical
			 Assessment
. As part of the prior authorization process, members
			 seeking ADH must undergo a clinical assessment to assess the member's clinical
			 status and need for ADH. 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.
(B)
Prior
			 Authorization
.
(1) As a
			 prerequisite for payment of ADH, the ADH provider must obtain prior
			 authorization from the MassHealth agency or its designee before the first date
			 of service delivery and annually thereafter, or upon significant
			 change.
(2) Prior authorization
			 determines the medical necessity for ADH services as described under
			 130 CMR
			 404.405 and in accordance with
			 130 CMR
			 450.204:
Medical
			 Necessity.
(3) Prior
			 authorization may specify the level of payment for ADH (as described under
			 130 CMR
			 404.414(D).
(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 517.008:
Potential Sources of Health
			 Care.
(5) When submitting
			 a request for prior authorization for payment of ADH to the MassHealth agency
			 or its designee, the ADH provider must submit requests in the form and format
			 as required by MassHealth. The ADH 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 its review and determination of prior authorization.
(6) In making its prior authorization
			 determination, the MassHealth agency or its designee, may require additional
			 assessments.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 404.000 - Adult Day Health Services › Section 404.410 - ADH Administrative Reporting Requirements

Current through Register 1525, July 5, 2024
(A) The ADH program director or designee is
			 responsible for notifying the MassHealth agency immediately in writing if there
			 is a change in telephone or fax number or e-mail address of the ADH
			 program.
(B) The ADH program must
			 inform notify the MassHealth agency or its designee before relocating a program
			 or expanding the certified capacity at an existing program.
(C) The ADH provider must document
			 transportation utilization as follows.
(1)
			 When a private carrier is used, the ADH provider must submit to the MassHealth
			 agency or its designee a copy of the contract or agreement with the
			 carrier.
(2) The ADH provider must
			 submit, per the MassHealth agency's requirements, a transportation
			 report.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 404.000 - Adult Day Health Services › Section 404.411 - Withdrawal by an ADH Provider from MassHealth

Current through Register 1525, July 5, 2024
An ADH provider that intends to withdraw from MassHealth must
				satisfy all of the following obligations:
(A)
MassHealth
			 Notification
.
(1) An ADH 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 ADH program. The ADH provider must send the withdrawal notice
			 by certified or registered mail (return receipt requested), to the MassHealth
			 Adult Day Health Unit. The notice must be received by the MassHealth agency or
			 its designee, no fewer than 90 days before the effective date of
			 withdrawal.
(2)
Emergency Withdrawal
. In the instance of alleged
			 emergency withdrawal, the ADH provider must contact the MassHealth agency, or
			 its designee, within one business day of the emergency withdrawal and
			 follow-up, in writing, within the next three business days informing
			 MassHealth, 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.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 404.000 - Adult Day Health Services › Section 404.412 - Quality Management

Current through Register 1525, July 5, 2024
ADH providers must participate in quality management and
				program integrity processes established by the MassHealth agency including
				making any necessary data available and access to 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 404.000 - Adult Day Health Services › Section 404.413 - Transportation Services

Current through Register 1525, July 5, 2024
(A)
Transportation Service
. Transportation service
			 provides for transporting members from the member's home to the ADH provider or
			 from the ADH provider to the member's home, including assisting the member
			 while entering and exiting the vehicle, as appropriate. For the purposes of
			 this section, a home includes a temporary housing environment where the member
			 is being sheltered.
(B)
Provision of Transportation
.
(1) ADH providers may provide transportation
			 as required at
			 130 CMR 404.414(C)(4)
			  either directly or through a
			 subcontractor;
(2) The
			 transportation plan must be documented in the participant's enrollment
			 agreement pursuant to
			 105 CMR
			 158.034(D)(5):
Participant Enrollment Agreement.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 404.000 - Adult Day Health Services › Section 404.414 - Conditions of Payment

Current through Register 1525, July 5, 2024
(A) The MassHealth
			 agency pays an ADH provider for ADH in accordance with the applicable payment
			 methodology and rate schedule established by EOHHS at 101 CMR 310.00:
Adult Day Health Services.
Rates of payment for ADH do not
			 cover or include any amount for room and board.
(B) Payment for ADH is subject to the
			 conditions, exclusions, and limitations set forth in 130 CMR 404.000 and
			 450.000:
Administrative and Billing Regulations.
(C) The MassHealth agency pays ADH providers
			 for ADH only if the
(1) MassHealth agency or
			 its designee determines that the ADH provided is medically necessary;
(2) member meets the clinical eligibility
			 criteria for MassHealth payment for ADH as described in
			 130 CMR
			 404.405;
(3) ADH provider has obtained prior
			 authorization for MassHealth payment for ADH in accordance with the
			 requirements set forth in
			 130 CMR
			 404.406; and
(4) ADH provider bills at the payment level
			 authorized by the MassHealth agency or its designee.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 404.000 - Adult Day Health Services › Section 404.415 - Noncovered Days

Current through Register 1525, July 5, 2024
The MassHealth agency does not pay an ADH provider
(A) for any portion of a day during which the
			 member is receiving services provided by a Home Health Agency while the member
			 is in attendance at the ADH program under 130 CMR 403.000:
Home Health
			 Agency
that are duplicative of services covered under ADH;
(B) when the member is a resident or
			 inpatient of a hospital, nursing facility, or intermediate care facility for
			 the intellectually disabled; except on dates of admission and
			 discharge;
(C) if the provider has
			 not received prior authorization from the MassHealth agency or its
			 designee;
(D) for any canceled
			 program days or any time periods missed by a member for any reason;
			 and
(E) for any portion of a day
			 during which the member is absent from the site, unless the program documents
			 that the member was receiving services from the program staff outside of the
			 ADH program in a community setting.
(F) The MassHealth agency does not pay for
			 ADH transportation for members on days where the member does not have an ADH
			 service claim for ADH attendance that day.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 404.000 - Adult Day Health Services › Section 404.416 - Prohibited Marketing Activities

Current through Register 1525, July 5, 2024
An ADH provider shall not:
(A) with the knowledge that a member is
			 enrolled in a 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 Capitated Program in order to retain the ADH provider to
			 provide ADH services on a fee-for-service basis; or
(B) offer to a member, or his or her family
			 or caregivers, in-person or through marketing any inducement to retain the ADH
			 provider to provide ADH 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 ADH 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 405.000 - Community Health Center Services › Section 405.401 - Introduction

Current through Register 1525, July 5, 2024
All community health centers (CHCs) participating in MassHealth
				must comply with the regulations governing MassHealth including, but not
				limited to,
				130 CMR
				405.000 and
				130 CMR
				450.000:
Administrative and Billing
				Regulations
.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 405.000 - Community Health Center Services › Section 405.403 - Eligible Members

Current through Register 1525, July 5, 2024
(A)
(1)
MassHealth
			 Members
. MassHealth covers CHC 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
.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 405.000 - Community Health Center Services › Section 405.404 - Provider Eligibility

Current through Register 1525, July 5, 2024
Payment for the services described in 130 CMR 405.000 will be
				made only to providers of CHC services who are participating in MassHealth on
				the date of service.
(A)
In
			 State
. To participate in MassHealth, a CHC located in
			 Massachusetts must meet the qualifications for certification or provisional
			 certification in
			 130 CMR
			 405.405.
(B)
Out of State
. To
			 participate in MassHealth, an out-of-state CHC must obtain a MassHealth
			 provider number and meet the following criteria:
(1) if the center is required by its own
			 state's law to be licensed, the center must be licensed by the appropriate
			 state agency under whose jurisdiction it operates;
(2) the center must participate in its
			 state's Medicaid program (or the equivalent); and
(3) the center must have a rate of payment
			 established by the appropriate rate setting regulatory body of its
			 state.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 405.000 - Community Health Center Services › Section 405.406 - Administrative Requirements

Current through Register 1525, July 5, 2024
A CHC must meet the administrative requirements specified in
				130 CMR
				405.406 to receive certification as outlined
				in
				130 CMR
				405.405.
(A)
Licensing
. The
			 CHC must be licensed as a clinic by the Massachusetts Department of Public
			 Health. For the purposes of 130 CMR 405.000, the term "licensee" means the
			 entity named in the license issued by the Department of Public Health. A CHC
			 can be comprised of multiple sites that are identified on the license as
			 "satellites". Services provided at satellites are considered to be provided on
			 site.
(B)
Nonprofit
			 Status
. The CHC must be a nonprofit organization.
(C)
Staffing
.
(1) The CHC must employ an on-site manager
			 who is qualified by education, training, or experience to serve as the
			 administrator of the CHC. The manager is responsible to the licensee for both
			 the management and administration of CHC services, for carrying out policies
			 established or approved by the licensee, and for ensuring that the CHC complies
			 with 130 CMR 405.000.
(2) The CHC
			 must employ a professional services director who is a health practitioner
			 qualified by education, training, or experience to direct and evaluate the
			 provision of health services in the CHC. The professional services director
			 must supervise the staff members providing health services and must ensure that
			 treatment and care are both adequate and appropriate to the needs of members
			 and are in compliance with 130 CMR 405.000. The professional services director
			 must be either on-site or on call at all times that the CHC is in
			 operation.
(3) The same individual
			 may serve as both the manager and the professional services director, if this
			 individual meets the requirements in
			 130 CMR 405.406(C)(1)
			 and (2).
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 405.000 - Community Health Center Services › Section 405.407 - Physician Time Required On-site

Current through Register 1525, July 5, 2024
Except as specified in
				130 CMR 405.407(A)
				and (B), a CHC must have at least one
				licensed physician on-site during its hours of operation to treat medical
				problems outside the expertise of other health practitioners on the CHC's
				staff. This physician may leave the CHC for limited periods to visit CHC
				patients in their homes, in hospitals, or in nursing facilities; but he or she
				must be on call to the CHC during such periods.
(A) CHCs that are located in isolated rural
			 areas where no licensed physician is available on a regular basis within a
			 20-mile radius and that have a licensed physician on call during all hours of
			 operation may apply to the MassHealth agency's Program Specialist for community
			 health centers for a waiver of this requirement.
(B) CHCs that employ family practitioners on
			 site may substitute family practitioners for other specialists who are
			 unavailable due to the center's geographic isolation, but whose specialized
			 services must be provided on-site. These specialties include pediatrics,
			 obstetrics/gynecology, and internal medicine.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 405.000 - Community Health Center Services › Section 405.409 - Medical Services Required On-site or by Referral

Current through Register 1525, July 5, 2024
All of the services listed in
				130 CMR
				405.409 must be provided on-site or,
				alternatively, through a referral network. For the purpose of
				130 CMR
				405.409, a service furnished by a
				practitioner other than an employee or contractor of the CHC for which the
				practitioner, rather than the CHC, claims payment is not considered to be
				"on-site", even if the service is provided on CHC premises. With the exception
				of audiology, electrocardiogram, laboratory, and radiology services, the CHC
				must notify the MassHealth agency, in writing, of each service listed in
				130 CMR
				405.409(A) through (N) that
				the CHC will provide on-site. All services provided on-site must be furnished
				by practitioners qualified to provide the service that are employees or
				contractors of the CHC. With the exceptions of audiology, electrocardiogram,
				laboratory, and radiology services provided on site (for which such services
				must be furnished and payment claimed by the CHC in accordance with applicable
				provisions set forth in 130 CMR 405.000 and Subchapter 6 of the
Community Health Center Manual
), all services set forth below
				that are provided on-site must be furnished, and associated payment claimed by
				the CHC, in compliance with the applicable MassHealth regulations and
				subchapter 6 for each such service, including applicable fee schedules. All
				services listed in
				130 CMR
				405.409(A) through (N) that
				are provided by referral must be based on written agreements between the CHC
				and each referral provider to ensure continuity of care, exchange of relevant
				health information such as test results and records, and avoidance of service
				duplication. Each referral provider must be a participating provider in
				MassHealth, and payment for the services provided by the referral provider must
				be claimed by the referral provider in compliance with the applicable
				MassHealth regulations for such service. All referrals must include follow-up
				to ensure that the referral process is successfully completed. Services that
				must be provided on-site or through the referral network are the
				following:
(A) audiology
			 services;
(B) chiropractor
			 services;
(C) dental
			 services;
(D) electrocardiogram
			 (EKG) services;
(E) laboratory
			 services;
(F) medical specialty
			 services such as, but not limited to, cardiology and neurology;
(G) mental health services, including
			 psychological testing;
(H)
			 occupational therapy services;
(I)
			 pharmacy services;
(J) physical
			 therapy services;
(K) podiatry
			 services;
(L) radiology
			 services;
(M) speech/language
			 therapy services; and
(N) vision
			 care services.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 405.000 - Community Health Center Services › Section 405.411 - Continuity of Care

Current through Register 1525, July 5, 2024
A CHC must maintain continuity of care in providing health
				services to members. Continuity of care ensures that a member will always be
				seen by a health practitioner knowledgeable about the member's case. Mere
				access to medical records by all practitioners who deliver services to a member
				will not suffice as a means of complying with
				130 CMR
				405.411.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 405.000 - Community Health Center Services › Section 405.412 - Record-keeping Requirements

Current through Register 1525, July 5, 2024
(A) A CHC must
			 comply with the MassHealth agency's record-keeping regulation contained in 130
			 CMR 450.000:
Administrative and Billing Regulations
. In
			 addition, each member's medical record must include the reason for each visit
			 and the data upon which the diagnostic impression or statement of the member's
			 problem is based, and must be sufficient to justify any further diagnostic
			 procedures, treatments, and recommendations for return visits or referrals.
			 Specifically, a medical record must include, but not be limited to:
(1) the date of each service;
(2) the member's name and date of
			 birth;
(3) the signature and title
			 of the person performing the services;
(4) the member's medical history;
(5) the diagnosis or chief
			 complaint;
(6) clear indication of
			 all findings, whether positive or negative, on examination;
(7) any medications administered or
			 prescribed, including strength, dosage, and regimen;
(8) a description of any treatment
			 given;
(9) recommendations for
			 additional treatments or consultations, when applicable
(10) any medical goods or supplies dispensed
			 or prescribed;
(11) any tests
			 administered and their results;
(12) a notation of hospitalization ordered by
			 a CHC practitioner and discharge summaries from such hospitalization;
			 and
(13) notations of all referrals
			 and results of referrals, including the referral provider's diagnoses,
			 treatment plans, test results, and medical outcomes.