Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 414.000 - Independent Nurse › Section 414.411 - Complex-care Members

Current through Register 1525, July 5, 2024
For complex-care members, as defined in
				130 CMR 414.402, the
				MassHealth agency or its designee provides care management that includes
				service coordination with independent nurses as appropriate. The purpose of
				care management is to ensure that a complex-care member is provided with a
				coordinated community-long-term-care service package that meets the member's
				individual needs and to ensure that the MassHealth agency pays for nursing and
				other community-long-term-care services only if they are medically necessary in
				accordance with
				130 CMR
				450.204:
Medical Necessity
.
				The MassHealth member eligiblity verification system identifies complex-care
				members.
(A)
Care
			 Management Activities
.
(1)
Enrollment
. The MassHealth agency or its designee
			 automatically assigns a clinical manager to members whom it has determined
			 require a nurse visit of more than two continuous hours of nursing and informs
			 such members of the name, telephone number, and role of the assigned clinical
			 manager.
(2)
Comprehensive Needs Assessment
. The clinical manager
			 performs an in-person visit with the member, to evaluate whether the member
			 meets the criteria to be a complex-care member as described in
			 130 CMR 414.402. If
			 the member is determined to meet the criteria for a Complex Care member, the
			 clinical manager will complete a comprehensive needs assessment. The
			 comprehensive needs assessment will identify
(a) services that are medically necessary,
			 covered by MassHealth, and required by the member to remain safely in the
			 community;
(b) services the member
			 is currently receiving; and
(c) any
			 other case-management activities in which the member participates.
(3)
Service
			 Record
. The clinical manager
(a)
			 develops a service record, in consultation with the member, the member's
			 primary caregiver, and where appropriate, the independent nurse and the
			 member's physician, that
1. lists those
			 MassHealth-covered services to be authorized by the clinical manager;
2. describes the scope and duration of each
			 service;
3. lists service
			 arrangements approved by the member or the member's primary caregiver;
			 and
4. informs the member of his or
			 her right to a hearing, as described in
			 130 CMR
			 414.414;
(b) provide the member with copies of the
			 service record, one copy of which the member or the member's primary caregiver
			 must sign and return to the clinical manager. On the copy being returned, the
			 member or the member's primary caregiver must indicate whether he or she
			 accepts or rejects each service as offered and that he or she has been notified
			 of the right to appeal and provided an appeal form; and
(c) provide information to the independent
			 nurse about services authorized in the service record that are applicable to
			 the independent nurse.
(4)
Service
			 Authorizations
. The clinical manager will authorize those
			 community-long term-care services in the service record, including nursing,
			 that require prior authorization and that are medically necessary, as provided
			 in
			 130 CMR
			 414.413, and coordinate all nursing services
			 and any subsequent changes with the independent nurse.
(5)
Discharge
			 Planning
. The clinical manager may participate in member hospital
			 discharge-planning meetings as necessary to ensure that medically necessary
			 community-long-term-care services necessary to discharge the member from the
			 hospital to the community are authorized and to identify third-party
			 payers.
(6)
Service
			 Coordination
. The clinical manager will work collaboratively with
			 any other identified case managers assigned to the member.
(7)
Clinical Manager Follow-up
			 and Reassessment
. The clinical manager will provide ongoing care
			 management for members to
(a) determine
			 whether the member continues to meet the definition of a complex-care member;
			 and
(b) reassess whether services
			 in the service plan are appropriate to meet the member's needs.