reglab/statecodes huggingface dataset:
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 435.000 - Chronic Disease And Rehabilitation Inpatient Hospital Services › Section 435.416 - Fair Hearings

Current through Register 1525, July 5, 2024
(A) A member may
			 request a fair hearing before the Division in cases when the Division or its
			 agent determines, as the result of a review, that there is no administrative
			 necessity for a continued stay due to the availability of an appropriate
			 placement as described in
			 130 CMR
			 435.413.
(B) A hospital may request a fair hearing
			 before the Division when the Division or its agent determines, as the result of
			 a review, that an admission or a continued stay, or any part thereof, is not
			 medically necessary but is administratively necessary.
(C) A member or a hospital may request a fair
			 hearing before the Division when the Division or its agent determines, as the
			 result of a review, that an admission or continued stay, or any part thereof,
			 is not medically or administratively necessary.
(D) Written notice of the right to a fair
			 hearing and the manner in which and time within which a hearing must be
			 requested will be provided at the time of the determination by the Division or
			 its agent.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 435.000 - Chronic Disease And Rehabilitation Inpatient Hospital Services › Section 435.417 - Discharge-planning Standards

Current through Register 1525, July 5, 2024
(A)
Effective Date
. The discharge-planning standards
			 defined in 130 CMR 435.417 apply to members admitted on or after January 1,
			 1984.
(B)
Exemptions
			 from Discharge-planning Standards
. A chronic disease or
			 rehabilitation hospital will be exempted from the discharge-planning standards
			 defined in 130 CMR 435.417 if the hospital has filed an application with the
			 Determination of Need Program of the Massachusetts Department of Public Health
			 to relicense the entire facility or a distinct unit within the facility as a
			 nursing facility.
(C)
Staff
.
(1) The
			 hospital must assign in writing the responsibility for all discharge planning
			 to one appropriate department (such as social services or continuing care).
			 That department in turn must designate specific staff members whose primary
			 duties are discharge planning.
(2)
			 The discharge-planning staff must include either a registered nurse or a social
			 worker who is licensed, or who is eligible for licensure and has submitted an
			 application for licensure to the appropriate Massachusetts board of
			 registration or licensing agency in its state, and is under the supervision of,
			 or in consultation with, a licensed graduate-level nurse or social
			 worker.
(3) Unless permitted a
			 lower ratio by the Division, the hospital must employ one discharge planner or
			 full-time equivalent for every 60 licensed beds. Visiting Nurse Association
			 (VNA) or home health staff who are not employed by the hospital, but who
			 regularly perform discharge-planning activities there, may be included in this
			 ratio.
(4) The hospital must
			 demonstrate to the Division that it provides formal in-service training
			 programs and regular case conferences for all discharge-planning staff and all
			 other personnel who affect the discharge-planning process.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 435.000 - Chronic Disease And Rehabilitation Inpatient Hospital Services › Section 435.418 - Service Limitations

Current through Register 1525, July 5, 2024
For MassHealth Family Assistance members who are not receiving
				premium assistance pursuant to
				130 CMR
				450.105(H)(1), the Division
				will cover chronic disease and rehabilitation inpatient services up to a
				maximum of 30 days per admission.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 435.000 - Chronic Disease And Rehabilitation Inpatient Hospital Services › Section 435.424 - Medical Leave of Absence: Responsibilities of the Hospital for the Transfer of a Member Who is a Resident of a Nursing Facility

Current through Register 1525, July 5, 2024
(A) The Division will pay a nursing facility
			 to reserve a bed during a member's medical leave of absence if the admitting
			 hospital meets the requirements of 130 CMR 435.424(B).
(B) Whenever a member is admitted to a
			 hospital from a nursing facility, the hospital must comply with the following
			 requirements.
(1) The hospital must ensure
			 that the Division's nursing facility bed reservation form for medical leave of
			 absence (hereafter referred to as "the bed reservation form") has been received
			 from the nursing facility.
(2) Not
			 later than the second working day of the member's hospital stay, the hospital
			 must:
(a) review the member's medical record
			 to determine the member's estimated length of stay;
(b) notify the nursing facility by telephone
			 of the estimated number of days of the stay and document in the member's
			 medical record the date of such telephone notification to the nursing facility;
			 and
(c) complete the appropriate
			 section of the bed reservation form, according to the instructions provided on
			 the form.
(3) When the
			 member's estimated length of stay will be ten consecutive days or less, the
			 facility must reserve a bed for the same number of days and the hospital must
			 so notify its discharge-planning unit.
(4) When the member's estimated length of
			 stay exceeds ten consecutive days, the facility must not reserve a bed and the
			 hospital must so notify its discharge-planning unit.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 436.000 - Radiation Oncology Treatment Centers › Section 436.401 - Introduction

Current through Register 1525, July 5, 2024
130 CMR 436.000 establishes
				the requirements for the provision and reimbursement of radiation oncology
				services under MassHealth. The MassHealth agency pays for radiation oncology
				services that are medically necessary and appropriately provided in accordance
				with
				130 CMR
				450.204. All radiation oncology centers
				participating in MassHealth must comply with all MassHealth regulations
				including, but not limited to,
				130 CMR 436.000 and
				130 CMR
				450.000.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 436.000 - Radiation Oncology Treatment Centers › Section 436.402 - Definitions

Current through Register 1525, July 5, 2024
The following terms used in
				130 CMR 436.000 have the
				meanings given in 130 CMR 436.402, unless the context clearly requires a
				different meaning. The reimbursability of services defined in
				130 CMR 436.000 is not
				determined by these definitions, but by application of regulations elsewhere in
				130 CMR 436.000 and in
				130 CMR 450.000.
Direct Supervision
- the physician is
				present in the office suite and immediately available to furnish assistance and
				direction throughout the performance of the procedure. It does not require that
				the physician be present in the room when the procedure is performed.
General Supervision
- the procedure is
				furnished under the physician's overall direction and control, but the
				physician is not necessarily required during the performance of the
				procedure.
Non-physician Personnel
- technicians,
				employed or contracted by the radiation oncology center, whose function is to
				perform the technical component of a given procedure.
Personal Supervision
- a physician is
				physically in the room during the performance of the procedure.
Referring Physician
- a physician who
				requests or orders the service but does not necessarily perform the
				service.
Supervising Physician
- the physician
				responsible for the personal, direct or general supervision of the testing
				performed, the quality of the testing performed, the proper operation and
				calibration of the equipment used to perform tests, and the actions of
				non-physician personnel who use the equipment.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 436.000 - Radiation Oncology Treatment Centers › Section 436.403 - Eligible Members

Current through Register 1525, July 5, 2024
(A)
(1)
MassHealth
			 Members
. The MassHealth agency pays for services provided by
			 radiation oncology centers to MassHealth members, subject to the restrictions
			 and limitations described in MassHealth regulations.
			 130 CMR 450.105
			 specifically states, for each MassHealth coverage type, which services are
			 covered and which members are eligible to receive those services.
(2)
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.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 436.000 - Radiation Oncology Treatment Centers › Section 436.404 - Provider Eligibility

Current through Register 1525, July 5, 2024
The MassHealth agency makes payment for services, described in
				130 CMR 436.000, only to
				eligible providers of radiation oncology services who are participating in
				MassHealth on the date of service. The participating provider is responsible
				for the quality of all services for which payment is claimed, the accuracy of
				such claims, and compliance with all regulations applicable to radiation
				oncology services under MassHealth. In order to claim payment, the
				participating provider must be the radiation oncology center that actually
				performed the service. A radiation oncology center must have one or more
				supervising physicians who are responsible for the personal, direct, or general
				supervision of the facility and its personnel in accordance with Medicare
				requirements at 42 CFR 410.323(b)(3), the operation and calibration of the
				equipment, and the quality of the testing performed.
(A)
In State
. To be
			 eligible to participate as a MassHealth provider, a radiation oncology center
			 must:
(1) be located and doing business in the
			 Commonwealth of Massachusetts;
(2)
			 operate under a clinic license issued by the Massachusetts Department of Public
			 Health (DPH), in accordance with
			 105 CMR
			 140.000. (Providers operating as a satellite location
			 under a Massachusetts DPH hospital license, or otherwise have Medicare
			 provider-based status under
			 42
			 CFR 413.65, do not meet this
			 requirement.);
(3) obtain a current
			 determination of need or acceptable substitute such as a physician's exemption
			 letter issued by the Massachusetts Department of Public Health, to provide
			 radiation therapy services;
(4)
			 employ to perform, oversee, and direct all care provided at the center one or
			 more physicians licensed by Commonwealth of Massachusetts as a radiation
			 oncologist, nuclear medicine provider, or radiologist;
(5) ensure that non-physician medical
			 technicians providing services are licensed by the Commonwealth of
			 Massachusetts to provide such services in accordance with 105 CMR 120.000;
			 and
(6) participate in the Medicare
			 program as a radiation therapy provider.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 436.000 - Radiation Oncology Treatment Centers › Section 436.405 - Maximum Allowable Fees

Current through Register 1525, July 5, 2024
(A) The
			 MassHealth agency pays for radiation oncology center services with rates set by
			 the Massachusetts Division of Health Care Finance and Policy (DHCFP), subject
			 to the conditions, exclusions, and limitations set forth in
			 130 CMR 436.000.
(B) The maximum allowable fee is full
			 compensation for the radiation oncology service and any related administrative
			 or supervisory duties in connection with the services, regardless of where the
			 service was provided.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 436.000 - Radiation Oncology Treatment Centers › Section 436.406 - Individual Consideration

Current through Register 1525, July 5, 2024
(A) Some services
			 listed in Subchapter 6 of the
Radiation Oncology Center Manual
are designated "I.C.," an abbreviation for individual consideration. Individual
			 consideration means that a fee could not be established for these services.
			 Payment for an individual-consideration service is determined by the MassHealth
			 agency's professional advisers, based on the radiation oncology centers
			 descriptive report of the services furnished, which must be included with the
			 claim.
(B) If a service is not
			 listed in Subchapter 6 of the
Radiation Oncology Center
			 Manual
, a radiation oncology center may submit a claim by using the
			 appropriate "unlisted service" service code. Payment for an unlisted service is
			 determined by individual consideration, based on the center's descriptive
			 report of the service, which must be included with the claim.
(C) The MassHealth agency considers the
			 following factors when determining the appropriate payment for an
			 individual-consideration service:
(1) the
			 amount of time required to perform the service;
(2) the degree of skill required to perform
			 the service;
(3) the policies,
			 procedures, and practices of other third-party insurers both governmental and
			 private;
(4) prevailing
			 professional ethics and accepted customs of the diagnostic testing and
			 radiation oncology community; and
(5) other standards and criteria as may be
			 adopted by DHCFP or the MassHealth agency.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 436.000 - Radiation Oncology Treatment Centers › Section 436.407 - Prior Authorization

Current through Register 1525, July 5, 2024
(A) The MassHealth
			 agency requires the radiation oncology center to obtain prior authorization for
			 services that are designated "P.A." in the service descriptions listed in
			 Subchapter 6 of the
Radiation Oncology Center
			 Manual
.
(B) 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.
(C) All requests for prior authorization must
			 be submitted in accordance with the instructions found in Subchapter 5 of the
Radiation Oncology Center Manual
. No payment will be made for
			 such services unless prior authorization has been obtained from the MassHealth
			 agency before the delivery of service. The MassHealth agency will not grant
			 retroactive prior-authorization requests.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 436.000 - Radiation Oncology Treatment Centers › Section 436.408 - Report Requirements

Current through Register 1525, July 5, 2024
A general written report or a discharge summary must accompany
				the claim for payment for any service that is listed in Subchapter 6 of the
Radiation Oncology Center Manual
as requiring a report or
				individual consideration (I.C.), or if the code is for an unlisted service.
				This report must be sufficiently detailed to enable the MassHealth agency to
				assess the extent and nature of the service.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 436.000 - Radiation Oncology Treatment Centers › Section 436.413 - Payment

Current through Register 1525, July 5, 2024
(A)
Global Fee
.
			 Payment for a diagnostic procedure performed at a radiation oncology center
			 will include facility costs, technical costs, and professional costs.
(B)
Terminated
			 Procedures
. Upon review, the MassHealth agency may pay for
			 procedures that were unable to be completed after the procedure was
			 initiated.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 436.000 - Radiation Oncology Treatment Centers › Section 436.414 - Levels of Physician Supervision

Current through Register 1525, July 5, 2024
Radiation oncology centers must provide the appropriate level
				of physician supervision for each procedure in accordance with Medicare
				requirements at 42 CFR 410.323(b)(3). The definition of each level of physician
				supervision is set forth in
				130 CMR
				436.402.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 436.000 - Radiation Oncology Treatment Centers › Section 436.415 - Covered Services

Current through Register 1525, July 5, 2024
The MassHealth agency pays for radiation oncology services
				necessary for the diagnosis, detection, and treatment of disease, and for the
				maintenance of the health of MassHealth members, subject to all restrictions
				and limitations described in
				130 CMR 436.000 and
				450.000.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 436.000 - Radiation Oncology Treatment Centers › Section 436.416 - Noncovered Services

Current through Register 1525, July 5, 2024
The MassHealth agency does not pay for the following
				services:
(A) Services performed for
			 experimental or investigational purposes, or that are themselves experimental
			 or investigational.
(B) Services
			 provided by a physician who individually or through a group practice has
			 contractual arrangements with an acute, chronic, or rehabilitation hospital,
			 medical school, or other medical institution that involve a salary,
			 compensation in kind, teaching, research, or payment from any other source, if
			 such payment would result in dual compensation for professional, supervisory,
			 or administrative services related to member care.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 436.000 - Radiation Oncology Treatment Centers › Section 436.417 - Recordkeeping Requirements

Current through Register 1525, July 5, 2024
(A) The radiation
			 oncology center is responsible for ensuring the medical necessity of the
			 services and maintaining test results in the patient's health record.
(B) Radiation oncology centers must maintain
			 a medical-record system promoting quality and confidential patient care in
			 accordance with Massachusetts Department of Public Health regulations at
			 105 CMR
			 140.000. This system must collect and retain data in a
			 comprehensive and efficient manner and permit the prompt retrieval of
			 information. Accurate and complete medical records must be maintained for each
			 member receiving testing services from the radiation oncology center. The data
			 maintained in the member's medical record must also be sufficient to justify
			 any further diagnostic procedures. The medical record must be clear and
			 legible, and readily accessible to health care practitioners and the MassHealth
			 agency. The medical record must be maintained by the radiation oncology center
			 for at least six years.
(C) The
			 medical record must contain, at a minimum, the following information:
(1) the member's name, address, telephone
			 number, date of birth, and MassHealth identification number;
(2) the date of service;
(3) the name, title and signature of the
			 referring physician;
(4) a written
			 order for the tests or treatment to be performed;
(5) the name, title, and signature of the
			 person performing the service;
(6)
			 the name of the supervising physician;
(7) pertinent findings on examination;
			 and
(8) the tests and treatment
			 performed and the respective results.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 436.000 - Radiation Oncology Treatment Centers › Section 436.418 - Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Services

Current through Register 1525, July 5, 2024
The MassHealth agency pays for all medically necessary
				radiation oncology center services for EPSDT-eligible members in accordance
				with
				130
				CMR 450.140
et seq
., without
				regard to service limitations described in
				130 CMR 436.000, and with
				prior authorization.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 437.000 - Hospice Services › Section 437.401 - Introduction

Current through Register 1525, July 5, 2024
130 CMR
				437.000 governs the provision of hospice services
				under MassHealth. All hospices participating in MassHealth must comply with
				MassHealth regulations including, but not limited to, MassHealth regulations
				set forth in
				130 CMR
				437.000 and
				130 CMR
				450.000
: Administrative and Billing
				Regulations.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 437.000 - Hospice Services › Section 437.403 - Eligible Members

Current through Register 1525, July 5, 2024
(A)
(1)
MassHealth
			 Members
. The MassHealth agency covers hospice services only when
			 provided to eligible MassHealth members, subject to the restrictions and
			 limitations described in MassHealth regulations. MassHealth regulations at
			 130
			 CMR 450.105:
Coverage Types
specifically state, for each MassHealth coverage type, which services
			 are covered and which members are eligible to receive those services.
(2)
Members 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 437.000 - Hospice Services › Section 437.404 - Provider Eligibility

Current through Register 1525, July 5, 2024
Payment for the services described in
				130 CMR
				437.000 is made only to hospices participating in
				MassHealth on the date of service.
(A)
In State
. To participate in MassHealth, a
			 Massachusetts hospice must
(1) be certified as
			 a provider of hospice services under the Medicare program, as defined in 42 CFR
			 Part 418; and
(2) be licensed as a
			 hospice program by the Massachusetts Department of Public Health pursuant to
			 M.G.L. c. 111, § 57D and
			 105 CMR
			 141.000:
Licensure of Hospice
			 Programs.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 437.000 - Hospice Services › Section 437.405 - Out-of-state Hospice Services

Current through Register 1525, July 5, 2024
The MassHealth agency pays for out-of-state hospice services in
				accordance with the criteria described in
				130
				CMR 450.109:
Out-of-state
				Services.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 437.000 - Hospice Services › Section 437.406 - Early and Periodic Screening, Diagnostic and Treatment (EPSDT) Services

Current through Register 1525, July 5, 2024
The MassHealth agency pays for all medically necessary hospice
				services for EPSDT-eligible members in accordance with
				130
				CMR 450.140:
Early and Periodic
				Screening, Diagnostic and Treatment (EPSDT) Services: Introduction
without regard to service limitations described in
				130 CMR
				437.000, and with prior
				authorization.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 437.000 - Hospice Services › Section 437.407 - Hospice Election Periods

Current through Register 1525, July 5, 2024
(A) A member who
			 meets all eligibility criteria set forth in
			 130 CMR
			 437.000,
			 130 CMR
			 450.000:
Administrative and Billing
			 Regulations,
and all other applicable federal and MassHealth
			 regulations may elect to receive hospice care during one or more of the
			 following election periods:
(1) an initial
			 90-day period;
(2) a subsequent
			 90-day period; or
(3) an unlimited
			 number of subsequent 60-day periods.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 437.000 - Hospice Services › Section 437.411 - Certification of Terminal Illness

Current through Register 1525, July 5, 2024
(A)
Timing of Certification
. The hospice provider must
			 obtain written certification of terminal illness for each of the periods listed
			 in 130 CMR 437.407, even if a
			 single election continues in effect for an unlimited number of periods, as
			 provided in
			 130
			 CMR 437.412.
(1) If the hospice provider cannot obtain the
			 written certification within two calendar days after a period begins, it must
			 obtain an oral certification within two calendar days after a period begins and
			 the written certification before the hospice provider submits a claim for
			 payment to the MassHealth agency.
(2) Certifications may be completed no more
			 than 15 calendar days prior to the effective date of election.
(3) Recertifications may be completed no more
			 than 15 calendar days prior to the start of the subsequent election
			 period.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 437.000 - Hospice Services › Section 437.412 - Electing Hospice Services

Current through Register 1525, July 5, 2024
(A)
Eligibility for Hospice Services
.
(1) MassHealth members, including
			 dual-eligible members, but not including those identified in
			 130
			 CMR 437.412(A)(2), are
			 eligible for hospice services if
(a) their
			 coverage type as set forth in
			 130
			 CMR 450.105:
Coverage Types
covers hospice services; and
(b)
			 they fulfill the following requirements:
1.
			 are certified as terminally ill in accordance with
			 130
			 CMR 437.411;
2. agree to waive certain MassHealth benefits
			 in accordance with
			 130
			 CMR 437.412(B);
			 and
3. elect to receive hospice
			 services in accordance with
			 130
			 CMR 437.412(C).
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 437.000 - Hospice Services › Section 437.421 - Administration and Staffing Requirements

Current through Register 1525, July 5, 2024
(A)
Governing Body
. The hospice provider must have a
			 governing body that assumes full legal responsibility for determining,
			 implementing, and monitoring policies governing the hospice's total operation.
			 The governing body must designate a person who is responsible for the
			 day-to-day management of the hospice program.
(B)
Medical
			 Director
. The medical director must be a doctor of medicine or
			 osteopathy and assume overall responsibility for the medical component of the
			 hospice's patient-care program.
(C)
Hospice Interdisciplinary Team
. The hospice provider
			 must designate a hospice interdisciplinary team composed of hospice personnel,
			 including a registered nurse, whose role is to provide coordination of care,
			 including in-home supports, continuous assessment of member and family needs,
			 and implementation of the interdisciplinary plan of care.
(1)
Composition of
			 Team
. The hospice interdisciplinary team must include at least the
			 following individuals who are employees of the hospice, except in the case of
			 the physician described in
			 130
			 CMR 437.421(C)(1)(a), who
			 may be under contract with the hospice:
(a) a
			 doctor of medicine or osteopathy;
(b) a registered nurse;
(c) a social worker; and
(d) a pastoral or other counselor.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 437.000 - Hospice Services › Section 437.422 - Initial and Comprehensive Assessment of the Member

Current through Register 1525, July 5, 2024
(A) The hospice
			 provider must conduct and document in writing a member-specific comprehensive
			 assessment that identifies the member's need for hospice care and services, and
			 the member's need for physical, psychosocial, emotional, and spiritual care.
			 This assessment includes all areas of hospice care related to the palliation
			 and management of the terminal illness and related conditions.
(B)
Timeframe for Completion of
			 the Initial and Comprehensive Assessments
. The hospice registered
			 nurse must complete an initial assessment within 48 hours after the election of
			 hospice care in accordance with
			 130
			 CMR 437.412. The hospice interdisciplinary
			 team, in consultation with the individual's attending physician (as
			 applicable), must complete the comprehensive assessment no later than five
			 calendar days after the election of hospice care in accordance with
			 130
			 CMR 437.412.
(C)
Content of the Comprehensive
			 Assessment
. The comprehensive assessment must identify the
			 physical, psychosocial, emotional, and spiritual needs related to the terminal
			 illness that must be addressed in order to promote the member's well-being,
			 comfort, and dignity throughout the dying process. The comprehensive assessment
			 must take into consideration the following factors:
(1) the nature and condition causing
			 admission (including the presence or lack of objective data and subjective
			 complaints);
(2) complications and
			 risk factors that affect care planning;
(3) functional status, including the member's
			 ability to understand and participate in his or her own care;
(4) imminence of death;
(5) severity of symptoms; and
(6) drug profile. A review of all of the
			 member's prescription and over-the-counter drugs, herbal remedies and other
			 alternative treatments that could affect drug therapy. This includes, but is
			 not limited to, identification of the following:
(a) effectiveness of drug therapy;
(b) drug side effects;
(c) actual or potential drug
			 interactions;
(d) duplicate drug
			 therapy; and
(e) drug therapy
			 currently associated with laboratory monitoring.
(7)
Bereavement
. An
			 initial bereavement assessment of the needs of the member's family and other
			 individuals focusing on the social, spiritual, and cultural factors that may
			 impact their ability to cope with the member's death. Information gathered from
			 the initial bereavement assessment must be incorporated into the plan of care
			 and considered in the bereavement plan of care.
(8) The need for referrals and further
			 evaluation by appropriate health professionals.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 437.000 - Hospice Services › Section 437.423 - Plan of Care

Current through Register 1525, July 5, 2024
(A)
Establishment of Plan
. The hospice interdisciplinary
			 team in collaboration with the attending physician if any, the member or
			 representative, and primary caregiver must establish and follow an
			 individualized written plan of care in accordance with the member's needs. The
			 hospice must ensure that each member and the primary care giver(s) receive
			 education and training from the hospice provider as appropriate to their
			 responsibilities for the care and services identified in the plan of
			 care.
(B)
Scope of
			 Plan
. The plan of care must reflect member and family goals and
			 interventions based on problems identified in the initial, comprehensive, and
			 updated comprehensive assessments as described in
			 130
			 CMR 437.422. The plan must include all
			 services necessary for the palliation and management of the terminal illness
			 and related conditions, including the coordination of all in-home supports. The
			 plan of care must be coordinated with any personal care services the member may
			 be authorized to receive from the MassHealth Personal Care Attendant Program
			 and the MassHealth Adult Foster Care /Group Adult Foster Care Program, and/or
			 personal care services provided through a MassHealth HCBS waiver as well as
			 with any in-home support services that the member is receiving or is eligible
			 to receive from a home and community-based services network. Services that
			 provide in-home personal care may be used only to the extent that the hospice
			 provider would routinely use the services of a hospice member's family in
			 implementing the plan of care. For members under age 21, the hospice plan of
			 care must identify any curative treatment the member is receiving.
(C)
Review of Plan
.
			 The plan of care must be reviewed, revised, and documented at intervals
			 specified in the plan of care, but no less frequently than every 15 days, by
			 the attending physician, and the hospice interdisciplinary team (in
			 collaboration with the member's attending physician, if any). These reviews
			 must be documented in the member's clinical record
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 437.000 - Hospice Services › Section 437.425 - Provider Responsibilities

Current through Register 1525, July 5, 2024
In addition to meeting all of the qualifications set forth in
				130 CMR
				437.000 and
				130 CMR
				450.000:
Administrative and Billing
				Regulations,
hospice providers must meet all of the following
				requirements.
(A)
Recordkeeping Requirements
(1)
Administrative
			 Records
. Hospice providers must maintain administrative records in
			 compliance with the record retention requirements set forth in
			 130
			 CMR 450.205:
Recordkeeping and
			 Disclosure.
All records including, but not limited to, the following,
			 must be accessible and made available on-site for inspection by the MassHealth
			 agency:
(a) payroll and staff records,
			 including evidence of completed staff orientation and training;
(b) financial records;
(c) staffing levels, including
			 volunteers;
(d) complaints and
			 grievances;
(e) contracts for
			 subcontracted services, including a description of how the hospice provider
			 will supervise the subcontracted services;
(f) contracts for independent contractor
			 services, including a description of how the hospice provider will supervise
			 the independent contractors and their services; and
(g) job descriptions that include titles,
			 reporting authority, qualifications, and responsibilities.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 437.000 - Hospice Services › Section 437.426 - Payment for Hospice Services

Current through Register 1525, July 5, 2024
(A)
Type of Care
. MassHealth payment for hospice services
			 is based on the type of care provided rather than the qualifications of the
			 person who provided the service. Payment rates correspond to the following four
			 categories of care.
(1)
Routine
			 Home Care
. The routine home care rate is paid for each day the
			 member is at home or residing in a nursing facility or ICF/IID, under the care
			 of the hospice provider, and not receiving continuous home care. This rate is
			 paid without regard to the volume or intensity of routine home care services
			 provided on any given day.
(2)
Service-intensity Add-on (SIA)
. Routine home care days
			 that occur during the last seven days of a hospice election ending with a
			 member discharge due to death are eligible for an SIA payment. The SIA rate may
			 be billed with the routine home care rate, for a minimum of 15 minutes and up
			 to four hours per day for RN or social worker visits to the member during the
			 last seven days of their hospice election ending in discharge due to
			 death.
(3)
Continuous
			 Home Care
. The continuous home care rate is paid when a member
			 receives hospice services consisting predominantly of nursing care on a
			 continuous basis at home or in a nursing facility or ICF/IID. Hospice aide or
			 homemaker services or both may also be provided on a continuous basis.
			 Continuous home care is only furnished during brief periods of crisis as
			 described in 42 CFR
			 418.204(a) and only as
			 necessary to maintain the member at home. A minimum of eight hours must be
			 provided in a 24-hour period to qualify for the continuous home care
			 rate.
(4)
Inpatient
			 Respite Care
. The inpatient respite care rate is paid to the
			 hospice provider for each day the member is in an approved inpatient facility
			 and is receiving respite care from the hospice provider. Payment for inpatient
			 respite care will be made for a maximum of five consecutive days' stay
			 including the date of admission but not counting the date of discharge except
			 in circumstances described in
			 42 CFR
			 418.302(e)(5). Payment for
			 any subsequent days will be made at the routine home care rate.
(5)
General Inpatient
			 Care
. The general inpatient care rate is paid for each day the
			 member receives general inpatient care in an inpatient facility for pain
			 control or acute or chronic symptom management that cannot be managed in other
			 settings. None of the other fixed payment rates will be applicable for a day on
			 which the member receives inpatient care except for the day of
			 discharge.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 437.000 - Hospice Services › Section 437.427 - Quality Management and Utilization Review

Current through Register 1525, July 5, 2024
(A) A hospice
			 provider 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 hospice provider's place of
			 business upon request by MassHealth or its designee.
(B) A hospice provider 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 certification of terminal illness
			 and other records to determine if services are medically necessary in
			 accordance with
			 130 CMR
			 437.000. The hospice provider 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.
(C) Upon
			 request, a hospice provider must submit to the MassHealth agency or its
			 designee a statement of fiscal soundness attesting to the financial viability
			 of the hospice provider supported by documentation to demonstrate that the
			 provider has adequate resources to finance the provision of services in
			 accordance with
			 130 CMR
			 437.000.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 437.000 - Hospice Services › Section 437.428 - Prohibited Marketing Activities

Current through Register 1525, July 5, 2024
A hospice 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 hospice provider to
			 provide hospice 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
			 hospice provider to provide hospice 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 hospice
			 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 438.000 - Continuous Skilled Nursing Agency › Section 438.401 - Introduction

Current through Register 1525, July 5, 2024
130 CMR
				438.000 states the requirements for the payment of
				continuous skilled nursing (CSN) services and complex care assistant services
				provided by a CSN agency. All CSN agencies participating in MassHealth must
				comply with MassHealth regulations including, but not limited to,
				130 CMR
				438.000 and
				130 CMR
				450.000:
Administrative and Billing
				Regulations
.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 438.000 - Continuous Skilled Nursing Agency › Section 438.403 - Eligible Members

Current through Register 1525, July 5, 2024
(A)
(1)
MassHealth
			 Members
. The MassHealth agency covers CSN agency services provided
			 by CSN
agencies only when provided to eligible MassHealth members,
				subject to the restrictions and limitations described in MassHealth regulations
				at 130 CMR
				438.000 and
				130 CMR
				450.000:
Administrative and Billing
				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 438.000 - Continuous Skilled Nursing Agency › Section 438.404 - Provider Eligibility

Current through Register 1525, July 5, 2024
To participate in MassHealth as a MassHealth CSN agency
				provider, an agency must
(A) be
			 accredited or certified as
(1) a provider of
			 home health services by a CMS-approved accrediting organization including one
			 of the following: Accreditation Association for Ambulatory Health Care,
			 Accreditation Commission for Health Care, Community Health Accreditation
			 Partners, the Joint Commission on Accreditation of Healthcare Organizations,
			 and meet all requirements of the CMS-approved accrediting organization;
			 or
(2) a provider of home care
			 services by the Accreditation Commission for Health Care and meet all
			 requirements of this accrediting organization; or
(3) a provider of home health services under
			 the Medicare program by the Massachusetts Department of Public Health and meet
			 all requirements within the Medicare Conditions of Participation for home
			 health agency services;
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 438.000 - Continuous Skilled Nursing Agency › Section 438.408 - Services Provided under Contract

Current through Register 1525, July 5, 2024
(A)
Introduction
. A CSN agency may provide CSN agency
			 services directly or through contractual arrangements made by the CSN agency.
			 Whether the services are provided directly or through contracts, the CSN agency
			 is responsible for submitting claims for services and for meeting the
			 requirements in
			 130 CMR
			 438.000 and all other applicable state and federal
			 requirements.
(B)
Contract Requirements
.
(1) If the CSN agency contracts with another
			 provider participating in MassHealth (
e.g
., hospital, nursing
			 facility, a home health agency, another CSN agency, or hospice), a written
			 contract must document the services to be provided and the corresponding
			 financial arrangements.
(2) If the
			 CSN agency contracts with a provider that does not participate in MassHealth,
			 the written contract must include
(a) a
			 description of the services to be provided;
(b) the duration of the agreement and how
			 frequently it is to be reviewed;
(c) a description of how personnel are
			 supervised;
(d) a statement that
			 the contracting organization will provide its services in accordance with the
			 plan of care established by the member's physician in conjunction with the CSN
			 agency's staff;
(e) a description
			 of the contracting organization's standards for personnel, including
			 qualifications, functions, supervision, and in-service training;
(f) a description of the method of
			 determining reasonable costs and payments by the home health agency for the
			 specific services to be provided by the contracting organization; and
(g) an assurance that the contracting
			 organization will comply with Title VI of the Civil Rights Act and all relevant
			 MassHealth provider requirements.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 438.000 - Continuous Skilled Nursing Agency › Section 438.409 - Administrative Requirements

Current through Register 1525, July 5, 2024
Whether services are provided by the CSN 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 438.402 relating to all services provided
			 in accordance with
			 130
			 CMR 438.415(D)(3);
(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 438.416(C);
			 and
(D) ensure that the CSN
			 agency's staff review the medical necessity of services and the physician or
			 ordering non-physician practitioner certification on a regular basis.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 438.000 - Continuous Skilled Nursing Agency › Section 438.410 - Clinical Eligibility Criteria for CSN Agency Services

Current through Register 1525, July 5, 2024
(A)
Clinical Criteria for Nursing
			 Services
.
(1) A nursing service
			 is a service that must be provided by a registered nurse or a licensed
			 practical nurse to be safe and effective, considering the inherent complexity
			 of the service, the condition of the patient, and accepted standards of medical
			 and nursing practice.
(2) Some
			 services are nursing services on the basis of complexity alone (for example,
			 intravenous and intramuscular injections). However, in some cases, a service
			 that is ordinarily considered unskilled may be considered a nursing service
			 because of the patient's condition. This situation occurs when only a
			 registered nurse can safely and effectively provide the service.
(3) When a service can be safely and
			 effectively performed (or self-administered) by the average nonmedical person
			 without the direct intervention of a registered nurse or licensed practical
			 nurse, the service is not considered a nursing service, unless there is no one
			 trained and able to provide it.
(4)
			 Nursing services for the management and evaluation of a plan of care are
			 medically necessary when only a registered nurse or licensed practical nurse
			 can ensure that essential care is effectively promoting the member's recovery,
			 promoting medical safety, or avoiding deterioration.
(5) Medical necessity of services is based on
			 the condition of the patient at the time the services were ordered and what
			 was, at that time, expected to be appropriate treatment throughout the
			 certification period.
(6) A
			 member's need for nursing care is based solely on his or her unique condition
			 and individual needs, whether the illness or injury is acute, chronic,
			 terminal, stable, or expected to extend over a long period.