reglab/statecodes huggingface dataset:
Code of Massachusetts Regulations › 651 CMR - EXECUTIVE OFFICE OF ELDER AFFAIRS › Title 651 CMR 12.00 - Certification Procedures and Standards for Assisted Living Residences › Section 12.03 - Certification

Current through Register 1525, July 5, 2024
(1)
Requirements and
			 Limitations
.
(a) No person or
			 legal entity shall advertise, operate, or maintain an Assisted Living Residence
			 until it has been certified by EOEA.
(b) Notwithstanding the requirement of 651
			 CMR 12.03(1), prior to the commencement of operations, an Applicant may
			 advertise an uncertified Assisted Living Residence only if it first initiates
			 the application process for Certification by notification to EOEA, and if it
			 clearly states in all advertising and marketing materials that it has not
			 completed the EOEA Certification process.
(c) An Applicant must have sufficient
			 property rights, as an owner or lessee, as the Secretary or his or her designee
			 finds necessary for the operation of an Assisted Living Residence.
(d) An Application for Certification shall
			 not be approved until the Applicant and premises meet the requirements of 651
			 CMR 12.03(2).
Code of Massachusetts Regulations › 651 CMR - EXECUTIVE OFFICE OF ELDER AFFAIRS › Title 651 CMR 12.00 - Certification Procedures and Standards for Assisted Living Residences › Section 12.04 - General Requirements for an Assisted Living Residence

Current through Register 1525, July 5, 2024
An Assisted Living Residence shall meet the following
				requirements to obtain and maintain Certification:
(1)
Physical
			 Requirements
.
(a) An Assisted
			 Living Residence shall provide only single or double Units with lockable doors
			 on the entry door of each Unit. Residents shall have exclusive rights to their
			 Units with lockable doors at the entrance of their individual or shared Units,
			 however, as part of a Resident's Service Plan, keys or access codes may be
			 readily available to specified shift staff;
(b) All Newly Constructed Assisted Living
			 Residences shall provide a private bathroom for each Unit which shall be
			 equipped with one lavatory, one toilet, and one bathtub or shower
			 stall;
(c) All other Assisted
			 Living Residences shall provide at a minimum, a private half-bathroom
			 (
i.e
., equipped with one washstand and one toilet) for each
			 living Unit and shall provide at least one Bathing Facility for every three
			 Residents;
(d) All Assisted Living
			 Residences shall provide at a minimum, either a kitchenette or access to a
			 refrigerator, sink, and heating element for all Residents, however, as part of
			 a Resident's Service Plan, such access may be limited to supervised access;
			 and
(e) Every Assisted Living
			 Residence shall meet the requirements, of all applicable federal and state laws
			 and regulations including, but not limited to, the state sanitary codes, state
			 building and fire safety codes and laws and regulations governing use and
			 access by persons with disabilities.
Code of Massachusetts Regulations › 651 CMR - EXECUTIVE OFFICE OF ELDER AFFAIRS › Title 651 CMR 12.00 - Certification Procedures and Standards for Assisted Living Residences › Section 12.06 - Staffing Requirements

Current through Register 1525, July 5, 2024
No person working in an Assisted Living Residence shall have
				been convicted of a felony related to the theft or illegal sale of a controlled
				substance.
(1)
Qualifications for the Manager
. The Manager of an
			 Assisted Living Residence shall be at least 21 years of age and must have
			 demonstrated experience in administration, supervision, and management skills.
			 The Manager must also have a Bachelor's degree or equivalent experience in
			 human services management, housing management or nursing home management. The
			 Manager must be of good moral character, and must never have been convicted of
			 a felony.
(2)
Qualifications for the Service Coordinator
. The
			 Service Coordinator of an Assisted Living Residence must have a minimum of two
			 years' experience working with elders or persons with disabilities. The Service
			 Coordinator shall be qualified by experience and training to develop, maintain
			 and implement or arrange for the implementation of individualized service
			 plans. The Service Coordinator must also have a Bachelor's degree or equivalent
			 experience, and knowledge of aging and disability issues.
(3)
General Staffing
			 Requirements
. All staff shall possess appropriate qualifications
			 to perform the job functions assigned to them. No person working in a Residence
			 shall have been determined by an administrative board or court to have violated
			 any local, state or federal statute, regulation, ordinance, or other law
			 reasonably related to the safety and well-being of a Resident at an Assisted
			 Living Residence or patient at a health care facility.
(4)
Staffing Levels
.
(a) Each Residence must develop and implement
			 a process for determining its staffing levels. The plan must include an
			 assessment, to be conducted at least quarterly but more frequently if the
			 Residence so chooses, of the appropriateness of staffing levels.
(b) The Residence shall have sufficient
			 staffing at all times to meet the scheduled and reasonably foreseeable
			 unscheduled Resident needs as required by the Residents' assessments and
			 service plans on a 24-hour per day basis. The Residence's staffing shall be
			 sufficient to respond promptly and effectively to individual Resident
			 emergencies. The Residence shall have a plan to secure staffing necessary to
			 respond to emergency, life safety and disaster situations affecting
			 Residents.
Code of Massachusetts Regulations › 651 CMR - EXECUTIVE OFFICE OF ELDER AFFAIRS › Title 651 CMR 12.00 - Certification Procedures and Standards for Assisted Living Residences › Section 12.07 - Training Requirements

Current through Register 1525, July 5, 2024
The purposes of the requirements of 651 CMR 12.07 are to ensure
				employees of Assisted Living Residences have a clear understanding of their
				jobs and the way in which their work intersects with and supports the work of
				other employees, of the policies and procedures of the Residence, of the rights
				of the Residents, and of the particular and distinctive service needs and
				health concerns of the Residents. All curricula for training should reflect
				current standards of practice and care, be designed to enhance the
				professionalism of the employees, and to enable employees to provide good
				service. Training requirements may be satisfied by such means as practical
				demonstration, lectures, lectures with accompanying role playing, video with
				facilitated discussion, and other generally accepted techniques. No more than
				two of the seven hours required for orientation may be conducted by
				un-facilitated media presentations by such means as video or audio. Instructors
				and facilitators shall be appropriately qualified by training or demonstrated
				experience. The Residence shall maintain documentation in the employee's
				personnel file regarding the completion of training or eligibility for any
				exemption.
(1)
General
			 Orientation
. Prior to active employment, all staff and contracted
			 providers who will have direct contact with Residents and all food service
			 personnel must receive a seven-hour orientation which includes the following
			 topics:
(a) Philosophy of independent living
			 in an Assisted Living Residence;
(b) Resident Bill of Rights;
(c) Elder Abuse, Neglect and Financial
			 Exploitation;
(d) Residence
			 policies and procedures related to disaster and emergency
			 preparedness;
(e) Communicable
			 diseases including, but not limited to, AIDS/HIV and Hepatitis B;
(f) Infection control in the Residence and
			 the principles of universal precautions based on DPH guidelines;
(g) Communication Skills;
(h) Review of the aging process;
(i) Dementia/Cognitive Impairment, including
			 a basic overview of the disease process, communication skills and behavioral
			 interventions;
(j) Resident Health
			 and related problems;
(k) General
			 overview of the employee's specific job requirements;
(l) The Residence's policy on emergency
			 response to acute health issues, and first aid; and
(m) Sanitation and Food Safety.
Code of Massachusetts Regulations › 651 CMR - EXECUTIVE OFFICE OF ELDER AFFAIRS › Title 651 CMR 12.00 - Certification Procedures and Standards for Assisted Living Residences › Section 12.09 - Compliance Reviews of Assisted Living Residences

Current through Register 1525, July 5, 2024
(1)
Purpose
. EOEA or
			 its authorized designee shall conduct a compliance review of an Assisted Living
			 Residence prior to the issuance of any initial or renewal Certification to
			 determine compliance with St. 1994, c. 354 and
			 651 CMR 12.00. An authorized
			 designee shall not be a Sponsor of an Assisted Living Residence.
(2)
Frequency
. EOEA
			 or its authorized designee shall conduct compliance reviews of Assisted Living
			 Residences no less than once every two years. In addition, EOEA may conduct a
			 compliance review any time it has cause to believe that an Assisted Living
			 Residence is in violation of an applicable section of St. 1994, c. 354 or any
			 applicable EOEA regulation. An authorized designee shall not be a Sponsor of an
			 Assisted Living Residence.
(3)
Compliance Review Requirements
. A compliance review
			 shall include, at a minimum, the following:
(a) A review of the operating plan and an
			 inspection of the common areas of the Assisted Living Residence. The inspector
			 may, in his or her discretion, interview the Applicant or Sponsor, Manager,
			 staff and Residents of the Assisted Living Residence. Interviews with Residents
			 shall be conducted privately and shall be confidential;
(b) An inspection of the living quarters of
			 any Resident, but only with the Resident's prior consent;
(c) An examination of any and all documents
			 within a Resident's record, including service plans and written progress
			 reports, incident reports (or similar document), Residency Agreement, and any
			 other financial or contractual agreements specific to the Resident. The
			 Resident may give consent in writing, on a form developed by EOEA, orally, or
			 by a sign of affirmation if the Resident is not able to give consent by other
			 means. Consent may include consent to photocopy such materials. If consent is
			 obtained by a means other than writing, confirmation of the consent shall be
			 written in the review record;
(d) A
			 review of staff and contracted provider records, including personnel
			 files;
(e) Review of all other
			 books, records, and other documents maintained in relation to the operations of
			 the Residence; and
(f) A review of
			 the quality improvement and assurance plans, including Resident satisfaction
			 surveys.
Refusal to grant EOEA timely access to Residents; staff; all
				books, records, and other documents maintained regarding the operations of the
				Residence shall constitute valid basis to suspend, revoke or deny an
				application for an initial or renewal Certification. EOEA shall be authorized
				to photocopy such materials or request the Residence send copies of identified
				materials to EOEA
via
facsimile or other electronic
				means.
Code of Massachusetts Regulations › 651 CMR - EXECUTIVE OFFICE OF ELDER AFFAIRS › Title 651 CMR 12.00 - Certification Procedures and Standards for Assisted Living Residences › Section 12.10 - Administrative Review: Procedure

Current through Register 1525, July 5, 2024
If an Applicant or Sponsor disagrees with the EOEA finding(s)
				or action, it may request an Administrative Review by submitting its request,
via
certified mail, return receipt requested, together with a
				detailed written rebuttal of the findings within ten days of receipt of the
				notice of noncompliance.
(1)
EOEA Review
.
(a)
Consultation
. The Applicant or Sponsor may consult
			 with the EOEA investigator about the findings and any action undertaken or
			 proposed by EOEA. This may take the form of an exit conference at the
			 conclusion of the compliance review, and, if this conference has been held
			 prior to issuance of the findings, the administrative review process will begin
			 with the Informal Review.
(b)
Informal Review
. An Applicant or Sponsor who disagrees
			 with an EOEA Compliance Review finding or the proposed action following the
			 consultation or after issuance of the findings, may request informal review by
			 the Director of the Assisted Living Certification Unit. The request for
			 Informal Review must be submitted within ten days of the issuance of the
			 findings, or ten days from the consultation, whichever is later. The Informal
			 Review shall be scheduled within ten days of the receipt of the request for
			 review, and shall consist of an informal presentation of the position of the
			 Applicant or Sponsor, and review of any applicable written documents. If the
			 matter is settled, the agreement shall be reduced to writing. If it is not, a
			 written decision shall be issued within ten days.
(c)
Informal Hearing
. An Applicant or Sponsor who disagrees with the decision of the Informal
			 Review may request an Informal Hearing before an Assistant Secretary or his or
			 her designee. Such request shall be delivered by hand or by certified mail,
			 return receipt requested, and must be submitted within ten days of the issuance
			 of the Informal Review decision. EOEA shall schedule an Informal Hearing within
			 15 days after receipt of the request for Informal Hearing. The Informal Hearing
			 shall consist of an informal presentation of the position of the parties and
			 any applicable written documents. If the matter is settled at the Informal
			 Hearing, EOEA and the Applicant or Sponsor shall reduce the settlement to
			 writing. If the matter is not settled at the Informal Hearing, an Assistant
			 Secretary or his or her designee shall review all material presented and within
			 30 days after the Informal Hearing, forward a decision to the Applicant or
			 Sponsor.
Code of Massachusetts Regulations › 651 CMR - EXECUTIVE OFFICE OF ELDER AFFAIRS › Title 651 CMR 12.00 - Certification Procedures and Standards for Assisted Living Residences › Section 12.11 - Right of Entry by EOEA and Contracting Agencies

Current through Register 1525, July 5, 2024
Any duly designated officer or employee of EOEA shall have the
				right to enter and inspect, at any time without prior notice, the common areas
				and office areas of any Assisted Living Residence for which an Application has
				been received or for which Certification has been issued. Any Application shall
				constitute permission for such entry and inspection. Inspections of any Unit
				shall be with the oral or written consent of the Resident.
Code of Massachusetts Regulations › 651 CMR - EXECUTIVE OFFICE OF ELDER AFFAIRS › Title 651 CMR 12.00 - Certification Procedures and Standards for Assisted Living Residences › Section 12.12 - Penalties for Uncertified Operation

Current through Register 1525, July 5, 2024
(1) Any
			 person operating an Assisted Living Residence without Certification under
			 M.G.L. c. 19D shall be subject to liability for a civil penalty of not more
			 than $500.00 for each day of such violation assessable by the Superior
			 Court.
(2) Any such violation shall
			 constitute grounds for refusing to grant or renew, modifying or revoking the
			 Certification of the Assisted Living Residence or of any part
			 thereof.
(3) Notwithstanding the
			 existence or use of any other remedy, EOEA may, in the manner provided by law,
			 maintain an action in the name of the Commonwealth for an injunction or other
			 process against any person to restrain or prevent the operation of an Assisted
			 Living Residence without Certification under M.G.L. c. 19D.
(4) Any person who knowingly refers an
			 individual for residency to an uncertified Assisted Living Residence shall be
			 subject to a civil penalty of not more than $500.00 for each such violation
			 assessable by the Superior Court.
Code of Massachusetts Regulations › 651 CMR - EXECUTIVE OFFICE OF ELDER AFFAIRS › Title 651 CMR 12.00 - Certification Procedures and Standards for Assisted Living Residences › Section 12.13 - Advisory Council

Current through Register 1525, July 5, 2024
Notwithstanding any general or special law to the contrary, an
				advisory council shall be established within EOEA. The advisory council shall
				advise the Secretary of EOEA relating to the regulations authorized under
				M.G.L. c. 19D. The advisory council shall be comprised of nine members, the
				Secretary of Elder Affairs or his or her designee who shall serve as
				chairperson, the Director of the Department of Housing and Community
				Development or his or her designee; the Secretary of Health and Human Services
				or his or her designee, and six members to be appointed by the Governor upon
				nomination by the Secretary of Elder Affairs. Of such six nominees, the
				Secretary shall nominate three persons who represent Resident consumer
				interests and two persons who represent Sponsors and Managers of the Assisted
				Living Residence. The advisory council shall by majority vote establish its own
				rules and procedures. Members of the council shall be appointed for terms of
				one year each. The council shall meet not less than on a quarterly basis, and
				it shall prepare a report of its activities, not less than annually. The annual
				report shall be made available to the public and the General
				Court.
Code of Massachusetts Regulations › 651 CMR - EXECUTIVE OFFICE OF ELDER AFFAIRS › Title 651 CMR 12.00 - Certification Procedures and Standards for Assisted Living Residences › Section 12.15 - Emergency Waivers

Current through Register 1525, July 5, 2024
The Secretary, or his or her designee, at his or her discretion
				and in consultation with the Commissioner of DPH, may temporarily waive,
				suspend, or modify one or more of the requirements of
				651 CMR 12.00 as necessary to
				respond to an emergency situation, provided that any such waiver, suspension,
				or modification:
(1) is documented in
			 writing;
(2) identifies the
			 conditions that have made such a waiver necessary;
(3) identifies the specific requirement of
			 651 CMR 12.00 to be addressed
			 and the action to be taken;
(4) is
			 narrowly tailored to achieve its stated objective;
(5) is implemented to ensure the health,
			 safety, and welfare of the citizens of the Commonwealth;
(6) is not in violation of any applicable
			 federal or state law; and
(7)
			 ceases upon the termination of the emergency situation.
Code of Massachusetts Regulations › 651 CMR - EXECUTIVE OFFICE OF ELDER AFFAIRS › Title 651 CMR 12.00 - Certification Procedures and Standards for Assisted Living Residences › Section 12.16 - Use or Disclosure of Personal Data between and among EOHHS Agencies

Current through Register 1525, July 5, 2024
EOEA may disclose information regarding a Residence or Resident
				to an EOHHS Agency when such disclosure is directly connected to the
				administration of an agency program or administrative oversight and the
				disclosure is not inconsistent with federal or state law.
Code of Massachusetts Regulations › 651 CMR - EXECUTIVE OFFICE OF ELDER AFFAIRS › Title 651 CMR 14.00 - Aging Service Access Points › Section 14.01 - Purpose and Scope

Current through Register 1525, July 5, 2024
The purpose of
				651
				CMR 14.00 is to set forth policies for the operation
				of Aging Services Access Points (ASAPs), for Elders in the Commonwealth of
				Massachusetts in accordance with c. 67, § 1 of the Acts of 1996 (M.G.L. c.
				19A, § 4B).
				651 CMR
				2.00 sets forth the functions and responsibilities of
				the Executive Office of Elder Affairs (Elder Affairs) and designated ASAP
				entities. The functions include the administration of the Home Care Program and
				activities defined in an interagency service agreement between Elder Affairs
				and the Division of Medical Assistance (DMA). The primary goal of this system
				of care is to assist elders to maintain residence in the community consistent
				with their clinical and psychosocial needs and in the most cost-effective
				manner possible.
(1) The legislative
			 and administrative authorizations for
			 651
			 CMR 14.00 are as follows:
(a) M.G.L c. l9A, § 4B providing that
			 the Executive Office of Elder Affairs "shall be responsible for management of
			 the home care program established in section four, and pursuant to an
			 interagency service agreement by the department with the division of medical
			 assistance, for clinical screening, service authorization activities and case
			 management for Medicaid community based long term care made available to
			 eligible elderly persons pursuant to the provisions of M.G.L. c. 118E and
			 regulations promulgated thereunder; provided that the programs and activities
			 authorized by this section shall be administered and coordinated with the
			 single state agency requirement under 42 CFR Part 431 and other applicable
			 requirements of Title XIX of the federal Social Security Act, or its successor
			 title.
(b) M.G.L. c.19A, § 6.
			 The general authority and responsibility of Elder Affairs to promulgate
			 regulations for the conduct of the business of the agency.
Code of Massachusetts Regulations › 651 CMR - EXECUTIVE OFFICE OF ELDER AFFAIRS › Title 651 CMR 14.00 - Aging Service Access Points › Section 14.02 - Functions and Responsibilities of the Executive Office of Elder Affairs in the Designation of ASAPs

Current through Register 1525, July 5, 2024
(1) As the
			 principal agency of the Commonwealth charged with the responsibility to
			 mobilize the human, physical, and financial resources available to plan,
			 develop and implement programs to insure the dignity and independence of Elders
			 in the Commonwealth, Elder Affairs shall carry out the functions and
			 responsibilities related to the designation of ASAPs as prescribed under these
			 specified authorities within the Commonwealth. Elder Affairs shall be
			 responsible for carrying out ongoing planning, coordination, administration,
			 monitoring, and evaluation activities necessary to establish ASAPs in the
			 Commonwealth and provide for an ongoing program of technical assistance to
			 ASAPs.
(2)
General
			 Functions and Responsibilities.
(a) Enter into a contract with the ASAPs
			 which sets forth the conditions under which the ASAP will receive reimbursement
			 from Elder Affairs for the provision of ASAP services;
(b) Develop performance standards and quality
			 measures to carry out ongoing monitoring and evaluation of ASAP
			 services;
(c) Establish reporting
			 procedures through which ASAPs shall inform Elder Affairs of program
			 information in order to assist Elder Affairs to effectively carry out its
			 legislative and administrative functions and responsibilities;
(d) Issue written policy instructions and
			 technical assistance information which relate to the operation of the ASAPs to
			 effectively carry out their functions and responsibilities;
(e) Establish written policies as to the
			 award of contracts by the ASAP in accordance with applicable Federal and State
			 laws; and
(f) Perform other
			 functions which relate to the appropriate and efficient administration of ASAPs
			 in the State, including provision for training, manpower development and public
			 information; and
(g) Manage,
			 administer and oversee activities related to the screening and authorization of
			 Community Based Long Term Care Services and related case management services,
			 as delegated by DMA pursuant to the terms of the interagency
			 agreement.
Code of Massachusetts Regulations › 651 CMR - EXECUTIVE OFFICE OF ELDER AFFAIRS › Title 651 CMR 14.00 - Aging Service Access Points › Section 14.04 - Financial and Administrative Responsibilities of ASAPs

Current through Register 1525, July 5, 2024
(1) The ASAP shall comply with regulations
			 set forth in
			 651
			 CMR 14.00,
et seq.,
requirements set
			 forth in the Commonwealth Terms and Conditions for Human and Social Services
			 Contracts and all written policies and procedures issued by Elder
			 Affairs.
(2) The ASAP shall
			 participate in the Peer Review Process and Quality Improvement activities in
			 cooperation with Elder Affairs.
(3)
			 ASAPs shall utilize the management information system (HOMIS) developed and
			 maintained by Elder Affairs for the purpose of managing client information,
			 ASAP expenditure and service delivery data. ASAPs shall submit reports as
			 required by Elder Affairs contracts and written requests.
(4) The ASAP shall establish financial
			 systems and procedures that shall comply with the requirements set forth in
			 808 CMR 1.00,
et
			 seq.,
Title 45 CFR Part 74, and written policies and procedures issued
			 by Elder Affairs.
(a) Expenses which do not
			 conform to generally accepted accounting principles, or which are specifically
			 identified as unallowable costs as defined in
			 808 CMR 1.00
et
seq., are unallowable costs for programs or services under
			 contract with Elder Affairs.
(b)
			 Costs of direct services, other than ASAP services as defined in
			 651 CMR 14.01,
			 are not allowable costs unless the ASAP has requested and been granted a waiver
			 in writing from Elder Affairs to provide such direct services.
(c) Each ASAP shall secure the services of an
			 independent certified public accountant to perform annual audits required by
			 808 CMR
			 1.04(2). Such auditor shall
			 be selected through an open competitive process conducted at least every three
			 years, including at a minimum an advertisement in a newspaper or a written
			 solicitation to at least three certified public accountants. The audit shall be
			 performed according to requirements of the Division of Purchased Services and
			 any requirements Elder Affairs may prescribe. Prior to initiation of the audit,
			 the ASAP shall provide any such requirements to the auditor and shall inform
			 the auditor in writing that the audit must meet these requirements.
Code of Massachusetts Regulations › 651 CMR - EXECUTIVE OFFICE OF ELDER AFFAIRS › Title 651 CMR 14.00 - Aging Service Access Points › Section 14.05 - General Provisions

Current through Register 1525, July 5, 2024
(1) The
			 establishment of a comprehensive service plan for an elder shall not establish
			 an entitlement to services for any eligible person for services beyond that
			 established by law or beyond the amounts appropriated for the
			 services.
(2) Insofar as a waiver
			 of a specific portion of
			 651
			 CMR 14.00 or
			 3.00 would not contradict any
			 applicable state or federal law or regulations, a waiver may be granted by the
			 Secretary. All requests for waivers must be made in writing to the Secretary by
			 the President of the Board of Directors of the ASAP. The waiver request must
			 clearly identify the applicable regulation; which conditions have made such a
			 waiver necessary; what steps have been taken to resolve current issues and
			 insure future waivers will not be necessary; the consequences to the Clients of
			 the ASAP of not granting the waiver request; and the consequences to the ASAP
			 of not granting the waiver request.
(3) All ASAPs and their contractors are
			 subject to audits by Elder Affairs or its authorized agents, the Secretary of
			 the Executive Office of Health and Human Services or his/her authorized agents,
			 or the Commonwealth of Massachusetts or its authorized agents. Furthermore, the
			 Governor or his/her designee, the Secretary of Administration and Finance or
			 his/her designee, and the State Auditor or his/her designee shall have the
			 right at reasonable times and upon reasonable notice to examine the books,
			 Client records, and other compilations of data of the ASAPs which pertain to
			 the performance of ASAP requirements. An audit may include but need not be
			 limited to a review of an ASAP's: financial statements, accounting records,
			 procedures, and management practices; compliance with and efficiency in
			 carrying out the terms of the ASAP contract.
Code of Massachusetts Regulations › 651 CMR - EXECUTIVE OFFICE OF ELDER AFFAIRS › Title 651 CMR 15.00 - Prescription Advantage Program › Section 15.01 - Scope and Purpose

Current through Register 1525, July 5, 2024
651 CMR 15.00 establishes a
				voluntary catastrophic prescription drug program to be administered by Elder
				Affairs. The name of the prescription drug program is Prescription Advantage
				(the Plan). The Plan is subject to appropriation. St. 2005, c. 45, § 27
				directs that, for Members in the Plan who qualify for Medicare Part D and who
				are at specified levels of income, the Plan shall provide supplemental
				assistance for premiums, Deductibles, payments and co-payments required by the
				Member's Medicare Part D Plan.
Code of Massachusetts Regulations › 651 CMR - EXECUTIVE OFFICE OF ELDER AFFAIRS › Title 651 CMR 15.00 - Prescription Advantage Program › Section 15.03 - Covered Benefits

Current through Register 1525, July 5, 2024
(1) Plan Members are
			 eligible to receive Covered Benefits subject to their compliance with the
			 payment specifications under
			 651 CMR 15.07.
(2) Covered Benefits include Prescription
			 Drugs that are on the Plan Formulary, are dispensed by a retail pharmacy
			 (including mail service) and can be self-administered. Covered Benefits do not
			 include any Prescription Drugs that are administered in an inpatient setting.
			 For Members enrolled in Medicare, Covered Benefits are only those products that
			 are covered by the Medicare Part D Plan or Creditable Coverage Plan in which
			 the Member is enrolled and benzodiazepines.
(3) Access to Covered Benefits shall not
			 commence until the Effective Date of Coverage. No Prescription Drug procured by
			 a Member prior to the Effective Date of Coverage shall be considered a Covered
			 Benefit.
(4) Covered Benefits
			 include items not on the Plan Formulary only when approved for coverage
			 pursuant to Review procedures set forth in
			 651 CMR 15.15.
(5) To ensure appropriate use of Covered
			 Benefits, the Plan may require Prior Authorization and may use benefit
			 management tools, including quantity limitations for certain Prescription
			 Drugs.
Code of Massachusetts Regulations › 651 CMR - EXECUTIVE OFFICE OF ELDER AFFAIRS › Title 651 CMR 15.00 - Prescription Advantage Program › Section 15.04 - Eligibility

Current through Register 1525, July 5, 2024
(1) A Member of the Plan must be a Resident
			 of the Commonwealth who is not eligible for MassHealth and:
(a)
1. is
			 65 years of age or older and is not eligible for Medicare; or
2. is 65 years of age or older and is
			 eligible for Medicare and has Gross Household Income less than or equal to 500%
			 of the poverty guidelines updated periodically in the Federal Register by the
			 U.S. Department of Health and Human Services; or
Code of Massachusetts Regulations › 651 CMR - EXECUTIVE OFFICE OF ELDER AFFAIRS › Title 651 CMR 15.00 - Prescription Advantage Program › Section 15.05 - Enrollment

Current through Register 1525, July 5, 2024
(1) The Secretary may establish a period of
			 Enrollment. Such Enrollment period may be continuous.
(2) Enrollment in the Plan is voluntary and
			 available to all persons eligible under
			 651 CMR 15.04, unless
			 a determination is made by the Secretary to close Enrollment.
(3) The Secretary shall close Enrollment
			 after making a written determination that Plan expenditures are projected to
			 exceed the amount appropriated for the Plan. Such determination may also be
			 made if, based on not less than nine months of claims and Enrollment data for
			 the current Fiscal Year, expenditures in the subsequent Fiscal Year are clearly
			 projected to annualize beyond the expenditures projected by the Secretary in
			 the subsequent Fiscal Year.
(4)
			 Persons eligible under
			 651 CMR 15.04 ( 1)
			 (b) may join or re-join the Plan at any time during which Enrollment is
			 open.
Code of Massachusetts Regulations › 651 CMR - EXECUTIVE OFFICE OF ELDER AFFAIRS › Title 651 CMR 15.00 - Prescription Advantage Program › Section 15.06 - Enrollment Process

Current through Register 1525, July 5, 2024
(1)
Applications
.
(a)
			 Applications shall be made available through the Plan, through Elder Affairs
			 and at locations frequented by potential Applicants.
(b) A toll-free telephone number shall be
			 available to provide Enrollment assistance and to take requests for
			 applications, and the telephone number shall conspicuously appear on
			 applications and other written materials regarding the Plan.
(c) The Plan shall publicize that assistance
			 with the application process is available to Applicants with limited English
			 proficiency.
(d) The Applicant or
			 the Applicant's designee must complete the application and attest that all
			 information submitted in the application is true to the best of his or her
			 knowledge and belief.
(e) An
			 application may be submitted by mail or any other acceptable method as
			 determined by the Plan.
Code of Massachusetts Regulations › 651 CMR - EXECUTIVE OFFICE OF ELDER AFFAIRS › Title 651 CMR 15.00 - Prescription Advantage Program › Section 15.07 - Payment

Current through Register 1525, July 5, 2024
(1)
Membership Category
			 Contribution Schedule
.
(a)
			 Contribution Schedules for applicable Enrollment Fees, Co-payments,
			 Deductibles, and Out-of-pocket spending limits shall be established by the Plan
			 and supplied to all Applicants and may be made available to other interested
			 parties upon request.
(b) Each
			 Member or his or her authorized representative shall be notified in writing of
			 any applicable Enrollment Fee, Co-payments and Deductibles.
(c) The Plan shall establish Enrollment Fee,
			 Co-payment and Deductible schedules annually. Written notification regarding
			 changes to Members' Enrollment Fee, Co-payment and Deductible rates shall be
			 mailed by the Plan to all affected Members or their authorized representatives
			 at least 30 calendar days before the effective date of the change.
(d) The Secretary shall modify Enrollment
			 Fee, Co-payment and Deductible schedules and income eligibility levels after
			 making a written determination that Plan expenditures are projected to exceed
			 the amount appropriated for the Plan or, based on not less than nine months of
			 claims and enrollment data for the current Fiscal Year, expenditures in the
			 subsequent Fiscal Year are clearly projected to annualize beyond the
			 expenditures projected by Elder Affairs in the subsequent Fiscal
			 Year.
Code of Massachusetts Regulations › 651 CMR - EXECUTIVE OFFICE OF ELDER AFFAIRS › Title 651 CMR 15.00 - Prescription Advantage Program › Section 15.08 - Formulary

Current through Register 1525, July 5, 2024
651 CMR 15.08 applies only to the Formulary developed and
				maintained by the Plan. Members of a Medicare Part D Plan shall refer to their
				Medicare Part D Plan Formulary to determine its rules and the included
				Prescription Drugs.
(1) The Plan will
			 develop and maintain a Plan Formulary consisting of a list of Prescription
			 Drags. The Plan Formulary shall include insulin and disposable insulin syringes
			 and needles. The Plan shall maintain a toll-free telephone number during
			 business hours through which an Applicant or Member or his or her authorized
			 representative may determine whether a particular Prescription Drag is included
			 on the Plan Formulary.
(2) The Plan
			 shall review the Plan Formulary and modify it as appropriate.
(3) The Plan shall not exclude any
			 Prescription Drug from the Plan Formulary unless a Therapeutically Equivalent
			 Prescription Drug is included on the Plan Formulary; however, the Secretary may
			 exclude certain outpatient Prescription Drags or classes of outpatient
			 Prescription Drags upon a written determination pursuant to M.G.L. 19A, §
			 39(r) that the exclusion is necessary to maintain the fiscal viability of the
			 program.
(4) Excluded from the Plan
			 Formulary are Prescription Drags labeled "Caution - limited by federal law to
			 investigational use" or experimental drags.
(5) To ensure appropriate use of Covered
			 Benefits, the Plan may require Prior Authorization and/or implement benefit
			 management tools, including quantity limitations for certain Prescription
			 Drags.
(6) Members shall have the
			 right to seek a Review of the following:
(a) a
			 Member's request to obtain a Non-preferred drug at the Co-payment level of a
			 Preferred Drug;
(b) a Member's
			 request to add to the Plan Formulary a Prescription Drug excluded from the Plan
			 Formulary; or
(c) a Member's
			 request to gain access to a Prescription Drag excluded from the Plan Formulary
			 at Plan Formulary rates.
Code of Massachusetts Regulations › 651 CMR - EXECUTIVE OFFICE OF ELDER AFFAIRS › Title 651 CMR 15.00 - Prescription Advantage Program › Section 15.09 - Coordination of Benefits

Current through Register 1525, July 5, 2024
A Member shall have access to Covered Benefits under the Plan
				only after said Member has exhausted all other prescription drug coverage,
				including all coverage available under the Member's Medicare Part D Plan or
				Creditable Coverage Plan.
(1) For
			 Members with coverage under a Medicare Part D Plan or Creditable Coverage Plan,
			 the Plan shall coordinate benefits by providing Supplemental Assistance as
			 established for the applicable Membership Category.
(2) For Members who are not eligible for
			 Medicare Part D coverage, but have another form of Prescription Drug Coverage,
			 if a Prescription Drag is not a Covered Benefit under the other Prescription
			 Drag coverage, but is a Covered Benefit under the Plan, the Plan will be the
			 primary payor for that Prescription Drug.
Code of Massachusetts Regulations › 651 CMR - EXECUTIVE OFFICE OF ELDER AFFAIRS › Title 651 CMR 15.00 - Prescription Advantage Program › Section 15.10 - Mail Service

Current through Register 1525, July 5, 2024
(1) The Plan may
			 administer Mail Service distribution of Maintenance Drags.
(2) Any such mail service shall dispense
			 Maintenance Drugs by an approved delivery service upon the Member's submission
			 of a Prescription and applicable payment to the Plan's mail service
			 facility.
(3) For Members of a
			 Medicare Part D Plan, the availability of mail service will be determined by
			 the Medicare Part D Plan.
Code of Massachusetts Regulations › 651 CMR - EXECUTIVE OFFICE OF ELDER AFFAIRS › Title 651 CMR 15.00 - Prescription Advantage Program › Section 15.11 - Applicant and Member Responsibility

Current through Register 1525, July 5, 2024
(1)
			 Applicants and Members, or their authorized representatives, must provide the
			 Plan with the information necessary to establish or maintain
			 enrollment.
(2) A Member or his or
			 her authorized representative must report in writing to the Plan within 15
			 Business Days any changes that may affect eligibility or a Membership Category
			 determination. These changes include, but are not limited to, changes in
			 residence, marital status, disability status, Medicare eligibility, eligibility
			 for the Low-income Subsidy, income, Prescription Drug coverage, and MassHealth
			 coverage, including CommonHealth.
(3) If the Plan determines that a Member may
			 qualify for the Low-income Subsidy, the Member must apply for that subsidy and
			 provide the Plan with any documentation the Plan may reasonably request to
			 verify the application.
(4)
			 Beginning January 1, 2006, a Member who receives the Low-income Subsidy, must
			 annually re-apply for that subsidy as required by the Social Security
			 Administration, and must provide the Plan with any documentation the Plan may
			 reasonably request to verify the reapplication.
(5) If the Member's file is selected for
			 audit and/or review, he or she must cooperate with the Plan to carry out the
			 purpose of the audit and/or review.
(6) Failure of an Applicant or Member to
			 fulfill any of their responsibilities set forth in 651 CMR 15.11 may result in
			 the denial or termination of enrollment, or, for Applicants or Members who may
			 be eligible for the Low-income Subsidy but fail to notify the Plan that they
			 have applied for it, classification in a Membership Category that offers no
			 supplemental assistance for premiums, and the lowest supplemental assistance
			 for Co-payments and Deductibles.
Code of Massachusetts Regulations › 651 CMR - EXECUTIVE OFFICE OF ELDER AFFAIRS › Title 651 CMR 15.00 - Prescription Advantage Program › Section 15.13 - Termination

Current through Register 1525, July 5, 2024
(1)
Voluntary Termination of
			 Enrollment
. A Member or his or her authorized representative may
			 request in writing at any time that his or her enrollment in the Plan be
			 terminated. Such termination shall be effective as of the first calendar day of
			 the month following receipt by the Plan of the written request. The Plan shall
			 mail written confirmation to the Member or his or her authorized representative
			 regarding such termination from the Plan.
(2)
Involuntary Termination of
			 Enrollment
. The Plan may terminate the enrollment of a Member and
			 render a written determination which sets forth the legal, regulatory and/or
			 policy basis for such determination, for any of the following reasons:
(a) a determination that a Member no longer
			 meets the eligibility standards set forth in
			 651 CMR
			 15.04;
(b) non-payment of Enrollment Fees pursuant
			 to
			 651 CMR
			 15.07(2), if
			 applicable;
(c) failure to comply
			 with requirements under
			 651 CMR
			 15.11;
(d) failure to submit re-determination
			 information under
			 651 CMR
			 15.12;
(e) a finding that a Member has committed
			 fraud under
			 651 CMR 15.16 (such Member
			 is prohibited from re-enrolling into the Plan);
(f) mail sent to a Member or his or her
			 authorized representative is returned as undeliverable with no forwarding
			 address and other reasonable attempts to locate the Member have
			 failed.
Code of Massachusetts Regulations › 651 CMR - EXECUTIVE OFFICE OF ELDER AFFAIRS › Title 651 CMR 15.00 - Prescription Advantage Program › Section 15.14 - Notification

Current through Register 1525, July 5, 2024
(1) All notifications issued by the Plan
			 shall include information regarding an Applicant's or Member's rights to
			 Review. Unless otherwise provided in these regulations, notice will be issued
			 at least ten business days in advance of the action to be taken by the
			 Plan.
(2) Written notification
			 shall be mailed by the Plan to an Applicant or Member or their authorized
			 representative regarding the following:
(a)
			 an Applicant's submission of an incomplete application;
(b) the determination of a Member's
			 Membership Category and applicable Enrollment Fee, Co-payments and Deductibles;
			 Effective Date of Coverage; or continued enrollment in the Plan;
(c) the voluntary or involuntary termination
			 of a Member's enrollment;
(d) a
			 Member's failure to make a timely an Enrollment Fee, if applicable;
(e) the denial of Prior Authorization for
			 Covered Benefits;
(f) any Plan
			 change regarding Membership Category and applicable Enrollment Fees,
			 Co-payments or Deductibles;
(g) the
			 Re-determination process and confirmation of a Member's status;
(h) a Reconsideration determination made by
			 the Plan; and
(i) an Administrative
			 Review determination made by the Plan.
Code of Massachusetts Regulations › 651 CMR - EXECUTIVE OFFICE OF ELDER AFFAIRS › Title 651 CMR 15.00 - Prescription Advantage Program › Section 15.15 - Review

Current through Register 1525, July 5, 2024
An Applicant or Member, or his or her designee, may seek Review
				of a Plan decision. An Applicant or Member may be assisted by his or her
				designee. Prescription Advantage will not provide review of any determination
				made by a Medicare Part D Plan, and members of those plans must seek review
				through those plans. Review consists of the following:
(1)
Customer
			 Service
. The Plan shall maintain a customer service center
			 accessible toll-free by telephone (including TTY services) to assist Applicants
			 and Members to resolve any issue regarding the Plan. Said customer service
			 center shall comply with applicable federal and state law regarding
			 communication accessibility. Contacting Customer Service is not a required step
			 in seeking review of a Plan decision.
(2)
Reconsideration
.
(a) An Applicant or Member, or his or her
			 designee, may request Reconsideration of a decision made by the Plan to deny or
			 terminate enrollment, the Plan's determination of a Member's Gross Annual
			 Household Income, or a decision by the Plan to deny or limit Covered Benefits.
			 A request for Reconsideration is the first step in the review process. Such
			 requests must be made in writing to the Plan.
(b) When an Applicant or Member, or his or
			 her designee, requests Reconsideration of a decision made by the Plan to deny
			 enrollment in the Plan pursuant to
			 651 CMR
			 15.06(6), or to terminate
			 enrollment in the Plan pursuant to
			 651 CMR 15.13, such
			 request must be made in writing and be received by the Plan within 15 Business
			 Days after the Applicant's or Member's receipt of such decisions rendered by
			 the Plan.
(c) Upon receipt of an
			 Applicant's or a Member's request for Reconsideration pursuant to 651 CMR
			 15.15(2)(a) or (b), a designated Plan representative shall review the
			 Applicant's or Member's enrollment file and attempt to resolve any outstanding
			 issues.
(d) The designated Plan
			 representative shall make a determination regarding an Applicant's or Member's
			 request for Reconsideration according to applicable statutes, regulations
			 and/or Plan policies.
(e) Within 15
			 Business Days after receiving a request for Reconsideration, the Plan shall
			 mail to the Applicant or Member, or his or her designee, a written notice
			 setting forth the Reconsideration determination, including the regulatory
			 and/or legal citations and policy basis supporting the determination and a
			 Member's right to an Administrative Review, if applicable.
Code of Massachusetts Regulations › 651 CMR - EXECUTIVE OFFICE OF ELDER AFFAIRS › Title 651 CMR 15.00 - Prescription Advantage Program › Section 15.16 - Fraud

Current through Register 1525, July 5, 2024
Any person who obtains coverage by knowingly and deliberately
				making false statements, suppressing facts, withholding information or making
				misrepresentations, commits fraud and is subject to recovery of the amount that
				the Plan has paid on that person's behalf and any other penalties permitted or
				prescribed by law. Those found to have committed fraud forfeit the right to
				re-join the Plan.
Code of Massachusetts Regulations › 651 CMR - EXECUTIVE OFFICE OF ELDER AFFAIRS › Title 651 CMR 15.00 - Prescription Advantage Program › Section 15.17 - Recovery

Current through Register 1525, July 5, 2024
The Plan may recover the cost of Covered Benefits that a Member
				was not entitled to receive, or for which a Member was not eligible, regardless
				of who was responsible for the overpayment and whether or not there was any
				fraudulent intent.
Code of Massachusetts Regulations › 651 CMR - EXECUTIVE OFFICE OF ELDER AFFAIRS › Title 651 CMR 16.00 - Home Care Worker Registry › Section 16.01 - Scope and Purpose

Current through Register 1525, July 5, 2024
651 CMR 16.00 sets forth the requirements for the creation,
				implementation, and administration of the Home Care Worker Registry in
				accordance with the provisions of St. 2017, c. 139.