Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 403.000 - Home Health Agency › Section 403.414 - Complex Community Care Management Services

Current through Register 1525, July 5, 2024
For complex-care members, as defined in
				130 CMR 403.402, the
				MassHealth agency or its designee provides care management that includes
				service coordination with home health agencies as appropriate. The purpose of
				care management is to ensure that complex-care members are provided with a
				coordinated LTSS service plan that meets such members' individual needs, avoids
				duplicative services, and ensures that the MassHealth agency pays for home
				health and other LTSS only if they are medically necessary in accordance with
				130 CMR
				403.409(C). The MassHealth
				member eligibility verification system identifies complex-care members.
(A)
Care Management
			 Activities
.
(1)
Enrollment
. The MassHealth agency or its designee
			 automatically assigns a clinical manager to members whom it has determined
			 require a nurse visit of more than two continuous hours of nursing, and informs
			 such members of the name, telephone number, and role of the assigned clinical
			 manager.
(2)
Comprehensive Needs Assessment
. The clinical manager
			 performs an in-person visit with the member to evaluate whether the member
			 meets the criteria to be a complex-care member as described in
			 130 CMR 403.402. If
			 the member is determined to meet the criteria for a complex-care member, the
			 clinical manager will complete a comprehensive needs assessment. The
			 comprehensive needs assessment identifies
(a)
			 services that are medically necessary, covered by MassHealth, and required by
			 the member to remain safely in the community;
(b) services the member is currently
			 receiving; and
(c) any other case
			 management activities in which the member participates.
(3)
Service Record
.
			 The clinical manager
(a) develops a service
			 record, in consultation with the member, the primary caregiver, and where
			 appropriate, the home health agency and the member's physician, that
1. lists those MassHealth-covered services to
			 be authorized by the clinical manager;
2. describes the scope and duration of each
			 service;
3. lists service
			 arrangements approved by the member or the member's primary caregiver;
			 and
4. informs the member of his or
			 her right to a hearing, as described in
			 130 CMR
			 403.411;
(b) provides to the member copies of the
			 service record, one copy of which the member or the member's primary caregiver
			 must sign and return to the clinical manager. On the copy being returned, the
			 member must indicate whether he or she accepts or rejects each service as
			 offered and that he or she has been notified of the right to appeal and
			 provided an appeal form; and
(c)
			 provides to the home health agency information from the service record that is
			 applicable to the home health agency.
(4)
Service
			 Authorizations
. The clinical manager authorizes those LTSS in the
			 service record, including home health, that require prior authorization (PA) as
			 provided in
			 130 CMR
			 403.410, and that are medically necessary,
			 and coordinates all home health services and any subsequent changes with the
			 home health agency.
(5)
Discharge Planning
. The clinical manager may
			 participate in member hospital discharge planning meetings as necessary to
			 ensure that LTSS medically necessary to discharge the member from the hospital
			 to the community are authorized and to provide coordination with all other
			 identified third-party payers.
(6)
Service Coordination
. The clinical manager works
			 collaboratively with any identified case managers assigned to the
			 member.
(7)
Clinical
			 Manager Follow-up and Reassessment
. The clinical manager provides
			 ongoing care management for members, and in coordination with the home health
			 agency, to
(a) determine whether the member
			 continues to be a complex-care member; and
(b) reassess whether services in the service
			 record are appropriate to meet the member's needs.