reglab/statecodes huggingface dataset:
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 406.000 - Pharmacy Services › Section 406.413 - Limitations on Coverage of Drugs

Current through Register 1525, July 5, 2024
(A)
Interchangeable Drug Products
. The MassHealth agency
			 pays no more for a brand-name interchangeable drug product than its generic
			 equivalent, unless
(1) the prescriber has
			 requested and received prior authorization from the MassHealth agency for a
			 nongeneric multiple-source drug (
see
130
			 CMR 406.422.); and
(2) the prescriber certified on the
			 prescription that the brand-name drug is
(a)
			 medically necessary and may not be substituted in a manner consistent with
			 Massachusetts Department of Public Health regulations, and with all other
			 applicable state and federal regulations; and
(b) is prescribed in the appropriate manner
			 (
e.g
., written or electronic) and consistent with
			 Massachusetts Department of Public Health regulations; or
(3) the MassHealth agency designates the
			 brand-name drug as preferred in the Brand-name Preferred section of the
			 MassHealth Drug List because the net cost of the brand-name drug after
			 consideration of all rebates, is less than the cost of the generic
			 equivalent.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 406.000 - Pharmacy Services › Section 406.421 - Drugs and Medical Supplies for Institutionalized Members

Current through Register 1525, July 5, 2024
(A) MassHealth pays for prescription drugs
			 provided to institutionalized members.
(B) MassHealth does not pay for
			 over-the-counter drugs or medical supplies provided to institutionalized
			 members, except in circumstances described in
			 130
			 CMR 406.421(C).
(C) MassHealth pays for insulin prescribed
			 for members who are residents of a nursing facility or rest home.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 406.000 - Pharmacy Services › Section 406.423 - Member Copayments

Current through Register 1525, July 5, 2024
Under certain conditions, the MassHealth agency requires that
				members make a copayment to the dispensing pharmacy for each original
				prescription and for each refill for all drugs (whether prescription or
				over-the-counter) covered by MassHealth. The copayment requirements are
				detailed in
				130
				CMR 450.130:
Copayments Required by
				the MassHealth Agency
.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 406.000 - Pharmacy Services › Section 406.424 - Cash Payments

Current through Register 1525, July 5, 2024
(A) No pharmacy
			 provider may solicit, charge, receive, or accept any money, gift, or other
			 consideration (including cash payments) from a member, or from any other person
			 on behalf of the member, for any drug for which payment is available under
			 MassHealth in accordance with
			 130
			 CMR 450.203:
Payment in
			 Full
, and nothing in
			 130
			 CMR 406.424 will relieve pharmacy providers
			 of their obligations under
			 130
			 CMR 450.203. Payment is considered to be
			 available under MassHealth even if a drug is subject to a quantity limit, dose
			 limit, or prior authorization requirement, or prospective drug utilization
			 review (PRO-DUR) edit, unless the prescriber has made diligent efforts to
			 secure prior authorization or the pharmacy or prescriber has sought a PRO-DUR
			 certification as applicable, and the MassHealth agency has denied prior
			 authorization for the drug as not medically necessary or denied PRO-DUR
			 certification.
(B) On the date of
			 service and prior to accepting any money, gift, or other consideration
			 (including cash payments) from a member, or from any other person on behalf of
			 the member, for any Schedule II-V drug (or other drug designated for reporting
			 to the Department of Public Health's Prescription Monitoring Program,
			 105
			 CMR 700.012(A):
Pharmacy Reporting Requirements
, listed on the MassHealth Drug
			 List for which payment is not available under MassHealth, a pharmacy must:
(1) verify that payment is not available from
			 MassHealth in at least one of the following ways:
(a) request and obtain verification from the
			 MassHealth agency Drug Utilization Review (DUR) Program that payment is not
			 available under MassHealth; or
(b)
			 request and obtain verification from the prescriber certifying that:
i. the prescriber made diligent efforts to
			 obtain prior authorization for the drug from the MassHealth agency; and
ii. the prescriber's prior
			 authorization request was denied by the MassHealth agency as not medically
			 necessary; or
(c) verify
			 that the drug is excluded from MassHealth coverage under
			 130
			 CMR 406.413(B).
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 406.000 - Pharmacy Services › Section 406.431 - Payment Rates

Current through Register 1525, July 5, 2024
Except as to drugs designated by Pharmacy Facts provider
				bulletin, or other written issuance from the MassHealth agency, the methods for
				determining payment of drugs are contained in
				101 CMR
				331.00:
Prescribed Drugs
. The methods
				for determining payment for medical supplies described in
				130
				CMR 406.412 are contained in
				101 CMR
				322.00:
Rates for Durable Medical Equipment,
				Oxygen, and Respiratory Therapy Equipment
and
				101 CMR
				317.00:
Rates for Medicine Services
.
				The methods for determining payment for services listed on the MassHealth
				Pharmacy Covered Professional Services List are contained in
				101 CMR
				317.00:
Medicine
. In the event of
				conflict between
				130 CMR
				406.000, and
				101 CMR
				331.00:
Prescribed Drugs
,
				101 CMR
				331.00:
Prescribed Drugs
shall
				govern.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 406.000 - Pharmacy Services › Section 406.436 - Disclosure of Information

Current through Register 1525, July 5, 2024
In order for the MassHealth agency to verify a pharmacy's
				compliance with
				101 CMR
				331.00:
Prescribed Drugs
, a pharmacy
				must, upon request, make available to the MassHealth agency for inspection and
				copying the following documentation:
(A) all prescriptions (for both members and
			 nonmembers) filled during the time period specified by the MassHealth agency
			 with the names of the patients and all other identifying information blocked
			 out;
(B) all documentation of a
			 drug's cost to the pharmacy provider, all documentation regarding the amount
			 the pharmacy provider has charged any entity, and the amount any purchaser or
			 reimburser has paid the pharmacy provider for any drug covered by MassHealth.
			 This must include, but is not limited to, all documentation used to calculate
			 charges billed to the MassHealth agency for any given date. In addition, all
			 reports, books, and records related to its operation must be available for
			 audit.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 406.000 - Pharmacy Services › Section 406.442 - Controlled Substance Management Program

Current through Register 1525, July 5, 2024
(A)
Introduction
. The MassHealth agency has established a
			 Controlled Substance Management Program for MassHealth members who over utilize
			 or improperly utilize prescribed drugs. Members in the Controlled Substance
			 Management Program are restricted to obtaining prescribed drugs only from the
			 provider that the MassHealth agency designates as the member's primary
			 pharmacy.
(B)
Criteria
			 for Member Enrollment
. The MassHealth agency may enroll in the
			 Controlled Substance Management Program those MassHealth members who meet one
			 of the following criteria:
(1) members whom
			 the MassHealth agency determines over-utilize or improperly utilize medications
			 in certain therapeutic classes, receive duplicative therapy from multiple
			 physicians, or frequently visit the hospital emergency department seeking pain
			 medications. The MassHealth Drug Utilization Program will identify criteria to
			 identify members for the Controlled Substances Management Program. These
			 criteria will be listed in the MassHealth Drug List; or
(2) members who were enrolled in the
			 Controlled Substance Management Program of a MassHealth-contracted managed care
			 organization (MCO) at the time the member disenrolled from the MCO. When the
			 MassHealth agency enrolls a member in the Controlled Substance Management
			 Program it notifies the member accordingly.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 406.000 - Pharmacy Services › Section 406.443 - Early and Periodic Screening, Diagnostic and Treatment (EPSDT) Services

Current through Register 1525, July 5, 2024
The MassHealth agency pays for all medically necessary acute
				outpatient hospital services for EPSDT-eligible members in accordance with
				130
				CMR 450.140 through
				450.149, without regard to
				service limitations described in
				130 CMR
				406.000, and with prior
				authorization.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 406.000 - Pharmacy Services › Section 406.446 - Prospective Drug Review and Counseling

Current through Register 1525, July 5, 2024
Pharmacies must offer prospective drug review and counseling
				consistent with the requirements in M.G.L. c. 94C, § 21A and
				247
				CMR 9.07:
Maintaining Patient
				Records, Conducting a Prospective Drug Utilization Review and Patient
				Counseling
. Only a patient's refusal of counseling must be documented,
				except as otherwise required under applicable state law.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 407.000 - Transportation Services › Section 407.401 - Introduction

Current through Register 1525, July 5, 2024
All transportation providers participating in MassHealth must
				comply with the regulations governing the MassHealth agency including, but not
				limited to, MassHealth regulations set forth in 130 CMR 407.000 and 450.000:
Administrative and Billing Regulations.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 407.000 - Transportation Services › Section 407.403 - Eligible Members

Current through Register 1525, July 5, 2024
(A)
(1)
MassHealth
			 Members
. The MassHealth agency covers transportation services only
			 when provided to eligible MassHealth members, subject to the restrictions and
			 limitations described in MassHealth regulations. The 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)
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 407.000 - Transportation Services › Section 407.404 - Early and Periodic Screening, Diagnostic and Treatment (EPSDT) Services

Current through Register 1525, July 5, 2024
The MassHealth agency pays for all medically necessary
				transportation 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 407.000, and with prior authorization.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 407.000 - Transportation Services › Section 407.406 - Provider Eligibility: Out-of-state

Current through Register 1525, July 5, 2024
In order to be eligible to receive payment from MassHealth, an
				out of state transportation provider must complete and submit an application to
				become an approved MassHealth provider; own, lease, or otherwise control, by
				means of a written agreement, vehicles required for the transportation services
				it seeks to provide; be a Medicare provider of any Medicare-covered services it
				seeks to provide; and be assigned a MassHealth provider number by the
				MassHealth agency. An out-of-state provider must have a valid license issued by
				the appropriate regulatory agency within its state to be approved as a
				MassHealth provider.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 407.000 - Transportation Services › Section 407.407 - Selective Contracting

Current through Register 1525, July 5, 2024
(A) In some
			 regions, the MassHealth agency may provide some or all transportation services
			 through selective contracts with brokers, such as regional transit authorities
			 or other transportation entities. In areas of the state where a selective
			 contract with a transportation broker is in effect, services are provided in
			 accordance with all applicable MassHealth regulations and the terms of the
			 contract.
(B) The MassHealth agency
			 may terminate, in whole or in part, or otherwise limit existing provider
			 agreements with transportation providers in those regions or for modes of
			 transportation for which selective contracts are in effect. In the event of any
			 such termination, the MassHealth agency notifies the affected providers in
			 writing, at least 30 days before termination. Such termination will not affect
			 payments to providers for services provided before the date of
			 termination.
(C) The MassHealth
			 agency informs eligible members of the availability of transportation services
			 through all applicable member handbooks. Additional information about
			 eligibility and the process for accessing transportation services can be
			 obtained by contacting MassHealth Customer Service. MassHealth may issue
			 provider bulletins to inform providers of services provided on a
			 fee-for-service basis and those provided pursuant to selective
			 contracts.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 407.000 - Transportation Services › Section 407.411 - Transportation Utilization Requirements

Current through Register 1525, July 5, 2024
(A)
Covered Services
. The MassHealth agency pays for
			 transportation services that meet the requirements of 130 CMR 407.000 only when
			 such services are covered under the member's MassHealth coverage type and only
			 when members are traveling to obtain medical services covered under the
			 member's coverage type
(see
130 CMR 450.105:
Coverage
			 Types').
(1) In the case of public
			 transportation, the MassHealth agency determines those medical services that
			 are covered by MassHealth.
(2) In
			 the case of fee-for-service ambulance and wheelchair van transportation, it is
			 the responsibility of the transportation provider to judge which medical
			 services are covered by MassHealth and to advise the member in cases where
			 transportation is requested to a service that, in the provider's judgment, may
			 not be or is not covered by MassHealth. If a member is in doubt as to whether
			 or not a medical service is covered by MassHealth, the member should contact
			 the MassHealth agency.
(3) In the
			 case of brokered transportation, the MassHealth agency determines those
			 services that are covered by MassHealth.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 407.000 - Transportation Services › Section 407.421 - Authorization for Transportation

Current through Register 1525, July 5, 2024
(A)
Types of Authorization
.
(1) All forms of transportation, except
			 public transportation, require authorization consisting of one or more of the
			 following:
(a) verbal authorization for
			 transportation following submission of a Provider Request for Transportation
			 (PT-1) as described in 130 CMR 407.421(A)(1)(b) or when urgent care is
			 needed;
(b) a Provider Request for
			 Transportation (PT-1) completed in accordance with 130 CMR 407.421(C) submitted
			 by an authorized provider, a day habilitation program representative, an early
			 intervention program representative, or a managed-care representative, and
			 approved by MassHealth; or
(c) a
			 Medical Necessity Form completed in accordance with 130 CMR 407.421(D) and
			 signed by an authorized provider or a managed-care representative, or, only for
			 members transported for hospitalization under M.G.L. c. 123, § 12, a
			 completed and signed Department of Mental Health Application for and
			 Authorization of Temporary Involuntary Hospitalization.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 407.000 - Transportation Services › Section 407.431 - Reimbursement to Members for Transportation Expenses

Current through Register 1525, July 5, 2024
(A)
Reimbursable
			 Expenses
. Members may obtain direct reimbursement from the
			 MassHealth agency in accordance with 130 CMR 407.431(B) for public
			 transportation expenses that the member incurred when traveling to services
			 covered by MassHealth.
(B)
Method and Amount of Reimbursement
.
(1) In order to obtain reimbursement for
			 public transportation expenses, a member must obtain documentation from an
			 authorized provider, a day habilitation program representative, an early
			 intervention program representative, a managed-care representative, a
			 registered nurse, a licensed practical nurse, a social worker, a case manager,
			 or another medical professional who provided services for which the member
			 seeks reimbursement of public transportation costs. The documentation must
			 demonstrate that medical services covered by MassHealth were received, identify
			 the date on which medical services were received, and identify the specific
			 address where medical services were received. In cases where urgent care is
			 needed, the documentation must also state the time medical services were
			 received. Transportation receipts are also required when available. The member
			 must submit documentation and receipts to the MassHealth agency and request
			 reimbursement for public transportation expenses.
(2) Transportation costs must total $5.00 or
			 more in order for the member to request reimbursement. The member must submit a
			 request for reimbursement no later than 90 days after the earliest date on
			 which transportation costs in excess of $5.00 occurred.
(3) If a member traveled outside his or her
			 locality, the documentation must state the medical services that were needed
			 and that could not be obtained locally. If a member traveled outside his or her
			 locality when necessary medical services were available locally, transportation
			 costs incurred are not reimbursable unless authorized by the MassHealth
			 agency.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 407.000 - Transportation Services › Section 407.432 - Payment to Providers for Transportation Services

Current through Register 1525, July 5, 2024
(A)
Amount of
			 Payment
. Payment for transportation is made directly to providers
			 of services except in the circumstances specified in 130 CMR 407.431 or
			 407.432(B). Payment for brokered transportation is made in accordance with the
			 terms of the selective contract. In all other cases, payment is made in
			 accordance with 101 CMR 327.00:
Rates of Payment for Ambulance and
			 Wheelchair Van Services.
When a member and an individual who is not a
			 member or an escort are transported together, the member is considered the
			 "additional person" for billing purposes.
(B)
Payment
			 Limitations
. The MassHealth agency does not pay a provider of
			 transportation services other than a transportation broker for services other
			 than those identified in 130 CMR 407.471(A)(2), 407.481(A) and 407.491(A) when
			 provided to MassHealth members who reside in an area of the state where a
			 selective contract with a transportation broker is in effect, unless the
			 MassHealth agency determines that
(1) the
			 transportation service is not available through the selective contract;
			 or
(2) the transportation service
			 available through the provider is more appropriate for the particular member
			 than the transportation service available through the transportation
			 broker.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 407.000 - Transportation Services › Section 407.471 - Nonemergency Wheelchair Van

Current through Register 1525, July 5, 2024
(A)
Criteria for Use
.
(1) Wheelchair van services may be provided
			 only in nonemergencies to the following persons:
(a) MassHealth members who use
			 wheelchairs;
(b) MassHealth members
			 who need to be carried up or down stairs (because they are unable to walk up or
			 down stairs or cannot walk without the assistance of two persons);
(c) MassHealth members whose severe mobility
			 handicaps prevent them from using public transportation or brokered
			 transportation in a sedan; and
(d)
			 MassHealth members who are being transported by a fee-for-service provider, who
			 are being discharged from inpatient psychiatric hospitals to community-based
			 behavioral health programs, and who require supervision during transportation,
			 when PT-1 transportation is unavailable or inappropriate.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 407.000 - Transportation Services › Section 407.481 - Ambulance

Current through Register 1525, July 5, 2024
(A)
Criteria for Use
.
(1)
Emergency
			 Situations
. Ambulance services are always covered in emergency
			 situations. An emergency situation is defined as one in which the member has a
			 critical or unknown illness or injury that apparently demands immediate medical
			 attention at a hospital to prevent permanent injury or loss of life. Emergency
			 cases must be transported to the nearest medical facility equipped for and
			 capable of treating such emergency cases.
(2)
Nonemergency
			 Situations
. In nonemergency situations, ambulance services are
			 covered when medically necessary as set forth in 130 CMR 407.481(B). The return
			 trip of an emergency transport is considered to be a nonemergency
			 situation.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 407.000 - Transportation Services › Section 407.491 - Other Licensed Carriers

Current through Register 1525, July 5, 2024
(A)
Criteria for Use
. The MassHealth agency pays for
			 services provided by a licensed carrier in the following circumstances:
(1) when there is no transportation provider
			 in the member's locality or when it is less expensive to use a licensed carrier
			 (for example, train) than a transportation provider;
(2) when the member is traveling to
			 specialized medical care that is a great distance from home and has obtained
			 approval from the MassHealth agency; or
(3) when the member lives on an island
			 accessible only by boat or airplane.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 408.000 - Adult Foster Care Services › Section 408.401 - Introduction

Current through Register 1525, July 5, 2024
130 CMR 408.000 governs adult foster care services and group
				adult foster care services provided under MassHealth. All adult foster care
				providers and group adult foster care providers participating in MassHealth
				must comply with 130 CMR 408.000 and 130 CMR 450.000:
Administrative
				and Billing Regulations
. Adult foster care services are governed by
				130
				CMR 408.402 through
				408.439. Group adult foster
				care services are governed by
				130
				CMR 408.502 through
				408.527.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 408.000 - Adult Foster Care Services › Section 408.403 - Eligible Members

Current through Register 1525, July 5, 2024
(A)
MassHealth Members
. MassHealth-eligible members 16
			 years of age or older, subject to the restrictions and limitations described in
			 130
			 CMR 450.105:
Coverage Types
that specifies, for each MassHealth coverage type, which services are covered
			 and which members are eligible to receive those services.
(B)
Recipients of 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
.
(C)
MassHealth Member Eligibility
			 and Coverage Type
. For information on verifying MassHealth member
			 eligibility and coverage type,
see
130
			 CMR 450.107:
Eligible Members and the
			 MassHealth Card
.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 408.000 - Adult Foster Care Services › Section 408.404 - Provider Eligibility

Current through Register 1525, July 5, 2024
(A) An organization
			 seeking to participate in MassHealth as an AFC provider must
(1) enter into a contract with the MassHealth
			 agency;
(2) maintain a business
			 office in Massachusetts and be duly authorized to conduct a business in
			 Massachusetts that delivers health and human services to elders or people with
			 disabilities. Such business offices must:
(a)
			 be available to members during regular, posted business hours;
(b) be physically accessible to members with
			 disabilities;
(c) have clear access
			 and space for storing of business records;
(d) have a sign visible from outside the
			 facility identifying the business name and hours that the business office is
			 open;
(e) have a publicly listed
			 business name, address, and local toll-free telephone number that is answered
			 by customer service staff during business hours and that has Telecommunication
			 Device for the Deaf/Teletype (TTY/TDD) transmission and reception capability;
			 provided, that during business hours, this number cannot be a pager, answering
			 service, voice message system, or cell phone; and
(f) maintain a 24-hour voice message
			 system;
(3) accept
			 MassHealth payments as payment in full for all AFC;
(4) establish, maintain, and comply with
			 written policies and procedures to comply with 130 CMR 408.000;
(5) agree to periodic inspections, by the
			 MassHealth agency or its designee, that assess the quality of member care and
			 ensure compliance with 130 CMR 408.000;
(6) agree to comply with all the provisions
			 of 130 CMR 408.000, 450.000:
Administrative and Billing
			 Regulations
, and all other applicable MassHealth rules and
			 regulations.
(7) participate in any
			 AFC provider orientation required by EOHHS;
(8) meet all provider participation
			 requirements described in 130 CMR 408.000 and 130 CMR 450.000:
Administrative and Billing Regulations
;
(9) agree to pay AFC caregivers on a timely
			 basis for services provided at applicable compensation levels.
(10) be accredited by the National Committee
			 for Quality Assurance (NCQA), the Council on Accreditation (COA), the
			 Commission on Accreditation of Rehabilitation Facilities (CARF), or other
			 nationally recognized accreditation organizations determined acceptable by the
			 MassHealth agency. AFC providers must provide evidence of accreditation in
			 accordance with
			 130
			 CMR 408.404(A)(10) in the
			 form and format as required by the MassHealth agency; and
(11) submit to the MassHealth agency or its
			 designee a statement of fiscal soundness attesting to the financial viability
			 of the AFC provider supported by documentation to demonstrate that the provider
			 has adequate resources to finance the provision of services in accordance with
			 130 CMR 408.000 in the form and format as required by the MassHealth
			 agency.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 408.000 - Adult Foster Care Services › Section 408.416 - Clinical Eligibility Criteria for AFC

Current through Register 1525, July 5, 2024
A member must meet the following clinical eligibility criteria
				for receipt of AFC.
(A) AFC must be
			 ordered by the member's PCP.
(B)
			 The member has a medical or mental condition that requires daily hands-on
			 (physical) assistance or cueing and supervision throughout the entire activity
			 in order for the member to successfully complete at least one of the following
			 activities:
(1) Bathing - a full-body bath or
			 shower or a sponge (partial) bath that may include washing and drying of face,
			 chest, axillae (underarms), arms, hands, abdomen, back and peri-area that may
			 include personal hygiene such as: combing or brushing of hair, oral care
			 (including denture care and brushing of teeth), shaving, and, when applicable,
			 applying make-up;
(2) Dressing -
			 upper and lower body, including street clothes and undergarments, but not
			 solely help with shoes, socks, buttons, snaps, or zippers;
(3) Toileting - member is incontinent
			 (bladder or bowel) or requires assistance or routine catheter or colostomy
			 care;
(4) Transferring - member
			 must be assisted or lifted to another position;
(5) Mobility (ambulation) - member must be
			 physically steadied, assisted, or guided during ambulation indoors and
			 outdoors, or is unable to self-propel a wheelchair appropriately without the
			 assistance of another person; and
(6) Eating - if the member requires constant
			 supervision and cueing during the entire meal, or physical assistance with
			 consuming a portion or all of the meal.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 408.000 - Adult Foster Care Services › Section 408.417 - Clinical Assessment and Prior Authorization

Current through Register 1525, July 5, 2024
(A)
Clinical Assessment
. As part of the prior
			 authorization process, members seeking AFC must undergo a clinical assessment
			 to assess the member's clinical status and need for AFC. Completed clinical
			 assessment documentation must be submitted to MassHealth, or its designee, in
			 the form and format requested by the MassHealth agency. A new clinical
			 assessment is required annually and upon significant change.
(B)
Prior
			 Authorization
.
(1) As a
			 prerequisite for payment of AFC, the AFC provider must obtain prior
			 authorization from the MassHealth agency or its designee before the first date
			 of service delivery and annually thereafter, and upon significant
			 change.
(2) Prior authorization
			 determines the medical necessity for AFC as described under
			 130
			 CMR 408.416 and in accordance with
			 130
			 CMR 450.204:
Medical
			 Necessity
.
(3) Prior
			 authorization may specify the service level for payment for the
			 service.
(4) Prior authorization
			 does not establish or waive any other prerequisites for payment such as the
			 member's financial eligibility described in
			 130 CMR
			 503.007:
Potential Sources of Health
			 Care and
130 CMR
			 517.008
: Potential Sources of Health
			 Care
.
(5) When submitting
			 a request for prior authorization for payment of AFC to the MassHealth agency,
			 or its designee, the AFC provider must submit requests in the form and format
			 as required by the MassHealth agency. The AFC provider must include all
			 required information including, but not limited to, documentation of the
			 completed clinical assessment conducted by the MassHealth agency or its
			 designee; other nursing, medical or psychosocial evaluations or assessments;
			 and any other documentation that the MassHealth agency, or its designee,
			 requests in order to complete the review and determination of prior
			 authorization.
(6) In making its
			 prior authorization determination, the MassHealth agency or its designee, may
			 require additional assessments of the member or require other necessary
			 information in support of the request for prior authorization.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 408.000 - Adult Foster Care Services › Section 408.418 - Quality Management

Current through Register 1525, July 5, 2024
AFC providers must participate in any quality management and
				program integrity processes established by the MassHealth agency, including
				making any necessary data available and access to visit the provider's place of
				business upon request by the MassHealth agency or its
				designee.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 408.000 - Adult Foster Care Services › Section 408.419 - Conditions for Payment

Current through Register 1525, July 5, 2024
(A) The MassHealth
			 agency pays an AFC provider for AFC in accordance with the applicable payment
			 methodology and rate schedule established by the EOHHS. Rates of payment for
			 AFC do not cover or include any amount for room and board.
(B) Payment for AFC is subject to the
			 conditions, exclusions, and limitations set forth in
			 130 CMR
			 408.000 and
			 130 CMR 450.000:
Administrative and Billing Regulations
.
(C) The MassHealth agency pays an AFC
			 provider for AFC only if
(1) the person
			 receiving AFC is eligible under
			 130 CMR
			 408.403;
(2) the member meets the clinical eligibility
			 criteria for AFC in accordance with
			 130 CMR
			 408.416;
(3) the AFC provider has obtained prior
			 authorization for AFC in accordance with130 CMR
			 408.417.
(4) the member resides in an AFC-qualified
			 setting in accordance with
			 130 CMR
			 408.435;
(5) the AFC provider bills at the payment
			 level authorized by the MassHealth agency or its designee; and
(6) the AFC provider is not billing for days
			 that are non-covered days under
			 130 CMR
			 408.437.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 408.000 - Adult Foster Care Services › Section 408.430 - Adult Foster Care Provider Responsibilities

Current through Register 1525, July 5, 2024
In addition to meeting all of the qualifications set forth in
				130 CMR 408.000 and 130 CMR 450.000:
Administrative and Billing
				Regulations
, the AFC provider must meet all of the following
				requirements.
(A)
Policies
			 and Procedures Manual
. Each AFC provider must develop, maintain,
			 annually review, and update a comprehensive policies and procedures manual
			 governing the delivery of AFC services. Each manual at a minimum must contain a
			 mission statement; the goals and objectives of the program; an organizational
			 chart describing the lines of authority and communication needed to manage the
			 AFC program, including the lines of authority for delegation of responsibility
			 down to the member care level; job descriptions that include titles, reporting
			 authority, qualifications, and responsibilities; and a description of the
			 governing body. Additionally, each policy and procedure manual must contain the
			 following:
(1) administrative policies and
			 procedures including, but not limited to:
(a)
			 human resource and personnel;
(b)
			 staff and staffing requirements;
(c) backup staff in the event coverage is
			 required due to illness, vacation, or other reasons;
(d) staff education and training;
(e) AFC provider staff evaluation and
			 monitoring;
(f) emergencies,
			 including fire, safety and disasters, including notifying the fire department
			 and police in emergencies and relocating members during an emergency;
(g) MassHealth basics and member
			 rights;
(h) human rights and
			 nondiscrimination;
(i) incident and
			 accident reporting;
(j) alternative
			 caregiver and/or arrangements for members when the AFC caregiver is temporarily
			 absent or temporarily unable to provide care;
(k) staff, AFC caregiver, and member
			 grievances;
(l) cultural
			 competency;
(m) quality assurance
			 and improvement;
(n) caregiver
			 training;
(o) emergency services
			 and plans;
(p) first aid and
			 cardiopulmonary resuscitation requirements;
(q) Health Insurance Portability and
			 Accountability Act (HIPAA);
(r)
			 coordination of AFC with other services the member is receiving; and
(s) procedures to be followed if a member is
			 missing or lost; and
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 408.000 - Adult Foster Care Services › Section 408.431 - Preadmission and Admission Procedures

Current through Register 1525, July 5, 2024
(A)
Preadmission Procedures and Activities
.
(1)
Preadmission
			 Procedures
. Before admitting a member in AFC, the AFC provider
			 must perform all of the activities in
			 130
			 CMR 408.431(A)(2). Intake
			 and assessment services are provided to members seeking admission to AFC but
			 who may have not yet received prior authorization by the MassHealth agency or
			 its designee, for AFC. The AFC provider must conduct a preadmission meeting
			 with the member, and if applicable or requested, the member's family, other
			 informal caregivers, and any other health or social service provider involved
			 in the member's care. The nurse must determine that the AFC provider is able to
			 meet all of the ADL and IADL needs of the member prior to admitting the member
			 to AFC, as well as use the meeting to obtain information about the member's
			 overall health characteristics, psychosocial condition, nutritional habits,
			 financial and health insurance information, housing situation, formal and
			 informal supports in place, and ethnic and cultural background. The AFC
			 provider must also use this meeting to inform the member and the member's
			 family about the scope of AFC to be provided and any other relevant
			 information;
(2)
Preadmission Activities
. Prior to admitting the
			 member, the AFC provider must perform the following intake and assessment
			 services:
(a) conduct clinical evaluations of
			 the need for AFC;
(b) review and
			 approve AFC caregiver applicants;
(c) instruct members on the rules, policies,
			 and procedures of the AFC program;
(d) identify appropriate potential AFC
			 caregivers and qualified settings, including conducting on-site interviews in
			 the qualified setting;
(e) schedule
			 meetings with the member or responsible party and potential AFC
			 caregiver;
(f) match the member
			 with the most appropriate potential AFC caregiver;
(g) provide information on the member's
			 rights and responsibilities when receiving AFC services;
(h) provide instruction and initial training
			 of AFC caregivers; and
(i) schedule
			 the member's move-in date with the AFC caregiver in circumstances in which the
			 member is moving into the AFC caregiver's home.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 408.000 - Adult Foster Care Services › Section 408.432 - Discharge Procedures

Current through Register 1525, July 5, 2024
(A) A member must be
			 discharged by the AFC provider upon the member's request, or if the member
			 ceases to benefit from AFC, including the following circumstances:
(1) the member no longer meets the clinical
			 eligibility criteria for AFC;
(2)
			 the member demonstrates behavioral or other problems that may endanger the
			 member, the AFC caregiver, or AFC provider staff;
(3) the member's clinical needs are beyond
			 the scope of AFC;
(4) the member's
			 needs cannot be met by the AFC provider;
(5) the member does not reside in an
			 AFC-qualified setting;
(6) the
			 member selects another service that is duplicative of AFC; or
(7) the member transitions to another AFC
			 provider.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 408.000 - Adult Foster Care Services › Section 408.433 - Adult Foster Care Staff Qualifications and Responsibilities

Current through Register 1525, July 5, 2024
All staff directly employed by the AFC provider, as well as any
				contract staff,
per diem
staff, backup staff, or anyone
				providing AFC on behalf of the AFC provider to members must meet the following
				requirements.
(A)
General
			 Staff Requirements
.
(1) Prior to
			 hiring or contracting with any staff the AFC provider must:
(a) check the candidate's references and job
			 history and ensure that the candidate meets all of the required experience,
			 education, and qualifications;
(b)
			 conduct a Criminal Offender Records Information (CORI) check and determine
			 whether any offender records may disqualify the individual for
			 employment;
(c) conduct a Sex
			 Offender Registry Information (SORI) check;
(d) conduct Office of Inspector General (OIG)
			 check;
(e) conduct licenses and
			 certification checks and validate that the candidate has obtained all necessary
			 licenses and certifications and that all licenses and certifications are
			 current;
(f) ensure that each AFC
			 staff person is not related to or legally responsible for the member receiving
			 AFC; and
(g) ensure that each AFC
			 registered nurse, licensed practical nurse, care manager, and AFC community
			 support specialist has received a tuberculosis screening within the previous 12
			 months;
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 408.000 - Adult Foster Care Services › Section 408.434 - Adult Foster Care Caregiver Qualifications and Responsibilities

Current through Register 1525, July 5, 2024
(A)
General
			 Requirements
. The AFC provider must
(1) uniformly administer an evaluation of all
			 prospective AFC caregivers to ensure that the individuals meet all of the
			 necessary qualifications defined in
			 130
			 CMR 408.434(B);
(2) conduct a Criminal Offender Records
			 Information (CORI) check and determine whether any offender records may
			 disqualify the individual from performing as an AFC caregiver;
(3) conduct a Sex Offender Registry
			 Information (SORI) check;
(4)
			 conduct Office of Inspector General (OIG) check;
(5) ensure that each AFC caregiver has
			 received a tuberculosis screening within the prior 12 months, and thereafter
			 every two years in accordance with current guidelines issued by the Centers for
			 Disease Control and Prevention (CDC) and Massachusetts Department of Public
			 Health;
(6) ensure that the AFC
			 caregiver is not serving more than a total of three persons, no more than two
			 of whom are authorized for AFC level II service payment, in the qualified
			 setting regardless of service provided or payer source;
(7) ensure that all AFC caregivers are
			 appropriately trained and managed; and
(8) ensure that the AFC caregiver is in the
			 qualified setting to provide the appropriate amount of necessary care to meet
			 the member's needs.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 408.000 - Adult Foster Care Services › Section 408.435 - Adult Foster Care Qualified Setting Requirements

Current through Register 1525, July 5, 2024
Any residence where AFC is provided must be qualified by the
				AFC provider and meet the setting requirements of
				130
				CMR 408.435.
(A) The qualified setting must be
(1) a private residence located in
			 Massachusetts, occupied by the AFC caregiver, and not subject to state
			 licensure or certification as a hospital, nursing facility, resident care
			 facility, group home, ICF/IID Disability, or ALR;
(2) accessible to meet the specific needs of
			 its residents, including the specific needs of any member with physical
			 disabilities. The provider may consult the Architectural Access Board
			 guidelines;
(3) compliant with
			 local health, fire, safety, occupancy, and state building codes for dwelling
			 units in accordance with 780 CMR 1.00:
Board of Building Regulations
			 and Standards
;
(4)
			 equipped with appropriate safety equipment including, at a minimum, an easily
			 accessible Class ABC fire extinguisher, smoke and carbon monoxide detectors,
			 and a first-aid kit on the premises;
(5) adequately heated and clean;
(6) in good repair, with the exterior of the
			 residence showing adequate maintenance in regard to paint, stairs, railings,
			 windows, screens, storm windows, and grounds; and
(7) occupied by no more than three persons
			 receiving services from the AFC caregiver, no more than two of whom are
			 authorized for AFC level II service payment, regardless of services provided or
			 payer source.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 408.000 - Adult Foster Care Services › Section 408.436 - Emergency Services and Plans

Current through Register 1525, July 5, 2024
The AFC provider must establish written plans for medical and
				other emergencies. Emergency plans must include, at a minimum, the
				following:
(A) an easily accessible
			 emergency plan for each member listing the member's name, telephone number of
			 the member's physician, special medical needs, including treatments and
			 medications, and emergency phone numbers for notification of the family or
			 legal guardian as specified in 408.430(C)(8), and contact information for an
			 alternative caregiver, if identified, and a primary contact person who is able
			 to address the member's needs and available if an unforeseen event occurs that
			 prevents the member's AFC caregiver from providing services;
(B) a written plan for emergency staff
			 coverage;
(C) a written plan for
			 emergency care and service in the event a member is displaced for any
			 reason;
(D) a written Continuity of
			 Operations Plan that follows the guidelines from the Department of Public
			 Health; and
(E) a written disaster
			 plan for evacuating the qualified setting in the event of a fire, flood, or
			 other natural or unnatural disaster.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 408.000 - Adult Foster Care Services › Section 408.437 - Non-covered Days

Current through Register 1525, July 5, 2024
The MassHealth agency does not pay an AFC provider when
(A) the member is receiving any other
			 personal care services including, but not limited to, personal care services
			 under 130 CMR 422.000:
Personal Care Attendant
			 Services
;
(B) the member
			 receives home health aide services provided by a home health agency under 130
			 CMR 403.000:
Home Health Agency
;
(C) the member is a resident or inpatient of
			 a hospital, nursing facility (with the exception of MLOA days), resident care
			 facility, ICF/IID, ALR, or any other residential facility subject to state
			 licensure or certification;
(D) the
			 AFC provider has not received prior authorization from the MassHealth agency;
			 or
(E) the provider is seeking
			 payment for alternative caregiver days in excess of 14 days within a calendar
			 year, or payment for NMLOA days in excess of 15 days within a calendar year, or
			 payment for MLOA days in excess of 40 days within a calendar year.