Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 438.000 - Continuous Skilled Nursing Agency › Section 438.414 - Administrative Care Management

Current through Register 1525, July 5, 2024
For complex care members, as defined in
				130
				CMR 438.402, the MassHealth agency or its
				designee provides administrative care management that includes service
				coordination with CSN agencies as appropriate. The purpose of administrative
				care management is to ensure that a complex care member is provided with a
				coordinated LTSS package that meets the member's individual needs and to ensure
				that the MassHealth agency pays for nursing, complex care assistant services,
				and other community LTSS only if medically necessary in accordance with
				130
				CMR 450.204:
Medical
				Necessity
. 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 who may 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)
LTSS 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 at
			 130
			 CMR 438.402 and
			 438.410(B).
			 If the member is determined to meet the criteria as a complex care member, the
			 clinical manager will complete a LTSS Needs Assessment. The LTSS Needs
			 Assessment will include input from the member, the member's caregiver, if
			 applicable, LTSS providers, and other treating clinicians. The LTSS Needs
			 Assessment will identify
(a) skilled and
			 unskilled care needs within a 24-hour period;
(b) current medications the member is
			 receiving;
(c) durable medical
			 equipment currently available to the member;
(d) services the member is currently
			 receiving in the home and in the community; and (e) any other case management
			 activities in which the member participates.
(3)
Service Record
.
			 The clinical manager
(a) develops a service
			 record, in consultation with the member, the member's primary caregiver, and
			 where appropriate, the CSN agency and the member's physician or ordering
			 non-physician practitioner, that
1. lists
			 those LTSS services that are medically necessary, covered by MassHealth, and
			 required by the member to remain safely in the community, and to be authorized
			 by the clinical manager;
2.
			 describes the scope and duration of each service;
3. lists other sources of payment
			 (
e.g
., TPL, Medicare, DDS, AFC); and
4. informs the member of his or her right to
			 a hearing, as described at
			 130
			 CMR 438.414.
(b) provides the member with copies of
1. the service record, one copy of which the
			 member or the member's primary caregiver is requested to sign and return to the
			 clinical manager. On the copy being returned, the member or the member's
			 primary caregiver should 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
2.
			 the LTSS Needs Assessment.
(c) provides information to the CSN agency
			 about services authorized in the service record that are applicable to the CSN
			 agency.
(4)
Service Authorizations
. MassHealth or its designee
			 will authorize those LTSS in the service record, including nursing and complex
			 care assistant services, that require prior authorization and that are
			 medically necessary, as provided in
			 130
			 CMR 438.412, and coordinate all nursing
			 services and complex care assistant services, any applicable home health agency
			 services, and any subsequent changes with the CSN agency, home health agency or
			 independent nurse prior authorization, as applicable. MassHealth or its
			 designee may also authorize other medically necessary LTSS including, but not
			 limited to, personal care attendant (PCA) services, therapy services, durable
			 medical equipment (DME), oxygen and respiratory therapy equipment, and
			 prosthetic and orthotics.
(5)
Discharge Planning
. The clinical manager may
			 participate in member hospital discharge-planning meetings as necessary to
			 ensure that medically necessary LTSS necessary to discharge the member from the
			 hospital to the community are authorized and to identify third-party
			 payers.
(6)
Service
			 Coordination
. The clinical manager will work collaboratively with
			 any other identified case managers assigned to the member.
(7)
Clinical Manager Follow-up
			 and Reassessment
. The clinical manager will provide ongoing care
			 management for members to
(a) determine
			 whether the member continues to meet the definition of a complex care member;
			 and
(b) reassess whether services
			 in the service record are appropriate to meet the member's needs.