130 CMR, § 403.409 - Clinical Eligibility Criteria for Home Health Services
(A)
Member Must Be under the Care
of a Physician or Ordering Non-physician Practitioner. The
MassHealth agency pays for home health services only if the member's physician
or ordering non-physician practitioner certifies the medical necessity for such
services and establishes an individual plan of care in accordance with
130 CMR
403.420. A member may receive home health
services only if he or she is under the care of a physician or ordering
non-physician practitioner. (A podiatrist may be considered a physician for the
purposes of meeting 130 CMR 403.409(A).) The physician or ordering
non-physician practitioner providing the certification of medical necessity and
submitting the plan of care for home health services must not be a physician or
ordering non-physician practitioner on the staff of, or under contract with,
the home health agency.
(B)
Limitations on Covered Services. The MassHealth agency
pays for home health services to a member who resides in a non-institutional
setting, which may include, without limitation, a homeless shelter or other
temporary residence or a community setting. In accordance with
42 CFR
440.70(c), the MassHealth
agency does not pay for home health services provided in a hospital, nursing
facility, intermediate care facility for the intellectually or developmentally
disabled, or any other institutional facility providing medical, nursing,
rehabilitative, or related care.
(C)
Medical Necessity
Requirement. In accordance with
130 CMR
450.204: Medical Necessity,
and MassHealth Guidelines for Medical Necessity Determination for Home Health
Services, the MassHealth agency pays for only those home health services that
are medically necessary. Home health services are not to be used for homemaker,
respite, or heavy cleaning or household repair.
(D)
Availability of Other
Caregivers. When a family member or other caregiver is providing
services, including nursing services, that adequately meet the member's needs,
it is not medically necessary for the home health agency to provide such
services.
(E)
Least
Costly Form of Care. The MassHealth agency pays for home health
agency services only when services are no more costly than medically comparable
care in an appropriate institution and the least costly form of comparable care
available in the community.
(F)
Safe Maintenance in the Community. The member's
physician or ordering non-physician practitioner and home health agency must
determine that the member can be maintained safely in the community.
(G)
Prior
Authorization. Home health services require prior authorization.
See
130
CMR 403.413 for requirements.
(H)
Continuous Skilled Nursing
(CSN) Services. For clinical eligibility criteria for CSN
services, see130 CMR 438.000: Continuous Skilled
Nursing Agency.
(1) the member meets
the criteria for nursing services as stated in
130 CMR
403.420;
(2) there is a clearly identifiable specific
medical need for a nursing visit of more than two continuous hours;
and
(3) prior authorization for CSN
services has been obtained from the MassHealth agency or its designee, in
accordance with
130 CMR
403.410.
(I)
Multiple-patient Care for CSN
Services.
(1) The MassHealth
agency pays for one nurse to provide CSN services simultaneously to more than
one member, but not more than three members if
(a) the members have been determined by the
MassHealth agency or its designee to meet the criteria listed at
130 CMR
403.420 and to require CSN
services;
(b) the members receive
services in the same physical location and during the same time
period;
(c) the MassHealth agency
or its designee has determined that it is appropriate for one nurse to provide
nursing services to the members simultaneously; and
(d) the home health agency has received a
separate prior authorization for each member as described in
130 CMR
403.410.
(2) Services provided pursuant to
130 CMR
403.410(C)(1) must be
billed by using the multiple-patient service code that reflects the number of
members receiving the services.
Notes
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