130 CMR, § 435.412 - Reimbursable Administrative Days

(A) For members younger than 21 years old, the MassHealth agency will pay a hospital for up to 30 administrative days for each admission or each continued stay resulting from a conversion, as defined in 130 CMR 435.402. The MassHealth agency may pay a hospital for administrative days exceeding the 30-day limit for members younger than 21 years old, when the hospital can demonstrate to the satisfaction of the MassHealth agency or its agent, that the hospital has

(1) experienced extraordinary difficulty in placing the member, including the specific reasons for such extraordinary difficulty; and

(2) exhaustively explored all potential appropriate placements.

(B) For members 21 years of age or older, the MassHealth agency will pay a hospital for administrative days for each admission or each continued stay resulting from a conversion, as defined in 130 CMR 435.402 only if they occur after the 45-day period described in 130 CMR 435.407(G) and where the hospital can demonstrate to the satisfaction of the MassHealth agency or its agent that the hospital has

(1) experienced extraordinary difficulty in placing the member, including the specific reasons for such extraordinary difficulty; and

(2) exhaustively explored all potential appropriate placements.

(C) An administrative day, as defined in 130 CMR 435.402, is reimbursable after the 45-day period described in 130 CMR 435.407(G) only if a hospital is making regular efforts to discharge the member to the appropriate setting. These efforts must be documented according to the procedures described in 130 CMR 450.205: Recordkeeping and Disclosure. The regulations covering discharge-planning standards described in 130 CMR 435.417 must be followed, but they do not preclude additional, effective discharge-planning activities.

(D) Examples of situations that may require hospital stays at less than a hospital level of care include, but are not limited to, the following.

(1) A member is awaiting transfer to a nursing facility or any other institutional placement, and no appropriate nursing-facility bed is available.

(2) A member is awaiting arrangement of home services (nursing, home health aide, durable medical equipment, personal care attendant, therapies, or other community-based services).

(3) A member is awaiting arrangement of residential, social, psychiatric, or medical services by a public or private agency.

(4) A member is awaiting results of a report of abuse or neglect made to any public agency charged with the investigation of such reports.

(5) A member in the custody of the Department of Children and Families is awaiting foster care when other temporary living arrangements are unavailable or inappropriate.

(6) A member cannot be treated or maintained at home because the primary caregiver is absent due to a medical or psychiatric crisis, and a substitute caregiver is not available.

(7) A member is awaiting a discharge from the hospital and is receiving skilled nursing or other skilled services. Skilled services include, but are not limited to the following:

(a) maintenance of tube feedings;

(b) ventilator management;

(c) dressings, irrigations, packing, and other wound treatments;

(d) routine administration of medications;

(e) provision of therapies, such as respiratory, speech, physical, and occupational;

(f) insertion, irrigation, and replacement of catheters; and

(g) intravenous, intramuscular, or subcutaneous injections, or intravenous feedings (for example, total parenteral nutrition).

Notes

130 CMR, § 435.412

Amended by Mass Register Issue 1302, eff. 12/18/2015.