Section 414.409 - Conditions of Payment(A)Place of Service. The MassHealth agency pays for nursing services to a member who meets the clinical criteria in 130 CMR 414.408 and resides in a noninstitutional 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 nursing services provided in a hospital, nursing facility, intermediate care facility for the mentally retarded, or any other institutional setting providing medical, nursing, rehabilitative, or related care.(B)Service Limitation. The MassHealth agency does not pay an independent nurse for a nursing visit of less than two continuous hours in duration.(C)Limit of Hours. The MassHealth agency does not pay an independent nurse for more than 60 hours of nursing care provided during any consecutive seven-day period or for more than 12 hours within a 24-hour period, regardless of the number of MassHealth members receiving care from the independent nurse.(D)Medical Necessity Requirement. In accordance with 130 CMR 450.204: Medical Necessity, the MassHealth agency pays for only those nursing services that are medically necessary.(E)Plan of Care. The MassHealth agency pays only for nursing services provided pursuant to a plan of care authorized by a physician and that meets the plan of care requirements at 130 CMR 414.412(B).(F)Continuous Skilled Nursing (CSN). The MassHealth agency pays for CSN services when (1) the member meets the clinical eligibility criteria for CSN services as stated in 130 CMR 414.408;(2) the CSN services are provided under an individualized plan of care developed for the member in accordance with 130 CMR 414.412; and(3) prior authorization for CSN services has been obtained from the MassHealth agency or its designee, in accordance with 130 CMR 414.413.(G)Members for Whom Services Are Approved. The MassHealth agency does not pay for nursing services provided to any individual other than the member who is eligible to receive such services and for whom such services have been authorized by the MassHealth agency or its designee.(H)Availability of Other Caregivers. When a family member or other caregiver is providing services that adequately meet the member's needs, it is not medically necessary for the independent nurse to provide such services.(I)Least Costly Form of Care. The MassHealth agency pays for nursing 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.(J)Safe Maintenance in the Community. The member's physician and independent nurse must determine that the member can be maintained safely in the community.(K)Teaching Activities. As part of a regular nursing treatment service, the independent nurse must teach a member, family member, or caregivers how to manage the member's treatment regimen. Ongoing teaching is required, as necessary, where there is a change in the procedure or the member's condition.(L)Prior Authorization. Nursing services provided by an independent nurse require prior authorization. See130 CMR 414.413 and 450.303: Prior Authorization for requirements. The MassHealth agency pays for all medically necessary nursing services for EPSDT-eligible members in accordance with 130 CMR 450.140: Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Services: Introduction, without regard to service limitations described in 130 CMR 414.000, and with prior authorization.(M)Continuous Skilled Nursing (CSN) Services Documentation in the Member's Home. The independent nurse and other nursing providers must maintain a copy of the member's medical record in the member's home. The record must include the total number of approved nursing hours for the member, the names and telephone numbers of all the providers involved in co-vending care, the number of nursing hours approved for each provider by the MassHealth agency or its designee, and all other recordkeeping requirements as described in 130 CMR 414.417(E).Amended by Mass Register Issue 1478, eff. 9/16/2022.