130 CMR, § 419.409

Current through Register 1536, December 6, 2024

Section 419.409 - Conditions of Payment

(A) The MassHealth agency pays for DH in accordance with the applicable payment methodology and rate schedule established by EOHHS, including supplemental staffing for those who reside in an NF and attend a community-based DH and for DH provided in NFs. Rates of payment for DH do not cover or include any room and board.

(B) Payment for services is subject to the conditions, exclusions, and limitations set forth in 130 CMR 419.000 and 130 CMR 450.000: Administrative and Billing Regulations.

(1)DH Payment Levels. Members qualify for DH based on the clinical eligibility criteria in 130 CMR 419.403. The Leveling Tool determines the member's qualifying needs while at DH, measured by the level of supports needed for the member to acquire, improve, or retain maximum skill level and independent functioning. Refer to 101 CMR 348.00: Rates for Day Habilitation Services for payment level reimbursement rates. Levels increase based on increased needs for supports.

(a)Level 1. The MassHealth agency pays the Payment Level 1 rate to DH providers for each date of service billed for a clinically eligible member whose Leveling Tool score identifies them as Level 1.

(b)Level 2. The MassHealth agency pays the Payment Level 2 rate to DH providers for each date of service billed for a clinically eligible member whose Leveling Tool score identifies them as Level 2.

(c)Level 3. The MassHealth agency pays the Payment Level 3 rate to DH providers for each date of service billed for a clinically eligible member whose Leveling Tool score identifies them as Level 3.

(d)Level 4. The MassHealth agency pays the Payment Level 4 rate to DH providers for each date of service billed for a clinically eligible member whose Leveling Tool score identifies them as Level 4. Members who live in an NF and have a Level II PASRR will qualify as Level 4. Members whose SNA demonstrates a need for six hours a day of nursing will be in Level 4 if the nursing services are delivered by the DH; additional documentation regarding nursing duties will be required.

(e)Leveling Adjustment. The skilled service needs related to nursing, performed by a continuous skilled nurse contracted to provide services to an individual member in a one-to-one capacity throughout the entire day, are not considered qualifying DH needs for the purpose of the Leveling Tool.

(C) The MassHealth agency pays a DH provider for DH only if

(1) the member receiving DH is eligible under 130 CMR 419.403;

(2) the member meets the clinical eligibility criteria for DH in accordance with 130 CMR 419.406;

(3) the DH provider has obtained prior authorization for DH in accordance with 130 CMR 419.407;

(4) the DH provider is not billing for days that are non covered under 130 CMR 419.431;

(5) the DH provider bills at the payment level authorized by the MassHealth agency or its designee; and

(6) for members who reside in an NF, the member's Level II PASRR conducted by DDS determines that the member requires specialized services.

(D) The MassHealth agency will pay only one DH provider per day for the provision of DH to a member.

(E) Every two years or upon significant change, the DH provider must review each member in its care to ensure that the clinical eligibility criteria for DH continues to be met. A DH provider may not bill and the MassHealth agency will not pay for any member who does not meet the clinical criteria for DH.

(F) The MassHealth agency's payment to a DH provider ends on the date on which a member no longer meets the clinical criteria for DH described in 130 CMR 419.406 or is no longer receiving DH, whichever comes first.

(G) The MassHealth agency pays for DH provided by a participating DH in an NF where the member resides if the conditions of 130 CMR 419.409 and 130 CMR 419.433 are met.

(H) The MassHealth agency pays for DH delivered at an approved site and census.