Section 419.431 - NoncoverageThe following are considered non-covered days and are ineligible for payment under 130 CMR 419.000.
(A) Any portion of a day outside the approved rate structure described in 101 CMR 348.00: Rates for Day Habilitation Services, during which the member is not receiving scheduled services from the DH provider, unless the provider documents that the member was receiving services from the DH provider's staff in a community setting.(B) DH provided to a member when the member's needs can no longer be met by the DH as determined by the PCP and the professional interdisciplinary team in consultation, or by a qualified representative of the MassHealth agency, DDS, or DPH.(C) Days or portion(s) of a day outside of the rate structure in 101 CMR 348.00: Rates for Day Habilitation Services on which the following services are provided: (1) vocational- and prevocational-training services, which include vocational-skills assessment, career counseling, job training, and job placement;(2) work-related services, which provide participants with work skills and supervised employment for the production of saleable goods;(3) educational services, which involve traditional classroom instruction of academic subjects, tutoring, and academic counseling; and(4) social, vocational, and recreational services not administered through the DH provider.(D) DH provided to members residing in ICF/ID.(E) DH provided more than five days per week and six hours per day per member;(F) DH provided at a site that has not been approved by the MassHealth agency or its designee or does not have a current approval on file;(G) DH provided on or after the effective date of the discharge plan; and(H) Claims billed above the census on file as approved by the MassHealth agency or its designee.Amended by Mass Register Issue 1373, eff. 9/7/2018.Amended by Mass Register Issue 1481, eff. 10/28/2022.Amended by Mass Register Issue 1514, eff. 1/19/2024 (EMERGENCY).Amended by Mass Register Issue 1520, eff. 1/19/2024 (EMERGENCY).Amended by Mass Register Issue 1521, eff. 5/10/2024.Amended by Mass Register Issue 1532, eff. 10/11/2024.