Section 403.414 - Complex Community Care Management ServicesFor complex-care members, as defined in 130 CMR 403.402, the MassHealth agency or its designee provides care management that includes service coordination with home health agencies as appropriate. The purpose of care management is to ensure that complex-care members are provided with a coordinated LTSS service plan that meets such members' individual needs, avoids duplicative services, and ensures that the MassHealth agency pays for home health and other LTSS only if they are medically necessary in accordance with 130 CMR 403.409(C). The MassHealth member eligibility verification system identifies complex-care members.
(A)Care Management Activities. (1)Enrollment. The MassHealth agency or its designee automatically assigns a clinical manager to members whom it has determined require a nurse visit of more than two continuous hours of nursing, and informs such members of the name, telephone number, and role of the assigned clinical manager.(2)Comprehensive Needs Assessment. The clinical manager performs an in-person visit with the member to evaluate whether the member meets the criteria to be a complex-care member as described in 130 CMR 403.402. If the member is determined to meet the criteria for a complex-care member, the clinical manager will complete a comprehensive needs assessment. The comprehensive needs assessment identifies (a) services that are medically necessary, covered by MassHealth, and required by the member to remain safely in the community;(b) services the member is currently receiving; and(c) any other case management activities in which the member participates.(3)Service Record. The clinical manager(a) develops a service record, in consultation with the member, the primary caregiver, and where appropriate, the home health agency and the member's physician, that 1. lists those MassHealth-covered services to be authorized by the clinical manager;2. describes the scope and duration of each service;3. lists service arrangements approved by the member or the member's primary caregiver; and4. informs the member of his or her right to a hearing, as described in 130 CMR 403.411;(b) provides to the member copies of the service record, one copy of which the member or the member's primary caregiver must sign and return to the clinical manager. On the copy being returned, the member must indicate whether he or she accepts or rejects each service as offered and that he or she has been notified of the right to appeal and provided an appeal form; and(c) provides to the home health agency information from the service record that is applicable to the home health agency.(4)Service Authorizations. The clinical manager authorizes those LTSS in the service record, including home health, that require prior authorization (PA) as provided in 130 CMR 403.410, and that are medically necessary, and coordinates all home health services and any subsequent changes with the home health agency.(5)Discharge Planning. The clinical manager may participate in member hospital discharge planning meetings as necessary to ensure that LTSS medically necessary to discharge the member from the hospital to the community are authorized and to provide coordination with all other identified third-party payers.(6)Service Coordination. The clinical manager works collaboratively with any identified case managers assigned to the member.(7)Clinical Manager Follow-up and Reassessment. The clinical manager provides ongoing care management for members, and in coordination with the home health agency, to (a) determine whether the member continues to be a complex-care member; and(b) reassess whether services in the service record are appropriate to meet the member's needs.(B)Home Health Agency - Case Management Activities.(1)Plan of Care. The home health agency participates in the development of the plan of care for each complex-care member as described in 130 CMR 403.420, in consultation with the physician, the clinical manager, the member, and the primary caregiver, or some combination, that (a) includes the appropriate assignment of home health services; and(b) incorporates full consideration of the member's and the caregiver's preferences for service arrangements.(2)Coordination and Communication. The home health agency closely communicates and coordinates with MassHealth's or its designee's clinical manager about the status of the member's home health needs.Amended by Mass Register Issue 1319, eff. 8/12/2016.Amended by Mass Register Issue 1343, eff. 7/14/2017.