Code of Massachusetts Regulations
130 CMR - DIVISION OF MEDICAL ASSISTANCE
Title 130 CMR 403.000 - Home Health Agency
Section 403.417 - Physical, Occupational, and Speech/Language Therapy
Universal Citation: 130 MA Code of Regs 130.403
Current through Register 1531, September 27, 2024
(A) Physical Therapy. The MassHealth agency pays for up to 20 visits within a calendar year for physical therapy without prior authorization when provided to an eligible MassHealth member, if the services are
(1) prescribed by a physician or an ordering
non-physician practitioner;
(2)
directly and specifically related to an active treatment regimen;
(3) of such a level of complexity and
sophistication that the judgment, knowledge, and skills of a licensed physical
therapist are required;
(4)
performed by a licensed physical therapist, or by a licensed physical therapy
assistant under the supervision of a licensed physical therapist;
(5) considered under accepted standards of
medical practice to be a specific and effective treatment for the member's
condition;
(6) medically necessary
for treatment of the member's condition. Services related to activities for the
general good and welfare of members (for example, general exercises to promote
overall fitness and flexibility, and activities to provide diversion or general
motivation) do not constitute physical therapy services for purposes of
MassHealth payment; and
(7)
certified by the physician or an ordering non-physician practitioner every 60
days.
(B) Occupational Therapy. The MassHealth agency pays for up to 20 visits within a calendar year for occupational therapy without prior authorization when provided to an eligible MassHealth member, if the services are
(1) prescribed by a physician or an
ordering non-physician practitioner;
(2) performed by a licensed occupational
therapist, or by a licensed occupational therapy assistant under the
supervision of a licensed occupational therapist;
(3) considered under accepted standards of
medical practice to be a specific and effective treatment for the member's
condition;
(4) medically necessary
for treatment of the member's illness or injury. Services related to activities
for the general good and welfare of the member (for example, general exercises
to promote overall fitness and flexibility, and activities to provide diversion
or general motivation) do not constitute occupational therapy services for
purposes of MassHealth payment; and
(5) certified by the physician or an ordering
non-physician practitioner every 60 days.
(C) Speech/Language Therapy. The MassHealth agency pays for up to 35 visits within a calendar year for speech and language therapy without prior authorization when provided to an eligible MassHealth member, if the services are
(1) prescribed by a physician or an ordering
non-physician practitioner;
(2)
performed by a licensed speech and language therapist;
(3) medically necessary for treatment of the
member's illness or injury; and
(4)
certified by the physician or an ordering non-physician practitioner every 60
days.
(D) Maintenance Program.
(1) The MassHealth agency pays for the
establishment of a maintenance program and the training of the member, member's
family, or other persons to carry it out, as part of a regular treatment visit,
not as a separate service. The MassHealth agency does not pay for performance
of a maintenance program, except as provided in 130 CMR
403.417(D)(2).
(2) In certain
instances, the specialized knowledge and judgment of a licensed therapist may
be required to perform services that are part of a maintenance program, to
ensure safety or effectiveness that may otherwise be compromised due to the
member's medical condition. At the time the decision is made that the services
must be performed by a licensed therapist, all information that supports the
medical necessity for performance of such services by a licensed therapist,
rather than a non-therapist, must be documented in the medical
record.
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