Code of Massachusetts Regulations
130 CMR - DIVISION OF MEDICAL ASSISTANCE
Title 130 CMR 403.000 - Home Health Agency
Section 403.420 - Plan-of-care Requirements

Universal Citation: 130 MA Code of Regs 130.403

Current through Register 1531, September 27, 2024

All home health services must be provided under a plan of care established individually for the member.

(A) Providers Qualified to Establish a Plan of Care.

(1) The member's physician or ordering non-physician practitioner must establish a written plan of care in consultation with the home health agency. The physician or ordering non-physician practitioner must review, sign and date the plan of care and revise it, as applicable:
(a) no less than every 60 days from the start of home health services;

(b) more frequently as the member's condition or needs require. The plan of care or other medical notes in the member record must document that a face-to-face encounter related to the primary reason the member requires home health services occurred no more than 90 days before or 30 days after the start of home health services. See130 CMR 403.420(E).

(c) in accordance with verbal order requirements described in 130 CMR 403.420(D).

(2) A home health agency nurse or skilled therapist may establish an additional, discipline-oriented plan of care, when appropriate. These plans of care may be incorporated into the plan of care, or be prepared separately, but do not substitute for the plan of care.

(B) Content of the Plan of Care. The orders on the plan of care must specify the service type and frequency of the services to be provided to the member, and the type of professional who must provide them. The physician or ordering non-physician practitioner must sign and date the plan of care before the home health agency submits its claim for those services to the MassHealth agency for payment, or must comply with the verbal-order provisions at 130 CMR 403.420(D). Any increase in the frequency of services or any addition of new services must be authorized in advance by the physician or ordering non-physician practitioner with verbal or written orders and authorized by the MassHealth agency or its designee as appropriate. If the member is enrolled in the Primary Care Clinician (PCC) Plan, the home health agency must communicate with the member's PCC both when the goals of the care plan are achieved and when there is a significant change in a member's health status. The plan of care must contain

(1) all pertinent diagnoses, including the member's mental, psychosocial, and cognitive status;

(2) the types of services, supplies, and equipment ordered;

(3) the frequency of the visits to be made;

(4) the prognosis, rehabilitation potential, functional limitations, permitted activities, nutritional requirements, medications, and treatments;

(5) any safety measures to prevent injury;

(6) a description of the member's risk for emergency department visits and hospital readmission, and all necessary interventions to address the underlying risk factors;

(7) any teaching activities to be conducted by the nurse or therapist, to teach the member, family member, or caregiver how to manage the member's treatment regimen (ongoing teaching may be necessary where there is a change in the procedure or the member's condition);

(8) the discharge plans;

(9) any additional items the home health agency or physician or ordering non-physician practitioner chooses to include;

(10) all patient care orders, including a record of verbal orders and/or initial referral to home health services; and

(11) member-specific home health aide care instructions created by the RN or therapist supervising the home health aide, as applicable (may be attached to the plan of care).

(C) Certification Period. Both the plan of care, required under 130 CMR 403.420(A)(1), and the discipline oriented plan of care, described in 130 CMR 403.420(A)(2), must be reviewed, signed, and dated by a physician or ordering non-physician practitioner at least every 60 days, unless the provider follows the verbal order provisions at 130 CMR 403.420(D).

(D) Verbal Orders.

(1) Notwithstanding the requirements of 130 CMR 403.420(A), services that are provided from the beginning of the certification period (see130 CMR 403.420(C)) and before the physician or ordering non-physician practitioner signs the plan of care are considered to be provided under a plan of care established and approved by the physician or ordering non-physician practitioner if
(a) the clinical record contains a documented verbal order from the ordering physician or ordering non-physician practitioner for the care before the services are provided; and

(b) the physician or ordering non-physician practitioner signature is on the 60-day plan of care either before the claim is submitted or within 45 days after submitting a claim for that period.

(2) If the member has other health insurance (whether commercial or Medicare), the provider must comply with the other insurer's regulations for physician or ordering non-physician practitioner signature before billing the MassHealth agency.

(3) The home health agency must obtain prior authorization for verbal orders where required.

(E) Face-to-face Encounter Requirements.

(1) A face-to-face encounter between the member and an authorized practitioner is required for initial orders for home health services. A face-to-face encounter is not required when the plan of care is reviewed and revised as required at 130 CMR 403.420(C) or at resumption of home health services.

(2) Authorized practitioners include:
(a) the ordering physician or ordering non-physician practitioner. In order to be an ordering physician or ordering non-physician practitioner, the physician or ordering non-physician practitioner must be enrolled in MassHealth;

(b) the physician or ordering non-physician practitioner who cared for the member in an acute or post-acute care facility (acute/post-acute care attending physician or non-physician practitioner) from which the member was directly admitted to home health; or

(c) certain authorized non-physician practitioners, which include one of the following in a home health context:
1. a nurse practitioner or clinical nurse specialist who is working in collaboration with the ordering physician or the acute/post-acute care attending physician;

2. a certified nurse midwife; or

3. a physician assistant under the ordering or acute/post-acute care attending physician.

(3) Documenting the Face-to-face Encounter in the Member's Record.
(a) The face-to-face encounter must be documented in the member's record either on the plan-of-care or in other medical notes sufficient to make the link between the individual's health conditions, the services ordered, an appropriate face-to-face encounter, and actual service provision.

(b) The ordering or acute/post-acute-care attending physician or ordering non-physician practitioner may write the plan of care. When the acute/post-acute-care attending physician or ordering non-physician practitioner writes the plan of care, such practitioners must document that the face-to-face encounter is related to the primary reason the patient requires home health services and that the encounter with an authorized practitioner occurred within the required timeframes. The plan of care or the medical notes must include which authorized practitioner conducted the encounter and the date of the encounter.

(c) If the face-to-face encounter was not provided by the ordering physician or ordering non-physician practitioner, the authorized practitioner who did conduct the face-to-face encounter is required to communicate the clinical findings of the face-to-face encounter to the ordering physician or ordering non-physician practitioner. This requirement is necessary to ensure that the ordering physician or ordering non-physician practitioner has sufficient information to determine the need for home health services in the absence of conducting the face-to-face encounter himself or herself.

(d) The home health agency must maintain a copy of the face-to-face documentation.

(4) Well Mom and Baby Visits. Face-to-face encounters must be conducted prior to home health services that arise from well mom and baby visits. If, in the course of such a visit, an authorized practitioner determines that home health services are required to address the condition of the mother or child, such a visit may be the basis for a documented face-to-face encounter to the extent that the visit involves examining the condition of the mother or child for whom services are being ordered.

(5) Dual-eligible Members. If the source of payment for the member's care has changed from Medicare to Medicaid, and a face-to-face encounter was performed at the start of Medicare-authorized home health services, a new face-to-face encounter is not required.

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