Code of Massachusetts Regulations
130 CMR - DIVISION OF MEDICAL ASSISTANCE
Title 130 CMR 403.000 - Home Health Agency
Section 403.424 - Intermittent or Part-time Requirement
Universal Citation: 130 MA Code of Regs 130.403
Current through Register 1531, September 27, 2024
The MassHealth agency pays for nursing visits and home health aide services provided pursuant to a need for skilled nursing services only on an intermittent or part-time basis, and only as described in 130 CMR 403.424(A), except as provided in 130 CMR 403.424(B). Services described in this section are paid for subject to any applicable prior authorization requirements as described at 130 CMR 403.410.
(A) Intermittent and Part-time Services.
(1) Services are
intermittent if up to eight hours per day of medically necessary nursing visits
and home health aide services, combined, are provided seven days per calendar
week for temporary periods of up to 30 days.
(2) Services are part-time if the combination
of medically necessary nursing visits and home health aide services does not
exceed 35 hours per calendar week, and those services are provided on a
less-than-daily basis.
(3) To
receive intermittent or part-time nursing care, the member must have a
medically predictable recurring need for skilled nursing services at least once
every 60 days, or the member must meet the conditions in 130 CMR
403.424(A)(4).
(4) In certain
circumstances, the member needs infrequent, yet intermittent, nursing services.
The following are nonexclusive examples of such services, which are payable.
(a) The member has an indwelling silicone
catheter and generally needs a catheter change only at 90-day
intervals.
(b) The member
experiences a fecal impaction due to the normal aging process (that is, loss of
bowel tone, restrictive mobility, and a breakdown in good health habits) and
must be manually disimpacted. Although these impactions are likely to recur, it
is not possible to predict a specific time frame.
(c) The member is diabetic and visually
impaired. He or she self-injects insulin, and has a medically predictable
recurring need for a nursing visit at least every 90 days. These nursing
visits, which supplement the physician's contacts with the member, are
necessary to observe and determine the need for changes in the level and type
of care that have been prescribed.
(d) The need for intermittent or part-time
nursing is medically predictable, but a situation arises after the first
nursing visit that makes additional visits unnecessary (for example, the member
becomes institutionalized or dies, or a primary caregiver has been trained to
provide care). In this situation, the one nursing visit is payable.
(B) Exceptions. Nursing visits and home health aide services in excess of the intermittent or part-time limit, as described in 130 CMR 403.424(A), may be provided to members under any of the following conditions:
(1) the physician has documented
that the death of the member is imminent, and the physician has recommended
that the member be permitted to die at home;
(2) the home health agency has documented
that the services are no more costly than medically comparable care in an
appropriate institution (for example, long-term care or chronic disease and
rehabilitation hospital care) and the least-costly form of comparable care
available in the community, and the member prefers to remain at home;
(3) the home health agency has documented
that it is seeking appropriate alternative modes of care, but has not yet found
them;
(4) the physician has
documented that the need for care in excess of 30 days or in excess of 35 hours
per calendar week is medically necessary in accordance with
130 CMR
403.409(C);
(5) the member qualifies for CSN services;
or
(6) for daily skilled nursing
services for diabetics unable to administer their insulin (when there is no
able and willing caregiver).
Disclaimer: These regulations may not be the most recent version. Massachusetts may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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