Code of Massachusetts Regulations
130 CMR - DIVISION OF MEDICAL ASSISTANCE
Title 130 CMR 405.000 - Community Health Center Services
Section 405.477 - CARES Program Services
Universal Citation: 130 MA Code of Regs 130.405
Current through Register 1531, September 27, 2024
(A) Introduction. The MassHealth Coordinating Aligned, Relationship-centered, Enhanced Support for Kids program (CARES program) is a Targeted Case Management (TCM) service rendered by CARES program providers certified in accordance with 130 CMR 405.477(D) to members younger than 21 years old who satisfy the eligibility criteria in 130 CMR 405.477(C). The MassHealth agency pays for CARES program services provided by CARES program providers subject to restrictions and limitations in 130 CMR 405.477(A) through 405.477(H) and Appendix M of the Physician Manual.
(B) Definitions. The following terms used in 130 CMR 405.477(A) through 405.477(H) have the meanings given in 130 CMR 405.477(B) unless the context clearly requires a different meaning.
Comprehensive Assessment - a systematic, timely, and clearly documented screening process that provides the foundation for care coordination and the individual care plan. The assessment includes information and data from multiple sources and reflects key information about the member and their parent/guardian's needs and priorities.
Individual Care Plan (ICP) - a plan that specifies the goals and actions to address the medical, educational, social, behavioral, or other services needed by the member and their parent/guardian.
Local Education Agency - a public authority legally constituted by the state as an administrative agency to provide control of and direction for kindergarten through grade 12 public educational institutions.
Medical Complexity - a combination of multiorgan system involvement from chronic health condition(s) that often result in functional limitations, ongoing use of medical technology, and high resource need and use.
Natural Supports - include family, friends, neighbors, and self-help groups intentionally identified to support the member. This support system is an active component of the ICP to support the member and their parent/guardian.
Subspecialist - a provider who specializes in a narrow field of professional knowledge/skills within a medical specialty, such as pediatric congenital heart disease within the broad specialty of cardiology.
(C) Clinical Eligibility Criteria. To receive CARES program services, a member must:
(1) be younger than 21 years old;
(2) not reside in a nursing facility or other
inpatient facility for longer than six consecutive months at the time of
seeking CARES program services; and
(3) satisfy:
(a) all of the eligibility criteria in
130
CMR 405.477(C)(3)(b)(1);
and
(b) all of the eligibility
criteria in either
130
CMR 405.477(C)(3)(b)(2) or
130
CMR 405.477(C)(3)(b)(3), as
follows:
1. The member is a child with special
health needs who requires ongoing medical management by at least two pediatric
subspecialists At least one of the specialists must treat a medical condition
that results in all of the following:
a.
functional impairment (e.g., need for assistance with
activities of daily living) that substantially interferes with or limits the
member's role/functioning in family, school, and community activities.
Functional impairment is defined as difficulties that substantially interfere
with or limit the member in achieving or maintaining developmentally
appropriate, social, behavioral, cognitive, communicative, or adaptive skills.
Functional impairments of episodic, recurrent, and continuous duration are
included unless they are temporary and expected responses to stressful events
in the environment.
b. at least one
condition must be:
(i) progressive, associated
with persistent deteriorating health; or
(ii) a chronic medical condition, expected to
last at least a year and expected to be episodically or continuously
debilitating and require ongoing treatment for control of the condition that
will use health care resources above the level of a healthy child; or
(iii) a progressive or metastatic
malignancy.
2. At the time the member begins receiving
CARES program services, the member is at high risk for adverse health outcomes
due to both of the following:
a. Demonstrated
inability to coordinate multiple medical, social, and other services impacting
medical condition, as evidenced by:
i. two or
more unplanned emergency department visits within the past 180 days; or
ii. a documented pattern of
multiple missed primary care physician (PCP) or subspecialty appointments; or
iii. chronic absenteeism from
school directly related to the member's medical conditions.
b. Demonstrated health-related
social needs impacting the management of the member's medical condition. Social
complexity/health-related social needs are defined by at least one of the
following:
i. experiencing homelessness or
housing insecurity;
ii.
experiencing food insecurity;
iii.
parent/caregiver experiencing employment instability;
iv. lacking access to basic resources such as
heat, electricity, internet, transportation, education, and social connections;
or
v. living in unsafe or violent
conditions.
3.
The member requires more than two continuous hours of skilled nursing services
to remain safely at home.
(D) Provider Requirements.
(1) Payment for
services described in
130
CMR 405.477(A) through
405.477(H)
will be made only to community health centers (CHCs) participating in
MassHealth on the date of service that are also certified by the MassHealth
agency for the provision of CARES program services at that location on the date
of service.
(2) A CHC seeking to
provide CARES program services must meet the requirements in
130
CMR 405.477(A) through
405.477(H).
A separate application for certification as a CARES program provider must be
submitted for each CHC that seeks to render such services. The application must
be made on the form provided by the MassHealth agency and must be submitted to
the MassHealth agency's physician program. The MassHealth agency may request
additional information from the applicant to evaluate the applicant's
compliance with
130
CMR 405.477(A) through
405.477(H).
Through this certification, the applicant must, among other requirements:
(a) agree to enter into a written agreement
with the MassHealth agency in which the applicant agrees to satisfy all of the
requirements in
130
CMR 405.477(A) through
405.477(H);
(b) agree to establish, maintain, and comply
with written policies and procedures to satisfy all the requirements in
130
CMR 405.477(A) through
405.477(H);
(c) agree to assess and annually reassess
each member in its care in accordance with
130
CMR 405.477(E)(3)(a) and
130
CMR 405.477(F)(1)(a) to
ensure that each such member satisfies, and continues to satisfy, the clinical
eligibility criteria for receipt of CARES program services;
(d) agree to periodic inspections, by the
MassHealth agency or its designee, that assess the quality of member care and
ensure compliance with
130
CMR 405.477(A) through
405.477(H);
(e) submit a written description of:
1. CARES program services offered by the
applicant and its care objectives, and
2. how the applicant will fulfill the
staffing requirements in
130
CMR 405.477(E);
(f) agree to participate in any
CARES program provider orientation required by EOHHS;
(g) attest that it:
1. actively provides covered services to
MassHealth members younger than 21 years of age with medical complexities;
and
2. has the capacity to provide
on-call care coordination to members assigned to the applicant 24 hours a day,
365 days per year;
(h)
agree to provide any documentation, data, and reports as required by
EOHHS;
(i) agree to subscribe to
and participate in the statewide ENS (Event Notification Service) Framework
described in
101
CMR 20.11: Statewide Event
Notification Service Framework, including having the capacity to
receive and send admission, discharge, and transfer messages, as that term is
defined in
101
CMR 20.04: Admission, Discharge, and
Transfer Messages (ADTs);
(j) agree to establish and implement policies
and procedures to increase the technological capabilities to share information
among providers involved in members' care, including increasing Health
Information Exchange (HIE) connections and enhancing digital systems
interoperability;
(k) agree to use
CMS required CEHRT (Certified Electronic Health Record Technology) criteria
(2015 edition or subsequent editions) and updates to said criteria, to document
and communicate clinical care information;
(l) agree to comply with the Office of the
National Coordinator for Health Information Technology (ONC) guidance on USCDI
(United States Core Data for Interoperability) for standardized health data
exchange, or such other guidance and standards for health data exchange as
specified by EOHHS;
(m) agree to
submit to the MassHealth agency or its designee a statement of fiscal soundness
attesting to the financial viability of the CARES program provider supported by
documentation to demonstrate that the provider has adequate resources to
finance the provision of services in accordance with
130
CMR 405.477(A) through
405.477(H);
and (n) agree to participate in any quality management and program integrity
processes as required by the MassHealth agency.
(3) The MassHealth agency requires
documentation from providers seeking to become CARES program providers. All
required application documentation will be specified by the MassHealth agency
and must be submitted and approved prior to participating as a CARES program
provider in MassHealth.
(4) Based
on the information provided in the certification application, the MassHealth
agency will determine whether the applicant is certifiable as a CARES program
provider. If the MassHealth agency determines that the applicant is not
certifiable, the notice will contain a statement of the reasons for that
determination and recommendations for corrective action so that the applicant
may reapply for certification once corrective action has been taken.
(5) The certification is valid only for the
CHC described in the application and is not transferable to any other provider.
Any additional location established by the applicant at a satellite facility
must obtain separate certification from the MassHealth agency in order to
receive payment.
(E) CARES Team.
(1) The
CARES program provider must establish a CARES team to meet the care
coordination needs of members, including on call after-hours availability to
assist as needed and to triage medical crises and emergencies. The CARES team
must include a program director, senior care manager, care coordinator, and
family support staff which may include a community health worker or peer, each
of whom must satisfy the staff composition requirements specified in Appendix M
of the Physician Manual. The CARES team must satisfy any other
staff composition requirements specified in Appendix M of the Physician
Manual. CARES team members may serve multiple roles for which they are
qualified as long as the staffing responsibilities and programmatic
requirements are met. In addition, care managers and supervisors serving on the
CARES team must complete trainings as outlined in Appendix M of the
Physician Manual. CARES program providers must establish
policies and procedures relating to such trainings to ensure the completion of
such trainings. CARES program providers must document compliance with training
requirements for care managers and supervisors within three months of starting
in that role.
(2) The CARES team is
responsible for ensuring that needed medical, social, educational, and other
CARES program services are accessed, coordinated, and delivered in a
strength-based, individualized, member-driven, culturally informed,
linguistically appropriate, and accessible manner. The CARES team must
establish referral relationships with members' pediatric specialty providers,
primary care providers, behavioral health providers, MassHealth managed care
entities, and any other entity, agency, system, or provider as needed for the
treatment of a member in the provider's care, as determined by the member's
CARES team.
(3) The CARES team
must:
(a) conduct a comprehensive assessment
of each member seeking CARES program services from the provider in order to
determine that the member is clinically eligible to receive such services. The
CARES team shall conduct this comprehensive assessment in accordance with
130
CMR 405.477(F) and Appendix
M of the Physician Manual.
(b) make referrals for and coordinate
services on- and off-site. These services include, but are not limited to,
making referrals for and coordinating the following services:
1. medical and behavioral health
care.
2. home and community
long-term services and supports, such as Durable Medical Equipment (DME) and
Continuous Skilled Nursing (CSN) services. For members enrolled in the
Community Case Management (CCM) program, the CARES team will serve as the lead
care coordination entity and will work directly with the CCM case manager to
coordinate DME, CSN, and other home health services.
3. health-related social needs, goods, and
services, including, but not limited to, housing stabilization and support
services, utility assistance, and nutritional assistance.
4. educational services and
entitlements.
5. any state agency
services for which the member may be eligible.
(c) have standardized processes for referrals
to ensure continuity of care, exchange of relevant health information, such as
test results and records, and avoidance of service duplication. This process
must also contain follow-up provisions to ensure that the referral is completed
successfully.
(d) establish and
maintain relationships with the member's health plan and any state or local
agencies with which the member is involved, including, but not limited to, the
Department of Children and Families (DCF), the Department of Developmental
Services (DDS), the Department of Mental Health (DMH), the Department of Public
Health (DPH), the Department of Transitional Assistance (DTA), the Department
of Youth Services (DYS), and any Local Education Agency (LEA).
(e) support care coordination and facilitate
collaboration through the establishment of regular case review meetings as
specified in Appendix M of the Physician Manual.
(f) provide all CARES program
services..
(F) Scope of Services. The CARES program provider must ensure that CARES program services are provided only by individuals serving on the CARES team who are qualified to render such services. Detailed service components are outlined in Appendix M of the Physician Manual.
(1) CARES program services must include at a
minimum:
(a) a comprehensive assessment of the
member at least once a year. These assessment activities include, but are not
limited to:
1. taking the member's history,
which must capture the full spectrum of medical, social, educational, and
emotional needs;
2. identifying the
member's needs and completing related documentation; and
3. gathering information from other sources
such as the parent/guardian, medical providers, state agencies, social services
providers, and educators, to complete the assessment or reassessment of the
member.
(b) development
of an ICP, which must be driven by the member and their parent/guardian,
authorized health care decision maker, and other relevant providers, and it
must be shared and included in transition of care communication with relevant
providers, state agencies, and members of the care management team. The ICP
must be in a form and format specified by the MassHealth agency and include:
1. goals and actions to address the medical,
social, educational, and other services needed by the member;
2. a course of action to respond to the
assessed needs of the member; and
3. an emergency plan;
(c) care coordination and family support
activities such as, but not limited to:
1.
having a designated CARES team member (either a care coordinator or a senior
care manager) serve as the primary and "first line" contact for the member and
their parent/guardian. The care manager must provide regular contact with the
member and their parent/guardian (either face-to-face or by telehealth, in
accordance with the preferenes of the member and their
parent/guardian);
2. providing a
phone number and on-call capacity 24 hours per day, 365 days per year to
respond to and triage any medical and care coordination related
questions;
3. helping the
parent/guardian/caregiver advocate for and access resources and services to
meet the family's needs;
4.
maintaining effective, coordinated, and communicative relationships with
designees from the member's care team, such as primary care physicians, health
systems, specialty providers, dental providers, behavioral health providers,
CCM, and CSN supports, and other state agencies, in order to facilitate
coordination;
5. coordinating with
early intervention providers and school and early childhood education
providers;
6. coordinating access
to DME, home care needs, scheduling appointments, referrals to providers for
needed medical services, and assistance with prior authorization;
7. coordinating goods and services related to
health-related social needs;
8.
providing ongoing support in maintaining MassHealth eligibility, accessing any
eligible benefits through state agencies, and coordinating with primary
insurance for members who have third-party coverage;
9. providing intensive support for
transitions of care between different health and community settings and the
member's home; and
10. performing
any other activities as detailed in Appendix M of the Physician
Manual.
(d)
appropriate services to address identified needs and achieve goals specified in
the ICP;
(e) intensive support for
member transitions into adult care, beginning once the member reaches 16 years
old; and
(f) all monitoring and
follow-up activities necessary to ensure that the ICP is implemented and
adequately addresses the member's needs.
(2) A CARES program provider is responsible
for providing any and all of the CARES program services described above to each
member receiving CARES program services from that provider when medically
necessary.
(G) Assignment and Removal of Assignment Procedures.
(1) To promote effective provision of TCM
services and prevent duplication, a member seeking CARES program services may
receive such services from only one CARES program provider at a time. To
facilitate this requirement, a CARES program provider must, prior to rendering
CARES program services to a member, check the Eligibility Verification System
to determine whether the member has been assigned to another CARES program
provider, in accordance with the process outlined in Appendix M of the
Physician Manual.
(a) If the
member is assigned to another CARES program provider, the provider from whom
the member seeks CARES program services must decline to provide such services
to the member and refer the member to the CARES program to which they are
assigned.
(b) If the member is not
assigned to another CARES program provider, and if the member agrees to receive
CARES program from the CARES program provider, the CARES program provider must
assign the member to the CARES program provider in accordance with the process
outlined in Appendix M of the Physician Manual, including
determining clinical eligibility and other education and information-sharing
activities with the eligible member and parent/guardian.
(2)
Removal of
Assignment. If a member no longer needs or is no longer eligible
for CARES program services provided by the CARES program provider, the CARES
program must follow the removal of assignment procedures as specified in
Appendix M of the Physician Manual, including convening a
meeting with the member and their family to develop an aftercare/transition
plan.
(H) Payment.
(1) The
MassHealth agency pays a CARES program provider for CARES program services only
if the member receiving CARES program services is eligible to receive such
services under
130
CMR 405.477(C).
(2) The MassHealth agency pays a CARES
program provider for services in accordance with the applicable payment
methodology and rate schedule established by EOHHS. Rates of payment for CARES
program services include only those services described in
130
CMR 405.477(F), and do not
cover or include any direct medical care.
(3) The MassHealth agency makes a single
monthly payment for all CARES program services rendered by a CARES program
provider to a member during that calendar month. In order to qualify for
payment of the monthly fee, the CARES program provider must provide at least
two of the CARES program services described in the regulation to that member
during that calendar month, with at least one of those services including live
interaction between the provider and the member and their parent/guardian,
whether in person or via telehealth. A CARES program provider may not bill
MassHealth the monthly fee for any calendar month in which the provider renders
only one of the services described in the regulation to the member.
(4) Payment for the CARES program is subject
to the conditions, exclusions, and limitations in 130 CMR 405.000 and 130 CMR
450.000: Administrative and Billing Regulations.
(5) The MassHealth agency does not pay for
CARES program services rendered to a member by a CARES program provider during
any period of time in which the member is assigned to another CARES program
provider.
(6) If the member
assigned to a CARES program provider is admitted to a nursing facility or other
inpatient facility during the period of assignment, the MassHealth agency pays
for CARES program services rendered by that CARES program provider to that
member for up to six consecutive months from the date of admission, subject to
compliance with all applicable requirements in
130
CMR 405.477(A) through
405.477(H)
and Appendix M of the Physician Manual. MassHealth will not
pay for CARES program services rendered to any member who has resided in a
nursing facility or other inpatient facility for more than six consecutive
months.
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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