Code of Massachusetts Regulations
130 CMR - DIVISION OF MEDICAL ASSISTANCE
Title 130 CMR 414.000 - Independent Nurse
Section 414.409 - Conditions of Payment
Current through Register 1531, September 27, 2024
(A) Place of Service. The MassHealth agency pays for nursing services provided by an independent nurse to a member who meets the clinical criteria in 130 CMR 414.408 and resides in a noninstitutional setting, which may include, without limitation, a homeless shelter or other temporary residence or a community setting. The MassHealth agency pays for nursing services provided by an independent nurse when the independent nurse must accompany the member in transport to or from an institutional setting to ensure medical stability during transitions in or out of the institutional setting. The MassHealth agency does not pay for nursing services provided by an independent nurse when the member is under the direct care of a hospital or emergency room, nursing facility, intermediate care facility, or any other institutional setting providing medical, nursing, rehabilitative, or related care.
(B) Limit of Hours. The MassHealth agency does not pay an independent nurse for more than 60 hours of nursing care provided during any consecutive seven-day period or for more than 12 hours within a 24-hour period, regardless of the number of MassHealth members receiving care from the independent nurse. An independent nurse may work up to 16 hours within a 24-hour period under the following circumstances:
(C) Medical Necessity Requirement. In accordance with 130 CMR 450.204: Medical Necessity, the MassHealth agency pays for only those nursing services that are medically necessary.
(D) Plan of Care. The MassHealth agency pays only for nursing services that are provided pursuant to a plan of care authorized by a physician or non-physician practitioner and meet the plan of care requirements in 130 CMR 414.412(B).
(E) Continuous Skilled Nursing. The MassHealth agency pays for CSN services when
(F) Members for Whom Services Are Approved. The MassHealth agency does not pay for nursing services provided to any individual other than the member who is eligible to receive such services and for whom such services have been authorized by the MassHealth agency or its designee.
(G) Teaching Activities. As part of a regular nursing treatment service, the independent nurse must teach a member, family member, or caregivers how to manage the member's treatment regimen. Ongoing teaching is required, as necessary, where there is a change in the procedure or the member's condition.
(H) Continuous Skilled Nursing Service Documentation in the Member's Home. The independent nurse and any other nursing providers must maintain a copy of the member's medical record in the member's home. The record must include the total number of approved nursing hours for the member, the names and telephone numbers of all the providers involved in co-vending care, the number of nursing hours approved for each provider by the MassHealth agency or its designee, and all other recordkeeping requirements as described in 130 CMR 414.417(E).
