Current through Register 1531, September 27, 2024
(A) A Service Needs Assessment (SNA) is
completed by the clinical members of the IDT and determines a member's
functional level, needs, and strengths, and makes specific recommendations to
address acquisition, improvement, or maintenance of each identified need area
for the member. Each SNA must
(1) be
completed within 45 business days of a member's admission and every two years
thereafter and upon a significant change in the member's condition;
(2) assess each of the following need areas:
self-help skills, sensorimotor skills, communication skills, independent living
skills, affective development skills, social development skills, behavioral
development skills, and wellness; and
(3) identify which need areas will be
addressed in the DHSP.
(B)
Day Habilitation Leveling
Tool. Using the results of the SNA, a DH provider must identify
the member's appropriate DH service level and acquire Prior Authorization (PA).
The DH Leveling Tool will identify a member as Low-Need, Moderate-Need, or
High-Need. If the SNA and DH Leveling Tool identifies that the member requires
one-to-one staffing supports in order to participate in DH services, the DH
provider must follow the prior authorization process for ISS in
130
CMR 419.407(C). A new DH
Leveling Tool is required every two years or sooner if the member experiences a
significant change.
(1)
Assessment
Period. Members newly seeking DH may receive DH for up to 45
business days concurrent with the provider's completion of the member's initial
clinical assessment for DH.
(2)
Assessment Criteria. Providers must include the
following as part of the initial assessment or reassessment of a member:
(a) confirmation that the member had a
physical examination or wellness visit by a PCP within 12 months prior to the
start of DH services; and
(b) a
certification, signed by a PCP, supporting the diagnosis of Intellectual
Disability (ID) or Developmental Disability (DD).
(3) For members residing in NFs for whom the
Level II PASRR conducted by DDS concluded that the member requires specialized
services, the DH provider must obtain a copy of the DDS Level II PASRR
determination notice and maintain a copy of this notice in the member's
record.
(C)
Prior Authorization.
(1) A DH provider must obtain PA from the
MassHealth agency or its designee as a prerequisite to payment for the
provision of DH upon admission, every two years thereafter, and upon
significant change. A DH provider must also obtain PA for Individualized
Staffing Supports (ISS) prior to claiming payment for DH ISS.
(2) PA determines the medical necessity for
DH as described under
130
CMR 419.406 and in accordance with
130
CMR 450.204: Medical
Necessity.
(3) PA
specifies the level of payment for the service, and as applicable, the
medically necessary units of ISS.
(a) The
MassHealth agency pays DH providers for DH provided from the first date on
which services are authorized through PA in the form and format
required.
(b) PA through MassHealth
authorizes DH providers to claim for DH services provided to an eligible member
at one of three levels of payment reflecting the member's assessed need for
DH.
(c) PA through the MassHealth
agency may also authorize DH providers to claim for the provision of DH ISS
provided to an eligible member. A PA for DH ISS specifies the units of DH ISS
the provider may claim and which reflects the member's need for one-to-one
staffing.
(4) PA does not
establish or waive any other prerequisites for payment such as the member's
financial eligibility described in
130
CMR 503.007: Potential Sources of
Health Care and
130
CMR 517.008: Potential Sources of
Health Care.
(5) When
submitting a request for PA for payment of DH to the MassHealth agency or its
designee, the DH provider must submit requests in the form and format as
required by the MassHealth agency. The DH provider must include all required
information, including, but not limited to, documentation of the completed SNA,
DH Leveling Tool, other nursing, medical, or psychosocial evaluations or
assessments, and any other additional assessments, documentation, or
information that the MassHealth agency, or its designee, requests in order to
complete the review and determination of PA.
(6) In making its prior authorization
determination, the MassHealth agency or its designee may require additional
assessments of the member or require other necessary information in support of
the request for prior authorization.
(D)
Notice of Determination of
Prior Authorization.
(1)
Notice of Approval. If the MassHealth agency or its
designee approves a request for prior authorization, it will send written
notice to the member and the DH provider.
(2)
Notice of Denial or Service
Modification. If the MassHealth agency or its designee denies, or
modifies, a request for prior authorization of DH, the MassHealth agency or its
designee will notify both the member and the DH provider. The notice will state
the reason for the denial or service modification and contain information about
the member's right to appeal and the appeal procedure.
(3)
Right of Appeal.
A member may appeal a service denial or modification by requesting a fair
hearing in accordance with 130 CMR 610.000: MassHealth: Fair Hearing
Rules.
(E)
Review. The MassHealth agency, or its designee, may at
any time review the medical necessity of the provision of DH and DH ISS to
MassHealth members, including, but not limited to, instances in which there has
been a significant change in the member's status as defined in
130
CMR 419.402.
