Code of Massachusetts Regulations
130 CMR - DIVISION OF MEDICAL ASSISTANCE
Title 130 CMR 419.000 - Day Habilitation Center Services
Section 419.409 - Conditions of Payment

Universal Citation: 130 MA Code of Regs 130.419

Current through Register 1531, September 27, 2024

(A) The MassHealth agency pays for DH in accordance with the applicable payment methodology and rate schedule established by EOHHS, including supplemental staffing for those who reside in an NF and attend a community-based DH and for DH provided in NFs. Rates of payment for DH do not cover or include any room and board.

(B) Payment for services is subject to the conditions, exclusions, and limitations set forth in 130 CMR 419.000 and 130 CMR 450.000: Administrative and Billing Regulations.

(C) The MassHealth agency pays a DH provider for DH only if

(1) the member receiving DH is eligible under 130 CMR 419.403;

(2) the member meets the clinical eligibility criteria for DH in accordance with 130 CMR 419.406;

(3) the DH provider has obtained prior authorization for DH and DH ISS, if applicable, in accordance with 130 CMR 419.407;

(4) the DH provider is not billing for days that are non-covered under 130 CMR 419.431; and

(5) the DH provider bills at the payment level authorized by the MassHealth agency or its designee; and

(6) for members who reside in an NF, the member's Level II PASRR conducted by DDS determines that the member requires specialized services.

(D) Transition between Two DH Providers. If a member changes from one DH provider to another DH provider, a new SNA and DH Leveling Tool is required and the new DH provider must obtain a new PA, and for DH ISS if applicable. The previous DH provider must discharge the member from its DH program before the new DH provider may bill the MassHealth agency for DH. The MassHealth agency will pay only one DH provider per day for the provision of DH to a member.

(E) Every two years or upon significant change, the DH provider must review each member in its care to ensure that the clinical eligibility criteria for DH continues to be met. A DH provider may not bill and the MassHealth agency will not pay for any member who does not meet the clinical criteria for DH.

(F) The MassHealth agency's payment to a DH provider ends on the date on which a member no longer meets the clinical criteria for DH described in 130 CMR 419.406 or is no longer receiving DH, whichever comes first.

(G) Day Habilitation Individualized Staffing Supports. DH ISS will only be paid to the provider if there is a valid PA on file.

(H) The MassHealth agency pays for DH provided by a participating DH in an NF where the member resides if the conditions of 130 CMR 419.409 and 130 CMR 419.433 are met.

(I) The MassHealth agency pays for DH delivered at an approved site and census.

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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