Physical, Occupational, and Speech/Language Therapy

(A) Physical Therapy. The MassHealth agency pays for up to 20 visits within a calendar year for physical therapy without prior authorization when provided to an eligible MassHealth member, if the services are (1) prescribed by a physician or an ordering non-physician practitioner; (2) directly and specifically related to an active treatment regimen; (3) of such a level of complexity and sophistication that the judgment, knowledge, and skills of a licensed physical therapist are required; (4) performed by a licensed physical therapist, or by a licensed physical therapy assistant under the supervision of a licensed physical therapist; (5) considered under accepted standards of medical practice to be a specific and effective treatment for the member's condition; (6) medically necessary for treatment of the member's condition. Services related to activities for the general good and welfare of members (for example, general exercises to promote overall fitness and flexibility, and activities to provide diversion or general motivation) do not constitute physical therapy services for purposes of MassHealth payment; and (7) certified by the physician or an ordering non-physician practitioner every 60 days. (B) Occupational Therapy. The MassHealth agency pays for up to 20 visits within a calendar year for occupational therapy without prior authorization when provided to an eligible MassHealth member, if the services are (1) prescribed by a physician or an ordering non-physician practitioner; (2) performed by a licensed occupational therapist, or by a licensed occupational therapy assistant under the supervision of a licensed occupational therapist; (3) considered under accepted standards of medical practice to be a specific and effective treatment for the member's condition; (4) medically necessary for treatment of the member's illness or injury. Services related to activities for the general good and welfare of the member (for example, general exercises to promote overall fitness and flexibility, and activities to provide diversion or general motivation) do not constitute occupational therapy services for purposes of MassHealth payment; and (5) certified by the physician or an ordering non-physician practitioner every 60 days. (C) Speech/Language Therapy. The MassHealth agency pays for up to 35 visits within a calendar year for speech and language therapy without prior authorization when provided to an eligible MassHealth member, if the services are (1) prescribed by a physician or an ordering non-physician practitioner; (2) performed by a licensed speech and language therapist; (3) medically necessary for treatment of the member's illness or injury; and (4) certified by the physician or an ordering non-physician practitioner every 60 days. (D) Maintenance Program. (1) The MassHealth agency pays for the establishment of a maintenance program and the training of the member, member’s family, or other persons to carry it out, as part of a regular treatment visit, not as a separate service. The MassHealth agency does not pay for performance of a maintenance program, except as provided in 130 CMR 403.417(D)(2). (2) In certain instances, the specialized knowledge and judgment of a licensed therapist may be required to perform services that are part of a maintenance program, to ensure safety or effectiveness that may otherwise be compromised due to the member’s medical condition. At the time the decision is made that the services must be performed by a licensed therapist, all information that supports the medical necessity for performance of such services by a licensed therapist, rather than a non-therapist, must be documented in the medical record.