Conditions of Payment

The following conditions for payment apply to all home health services, in addition to conditions of payment described throughout 130 CMR 403.000. (A) The MassHealth agency pays for home health in accordance with the applicable payment methodology and rate schedule established by EOHHS. (B) The home health provider must review each member in its care to ensure that the clinical eligibility criteria for home health continue to be met. A home health provider may not bill and the MassHealth agency will not pay for any member who does not meet the clinical criteria for home health. (C) Initial Patient Assessments. The MassHealth agency pays for one initial member assessment visit by a home health agency with a physician or ordering non-physician practitioner’s order. The MassHealth agency does not pay for any subsequent services provided to the member unless the physician or ordering non-physician practitioner has ordered the service prior to the continuation of care and includes them in the written plan of care. (D) Observation and Evaluation Visits. The MassHealth agency pays for observation and evaluation (or reevaluation) visits when they are made by a registered nurse or physical, occupational, or speech/language therapist ordered by the physician or ordering non-physician practitioner, for the purpose of evaluating the member's condition and his or her continuing need for home health services. (E) Supervisory Visits. The MassHealth agency does not pay for a supervisory visit made by a nurse or physical and occupational therapist for the purpose of evaluating the specific personal- care needs of the member, or reviewing the manner in which the personal-care needs of the member are being met by the home health aide. These visits are administrative and are, therefore, not payable. (F) Nursing Visits for Members Receiving Home Health Services After 30 Calendar Days. The MassHealth agency pays a reduced rate for any additional nursing visit provided to the member on or after the 31st calendar day of the member’s first home health service, even if some or all of those services were provided by a different home health agency or paid by a third-party insurer other than MassHealth. When billing the MassHealth agency for any nursing visit on or after the 31st calendar day, the service code and modifier must reflect the nursing visit. The MassHealth agency resumes the full nursing visit rate of one through 30 calendar days under the following conditions: (1) Admission to a hospital for at least one overnight. (2) Admission to a Crises Stabilization Unit of at least one overnight. (3) Admission to a skilled nursing facility of at least three nights. (4) Following a break in home health services of 60 days or more. (G) Medication Administration Visit. The MassHealth agency pays a separate rate for nursing visits conducted for the purpose of medication administration, as defined in 403.402. Medication Administration Visits must include teaching on medication management to maximize independence, as applicable, documentation as specified in 130 CMR 403.419(C)(3)(b)9., and assessment of the member response to medication. (H) 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.