Intermittent or Part-time Requirement

The MassHealth agency pays for nursing visits and home health aide services provided pursuant to a need for skilled nursing services only on an intermittent or part-time basis, and only as described in 130 CMR 403.424(A), except as provided in 130 CMR 403.424(B). Services described in this section are paid for subject to any applicable prior authorization requirements as described at 130 CMR 403.410. (A) Intermittent and Part-time Services. (1) Services are intermittent if up to eight hours per day of medically necessary nursing visits and home health aide services, combined, are provided seven days per calendar week for temporary periods of up to 30 days. (2) Services are part-time if the combination of medically necessary nursing visits and home health aide services does not exceed 35 hours per calendar week, and those services are provided on a less-than-daily basis. (3) To receive intermittent or part-time nursing care, the member must have a medically predictable recurring need for skilled nursing services at least once every 60 days, or the member must meet the conditions in 130 CMR 403.424(A)(4). (4) In certain circumstances, the member needs infrequent, yet intermittent, nursing services. The following are nonexclusive examples of such services, which are payable. (a) The member has an indwelling silicone catheter and generally needs a catheter change only at 90-day intervals. (b) The member experiences a fecal impaction due to the normal aging process (that is, loss of bowel tone, restrictive mobility, and a breakdown in good health habits) and must be manually disimpacted. Although these impactions are likely to recur, it is not possible to predict a specific time frame. (c) The member is diabetic and visually impaired. He or she self-injects insulin, and has a medically predictable recurring need for a nursing visit at least every 90 days. These nursing visits, which supplement the physician's contacts with the member, are necessary to observe and determine the need for changes in the level and type of care that have been prescribed. (d) The need for intermittent or part-time nursing is medically predictable, but a situation arises after the first nursing visit that makes additional visits unnecessary (for example, the member becomes institutionalized or dies, or a primary caregiver has been trained to provide care). In this situation, the one nursing visit is payable. (B) Exceptions. Nursing visits and home health aide services in excess of the intermittent or part-time limit, as described in 130 CMR 403.424(A), may be provided to members under any of the following conditions: (1) the physician has documented that the death of the member is imminent, and the physician has recommended that the member be permitted to die at home; (2) the home health agency has documented that the services are no more costly than medically comparable care in an appropriate institution (for example, long-term care or chronic disease and rehabilitation hospital care) and the least-costly form of comparable care available in the community, and the member prefers to remain at home; (3) the home health agency has documented that it is seeking appropriate alternative modes of care, but has not yet found them; (4) the physician has documented that the need for care in excess of 30 days or in excess of 35 hours per calendar week is medically necessary in accordance with 130 CMR 403.409(C); (5) the member qualifies for CSN services; or (6) for daily skilled nursing services for diabetics unable to administer their insulin (when there is no able and willing caregiver). (130 CMR 403.425 through 130 CMR 403.427 Reserved)