Conditions of Payment

(A) Place of Service. The MassHealth agency pays for nursing services provided by an independent nurse to a member who meets the clinical criteria in 130 CMR 414.408 and resides in a noninstitutional setting, which may include, without limitation, a homeless shelter or other temporary residence or a community setting. The MassHealth agency pays for nursing services provided by an independent nurse when the independent nurse must accompany the member in transport to or from an institutional setting to ensure medical stability during transitions in or out of the institutional setting. The MassHealth agency does not pay for nursing services provided by an independent nurse when the member is under the direct care of a hospital or emergency room, nursing facility, intermediate care facility, or any other institutional setting providing medical, nursing, rehabilitative, or related care. (B) Limit of Hours. The MassHealth agency does not pay an independent nurse for more than 60 hours of nursing care provided during any consecutive seven-day period or for more than 12 hours within a 24-hour period, regardless of the number of MassHealth members receiving care from the independent nurse. An independent nurse may work up to 16 hours within a 24-hour period under the following circumstances: (1) An emergency, where no other paid or unpaid trained caregiver is available to care for the member. In this case, (a) An independent nurse may work up to 16 hours within a 24-hour period provided that the member has CSN hours authorized and available for use. (b) The independent nurse must notify the MassHealth agency or its designee by the next business day and provide the reason for working more than 12 hours within a 24-hour period. (2) The MassHealth member or their representative has provided written or verbal confirmation to the MassHealth agency or its designee that they approve the independent nurse to work up to 16 hours within a 24-hour period, including the length of time they are requesting that the independent nurse work up to 16 hours in a 24-hour period; so long as (a) the independent nurse does not work for another member or employer during the remaining eight hours of the same 24-hour period in which they work up to 16 hours; and (b) the independent nurse submits a signed attestation to the MassHealth agency or its designee affirming that they will not work or seek alternative employment for the remaining eight hours of the same 24-hour period. (C) Medical Necessity Requirement. In accordance with 130 CMR 450.204: Medical Necessity, the MassHealth agency pays for only those nursing services that are medically necessary. (D) Plan of Care. The MassHealth agency pays only for nursing services that are provided pursuant to a plan of care authorized by a physician or non-physician practitioner and meet the plan of care requirements in 130 CMR 414.412(B). (E) Continuous Skilled Nursing. The MassHealth agency pays for CSN services when (1) the member meets the clinical eligibility criteria for CSN services as stated in 130 CMR 414.408; (2) the CSN services are provided under an individualized plan of care developed for the member in accordance with 130 CMR 414.412; and (3) prior authorization for CSN services has been obtained from the MassHealth agency or its designee, in accordance with 130 CMR 414.413. (F) 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. (G) Teaching Activities. As part of a regular nursing treatment service, the independent nurse must teach a member, family member, or caregivers how to manage the member’s treatment regimen. Ongoing teaching is required, as necessary, where there is a change in the procedure or the member’s condition. (H) Continuous Skilled Nursing Service Documentation in the Member’s Home. The independent nurse and any other nursing providers must maintain a copy of the member’s medical record in the member’s home. The record must include the total number of approved nursing hours for the member, the names and telephone numbers of all the providers involved in co-vending care, the number of nursing hours approved for each provider by the MassHealth agency or its designee, and all other recordkeeping requirements as described in 130 CMR 414.417(E).