Administrative Care Management

For complex care members, as defined in 130 CMR 414.402, the MassHealth agency or its designee provides care management that includes service coordination with independent nurses as appropriate. The purpose of care management is to ensure that a complex care member is provided with a coordinated LTSS service package that meets the member’s individual needs and to ensure that the MassHealth agency pays for nursing and other LTSS only if they are medically necessary in accordance with 130 CMR 450.204: Medical Necessity. The MassHealth member eligibility verification system identifies complex care members. (A) Care Management Activities. (1) Enrollment. The MassHealth agency or its designee automatically assigns a clinical manager to members who it has determined require a nurse visit of more than two continuous hours of nursing and informs such members of the name, telephone number, and role of the assigned clinical manager. (2) LTSS Needs Assessment. The clinical manager performs an in-person visit with the member to evaluate whether they meet the criteria to be a complex care member as described in 130 CMR 414.402. If the member is determined to meet the criteria for a complex care member, the clinical manager will complete an LTSS needs assessment. The LTSS needs assessment will identify (a) skilled and unskilled care needs within a 24-hour period; (b) current medications the member is receiving; (c) DME currently available to the member; (d) services the member is currently receiving in the home and in the community; and (e) any case management activities in which the member participates. (3) Service Record. The clinical manager (a) develops a service record, in consultation with the member, the member’s primary natural caregiver, and where appropriate, the independent nurse and the member’s physician or ordering non-physician practitioner, that 1. lists those LTSS services that are medically necessary, covered by MassHealth, and required by the member to remain safely in the community and to be authorized by the clinical manager; 2. describes the scope and duration of each service; 3. lists other sources of payment (e.g., third-party liability, Medicare, Department of Developmental Services, adult foster care); and 4. informs the member of their right to a hearing, as described in 130 CMR 414.414; (b) provides the member with copies of the service record, one copy of which the member or the member’s primary natural caregiver is asked to sign and return to the clinical manager. On the copy being returned, the member or the member’s primary natural caregiver must indicate whether they accept or reject each service as offered and that they have been notified of the right to appeal and provided an appeal form; and (c) provides information to the independent nurse about services authorized in the service record that are applicable to the independent nurse. (4) Service Authorizations. The MassHealth agency or its designee will authorize the LTSS services in the service record, including nursing, that require prior authorization and that are medically necessary, as provided in 130 CMR 414.413, and coordinate all nursing services and any subsequent changes with the CSN agency, home health agency, or independent nurse prior authorization, as applicable. The MassHealth agency or its designee may also authorize other medically necessary LTSS including, but not limited to, PCA services, complex care assistant services, therapy services, DME, oxygen and respiratory therapy equipment, and prosthetics and orthotics. (5) Discharge Planning. The clinical manager may participate in member hospital discharge- planning meetings as necessary to ensure that LTSS that are medically necessary to discharge the member from the hospital to the community are authorized and to identify third-party payers. (6) Service Coordination. The clinical manager will work collaboratively with any other identified case managers assigned to the member. (7) Clinical Manager Follow-up and Reassessment. The clinical manager will provide ongoing care management for members to (a) determine whether the member continues to meet the definition of a complex care member; and (b) reassess whether services in the service plan are appropriate to meet the member’s needs. (B) Independent Nurse—Coordination with the Clinical Manager. The independent nurse must closely communicate and coordinate with the MassHealth agency’s or its designee’s clinical manager about the status of the member’s nursing needs, including, but not limited to, the following: (1) the number of authorized CSN hours the independent nurse is able and unable to fill upon accepting the member’s case, and periodically any significant changes in availability; (2) any recent or current hospitalizations or emergency department visits, including providing copies of discharge documents, when known; (3) any known changes to the member’s nursing needs that may affect their CSN needs; (4) needed changes in the independent nurse’s CSN prior authorization; and (5) any incidents or accidents warranting an independent nurse submitting to the MassHealth agency or its designee an incident or accident report (see 130 CMR 414.417(H)).