Reimbursable Administrative Days

(A) The MassHealth agency pays a private psychiatric inpatient hospital for a continued length of stay of up to 30 administrative days, as defined in 130 CMR 425.402. For members younger than 21 years of age and members 65 years of age and older, the MassHealth agency may pay a private psychiatric inpatient hospital for administrative days exceeding the 30-day limit where the hospital can demonstrate, to the satisfaction of the MassHealth agency or its agent, that the hospital has (1) experienced extraordinary difficulty in placing the member, including the specific reasons for such extraordinary difficulty; and (2) exhaustively explored all potential appropriate placements. (B) An administrative day, as defined in 130 CMR 425.402, is reimbursable only if a hospital is making regular efforts to move the member to a less intensive level of care. These efforts must be documented according to the procedures described in 130 CMR 450.205: Recordkeeping and Disclosure. The regulations covering discharge-planning standards described in 130 CMR 425.418 must be followed, but they do not preclude additional, effective discharge-planning activities. (C) Examples of situations that may require hospital stays at an administrative-day level include, but are not limited to, the following. (1) A member is awaiting transfer to a nursing facility or any other institutional placement, and no appropriate nursing-facility bed is available. (2) A member is awaiting arrangement of residential, social, psychiatric, or medical services by a public or private agency. (3) A member is awaiting results of a report of abuse or neglect made to any public agency charged with the investigation of such reports. (4) A member in the custody of the Department of Children and Families is awaiting foster care when other temporary living arrangements are unavailable or inappropriate. (5) A member cannot be treated or maintained at home because the primary caregiver is absent due to a medical or psychiatric crisis, and a substitute caregiver is not available.