Introduction

All rehabilitation centers participating in MassHealth must comply with the regulations of MassHealth, including, but not limited to, 130 CMR 430.000 and 130 450.000. (A) Definitions. (1) Eligible Provider of Rehabilitation Center Services – a freestanding center providing rehabilitation services that is licensed by the Massachusetts Department of Public Health and accredited by the Commission on Accreditation of Rehabilitation Facilities (CARF). (2) Group Session – therapeutic services directed toward more than one patient in a single visit, using group participation as a treatment technique. (3) Maintenance Program – repetitive services, required to maintain or prevent the worsening of function, that do not require the judgment and skill of a licensed therapist for safety and effectiveness. (4) Occupational Therapy – therapy services, including diagnostic evaluation and therapeutic intervention, designed to improve, develop, correct, rehabilitate, or prevent the worsening of functions that affect the activities of daily living that have been lost, impaired, or reduced as a result of acute or chronic medical conditions, congenital anomalies, or injuries. Occupational therapy programs are designed to improve quality of life by recovering competence, preventing further injury or disability, and to improve the individual’s ability to perform tasks required for independent functioning, so that the individual can engage in activities of daily living. (5) Physical Therapy – therapy services, including diagnostic evaluation and therapeutic intervention, designed to improve, develop, correct, rehabilitate, or prevent the worsening of physical functions that have been lost, impaired, or reduced as a result of acute or chronic medical conditions, congenital anomalies, or injuries. Physical therapy emphasizes a form of rehabilitation focused on treatment of dysfunctions involving neuromuscular, musculoskeletal, cardiovascular/pulmonary, or integumentary systems through the use of therapeutic interventions to optimize functioning levels. (6) Physician’s Comprehensive Rehabilitation Evaluation – a cardiopulmonary, neuro- muscular, orthopedic, and functional assessment performed at a rehabilitation center by a physician. (7) Rehabilitation – the process of providing, in a coordinated manner, those comprehensive services deemed appropriate to the needs of a physically disabled individual, in a program designed to achieve objectives of improved health and welfare with the realization of his or her maximum physical, social, psychological, and vocational potential. (8) Speech/Language Therapy – therapy services, including diagnostic evaluation and therapeutic intervention, that are designed to improve, develop, correct, rehabilitate, or prevent the worsening of speech/language communication and swallowing disorders that have been lost, impaired, or reduced as a result of acute or chronic medical conditions, congenital anomalies, or injuries. Speech and language disorders are those that affect articulation of speech, sounds, fluency, voice, swallowing (regardless of presence of a communication disability), and those that impair comprehension, spoken, written, or other symbol systems used for communication. (9) Therapist’s Evaluation – an evaluation performed by a physical therapist, an occupational therapist, or a speech therapist at a rehabilitation center. (10) Therapy Visit – a personal contact with a member by a licensed physical therapist, occupational therapist, or speech and language therapist for the purpose of providing a covered service. Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 4. Program Regulations (130 CMR 430.000) Page 4-2 Rehabilitation Center Manual Transmittal Letter RHB-21 Date 06/01/11 (B) Eligible Members. (1) (a) MassHealth Members. MassHealth covers rehabilitation services only when provided to eligible MassHealth members, subject to the restrictions and limitations described in MassHealth regulations. 130 CMR 450.105 specifically states, for each MassHealth coverage type, which services are covered and which members are eligible to receive those services. (b) Recipients of the Emergency Aid to the Elderly, Disabled and Children Program. For information on covered services for recipients of the Emergency Aid to the Elderly, Disabled and Children program, see 130 CMR 450.106. (2) For information on verifying member eligibility and coverage type, see 130 CMR 450.107. (C) General Requirements. (1) The rate of payment for a service is the lower of either the provider’s usual fee to patients other than MassHealth members or the amount in the applicable Division of Health Care Finance and Policy fee schedule. (2) The rates of payment do not apply to the following services: (a) medical services except as required for a comprehensive rehabilitation evaluation; (b) psychology services; and (c) audiology services. (D) Prior Authorization. (1) The MassHealth agency requires rehabilitation centers to obtain prior authorization for the following services to eligible MassHealth members. (See also 130 CMR 450.303.) (a) more than 20 occupational-therapy visits or 20 physical-therapy visits, including group-therapy visits, for a member in a 12-month period; and (b) more than 35 speech/language therapy visits, including group-therapy visits, for a member in a 12-month period. (2) The rehabilitation center must submit all prior-authorization requests in accordance with the instructions in Subchapter 5 of the Rehabilitation Center Manual. Prior authorization determines only the medical necessity of the authorized service, and does not establish or waive any other prerequisites for payment, such as member eligibility or resort to health insurance payment. (E) Maintenance Programs. (1) The MassHealth agency pays for the establishment of a maintenance program and the training of the member, member’s family, or other persons to carry it out, as part of a regular treatment visit, not as a separate service. The MassHealth agency does not pay for performance of a maintenance program, except as provided in 130 CMR 430.601(E)(2). (2) In certain instances, the specialized knowledge and judgment of a licensed therapist may be required to perform services that are part of a maintenance program, to ensure safety or effectiveness that may otherwise be compromised due to the member’s medical condition. At the time the decision is made that the services must be performed by a licensed therapist, all information that supports the medical necessity for performance of such services by a licensed therapist, rather than a non-therapist, must be documented in the medical record.