Administrative Care Management

For complex care members, as defined in 130 CMR 438.402, the MassHealth agency or its designee provides administrative care management that includes service coordination with CSN agencies as appropriate. The purpose of administrative care management is to ensure that a complex care member is provided with a coordinated LTSS package that meets the member’s individual needs and to ensure that the MassHealth agency pays for nursing, complex care assistant services, and other community LTSS only if 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 may 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 the member meets the criteria to be a complex care member as described at 130 CMR 438.402 and 438.410(B). If the member is determined to meet the criteria as a complex care member, the clinical manager will complete an LTSS needs assessment. The LTSS needs assessment will include input from the member; the member’s caregiver, if applicable; LTSS providers; and other treating clinicians. 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 other 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 CSN agency 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 at 130 CMR 438.414. (b) provides the member with copies of 1. the service record, one copy of which the member or the member’s primary natural caregiver is requested to sign and return to the clinical manager. On the copy being returned, the member or the member’s primary natural caregiver should 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 2. the LTSS needs assessment. (c) provides information to the CSN agency about services authorized in the service record that are applicable to the CSN agency. (4) Service Authorizations. The MassHealth agency or its designee will authorize those LTSS in the service record, including nursing and complex care assistant services, that require prior authorization and that are medically necessary, as provided in 130 CMR 438.412, and coordinate all nursing services and complex care assistant services; any applicable home health agency 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, 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 medically necessary LTSS 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 record are appropriate to meet the member’s needs. (B) CSN Agency Care Management Activities. The CSN agency must closely communicate and coordinate with the MassHealth agency’s or its designee’s clinical manager about the status of the member’s nursing and complex care assistant needs, in addition, but not limited to (1) The amount of authorized CSN and complex care assistant hours the agency is able and unable to fill upon agency admission, and periodically with 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 and services that may affect the member’s CSN agency service needs; (4) Needed changes in the agency’s CSN agency PA; and (5) Any incidents warranting an agency submitting to the MassHealth agency or its designee an incident or accident report. See 130 CMR 438.415(D)(2).