Covered Services

(A) Facilities that provide covered services must meet the staff requirements outlined in 130 CMR 449.413 and as more fully described in provider bulletins and other guidance that may be issued by the MassHealth agency. (B) Covered CAA, 2023 services include: (1) Targeted Case Management (TCM) provided during the 30 days prior to the individual's release. (a) The TCM service must include the following elements: 1. Comprehensive assessment and periodic reassessment of individual needs, to determine the need for any medical, educational, social, or other services, including: a. taking client history; b. identifying the individual’s needs and completing related documentation; and c. gathering information from other sources such as family members, medical providers, social workers, and educators (if necessary), to form a complete assessment of the eligible individual. 2. Development (and periodic revision) of a specific person-centered care plan based on the information collected through the assessment that a. specifies the goals and actions to address the medical, social, educational, and other services needed by the individual; b. includes activities such as ensuring the active participation of the eligible individual, and working with the individual (or the individual’s authorized health care decision maker) and others to develop those goals; and c. identifies a course of action to respond to the assessed needs of the eligible individual. 3. Referral and related activities, including but not limited to referrals to appropriate care and services available in the geographic region of the home or residence of the eligible individual, (such as scheduling appointments for the individual) to help the eligible individual obtain needed services, including activities that help link the individual with medical, social, and educational providers or other programs and services that can provide needed services to address identified needs and achieve goals specified in the care plan. 4. A warm hand-off to a post-release case manager to transition case management and support continuity of care of needed services that are documented in the person- centered care plan. (2) Screening and Diagnostics provided during the 30 days before the individual's release. (a) Screenings for individuals younger than 21 years of age must include 1. services indicated as medically necessary in accordance with the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) requirements in 130 CMR 450.140; and 2. any additional screenings required by EOHHS as announced in sub-regulatory guidance, including but not limited to a behavioral health screening. (b) Screenings for former foster care youth ages 21 through 25 must include the screenings required by EOHHS as announced in sub-regulatory guidance, including but not limited to a behavioral health screening. (c) Diagnostics must include any diagnostics indicated as medically necessary based upon the required screenings that are feasible for the facility to provide. (C) Subject to the Commonwealth’s approval of a facility’s readiness, covered reentry demonstration services include: (1) Pre-Release Case Management provided during the 90 days prior to the individual’s release from the facility. (a) The Pre-Release Case Management service must include the following elements: 1. conducting a health risk assessment, as appropriate; 2. assessing the needs of the individual in order to inform development, with the client, of a discharge/reentry person-centered care plan, with input from the clinician providing consultation services and the facility’s reentry planning team. While the person-centered care plan is created in the pre-release period and is part of the case management pre-release service to assess and address physical and behavioral health needs and health related social needs (HRSN) identified, the scope of the plan extends beyond release; 3. obtaining informed consent, when needed, to furnish services and/or to share information with other entities to improve coordination of care; 4. providing warm linkages to a post-release care manager, which includes sharing discharge/reentry care plans with the post-release care manager upon reentry; 5. ensuring that necessary appointments with physical and behavioral health care providers, including, as relevant to care needs, with behavioral health coordinators and post-release care managers are arranged; 6. making warm linkages to community-based services and supports, including but not limited to educational, social, prevocational, vocational, housing, nutritional, transportation, childcare, child development, and mutual aid support groups; 7. providing a warm hand-off, as appropriate, to post-release case managers; and8. ensuring that, as allowed under federal and state laws and through consent with the member, data is shared with post-release care managers, and, as relevant, to physical and behavioral health/serious mental illness (SMI)/substance use disorder (SUD) providers to enable timely and seamless hand-offs. (b) EOHHS may issue, via administrative bulletin or other written issuance, additional guidance regarding the requirements of pre-release case management. (D) Case management services delivered after an individual’s release from the facility are not included in the scope of 130 CMR 449.412.