Conditions for Payment

(A) The MassHealth agency pays for nursing facility services if all of the following conditions are met. (1) The MassHealth agency or its designee has determined that individuals 22 years of age or older meet the nursing facility services requirements of 130 CMR 456.409 or the multi- disciplinary medical review team coordinated by the Department of Public Health has determined that individuals 21 years of age or younger meet the criteria of 130 CMR 519.006(A): Eligibility Requirements. (2) The MassHealth agency or its designee has determined that community care is either not available or not appropriate to meet the individual’s needs. (3) The requirements for the pre-admission screening and resident review (PASRR) process in 130 CMR 456.410 and as required by sub-regulatory guidance have been met. Failure to follow applicable PASRR rules will result in denial of MassHealth payments to the nursing facility for MassHealth members during the period of noncompliance pursuant to 42 CFR 483.122. (B) The MassHealth agency pays for nursing facility services beginning with the date of financial eligibility provided that the member shows that they were medically eligible for these services as of the date of financial eligibility. If the member was not medically eligible for nursing facility services as of the first date of financial eligibility, the MassHealth agency will pay for these services beginning on the first date the member is medically eligible, provided that this date is after the first date of financial eligibility. A person may request a determination of medical eligibility at or after application for MassHealth. (C) Nothing in 130 CMR 456.408 will be construed to prevent MassHealth from taking action, including overpayment and/or sanction action, for failure to meet the requirements of 130 CMR 456.000, of 101 CMR 206.00: Standard Payments to Nursing Facilities, or of the applicable requirements for long-term care facilities in 105 CMR 150.000: Standards for Long-Term Care Facilities. (D) 130 CMR 456.408(A) and (B) do not apply to MassHealth members enrolled in any MassHealth affiliated managed care plan or integrated care plan. Providers are responsible for verifying member status on a daily basis. For more information, see 130 CMR 450.117(B).