Eligible Members

(A) MassHealth members. The MassHealth agency covers medical respite services only when provided to eligible MassHealth members, subject to the restrictions and limitations described in the MassHealth agency’s regulations, including, but not limited to, the restrictions and limitations of 130 CMR 458.000: Homeless Medical Respite Services and 130 CMR 450.000: Administrative and Billing Regulations. (B) Member Eligibility Criteria. To receive Medical Respite services, a member must: (1) Be 18 years of age or older; (2) Be an individual currently experiencing homelessness as defined in 130 CMR 458.402; (3) Meet any medical necessity criteria for medical respite, which may be established by MassHealth via provider bulletin, administrative bulletin or other written issuance; and (4) Satisfy either all of the eligibility criteria in 130 CMR 458.403(B)(4)(a) or all of the eligibility criteria in 130 CMR 458.403(B)(4)(b): (a) Eligibility for post hospitalization medical respite services: 1. The member has been admitted to an acute care hospital medical or surgical service or has presented to an acute care hospital emergency department with a medical or surgical issue; 2. The member has a primary acute medical issue that is not yet resolved but is expected to resolve and can be safely managed in a medical respite setting with the medical respite provider’s support accessing primarily home- and community-based MassHealth services; 3. The member does not meet nursing facility level of care criteria in accordance with 130 CMR 456.409; 4. The member is anticipated to no longer require or does not currently require acute care hospital level of care in accordance with 130 CMR 415.000 and has been deemed stable and ready for discharge to a home-based setting in the community; 5. The member is experiencing homelessness and does not have a stable and safe housing option identified or the resources to obtain appropriate housing where they can be safely discharged; and 6. The member is independent with regards to Activities of Daily Living (ADL) and Instrumental Activities of Daily Living (IADL), except for needing short-term assistance with regaining the ability to perform ADLs and IADLs as part of the recuperative process. (b) Eligibility for pre-procedure medical respite: 1. The member has a referral for a colonoscopy procedure or a colonoscopy procedure scheduled within one day of admission to the medical respite; and 2. The member cannot prepare for the colonoscopy effectively due to not having consistent access to a private bathroom.