Section 438.419 - Conditions of PaymentThe following conditions for payment apply to all CSN agency services, in addition to conditions of payment described throughout 130 CMR 438.000.
(A)Place of Service. The MassHealth agency pays for CSN agency services provided to a member who meets the clinical criteria in 130 CMR 438.410 and resides in a noninstitutional setting, which may include, without limitation, a homeless shelter or other temporary residence or a community setting. The MassHealth agency does not pay for CSN agency services provided in a hospital, nursing facility, intermediate care facility, or any other institutional setting providing medical, nursing, rehabilitative, or related care. The MassHealth agency will pay for CSN agency services when the CSN agency must accompany the member in transport to and from an institutional setting to ensure medical stability during transitions in and out of the institutional setting. The MassHealth agency does not pay for CSN agency services provided to a member under the direct care of a hospital or emergency room, a nursing facility, an intermediate care facility, or any other institutional setting providing medical, nursing, rehabilitative, or related care.(B)Medical Necessity Requirement. In accordance with 130 CMR 450.204: Medical Necessity, the MassHealth agency pays for only those CSN agency services that are medically necessary.(C)Plan of Care. The MassHealth agency pays only for CSN agency services that are provided according to a plan of care authorized by a physician or a non-physician practitioner and meet the plan of care requirements at 130 CMR 438.416.(D)Prior Authorization. The MassHealth agency pays for CSN agency services only when prior authorization has been obtained from the MassHealth agency or its designee, in accordance with 130 CMR 438.411.(E)Members for Whom Services Are Approved. The MassHealth agency does not pay for CSN agency services provided to any individual other than the member who is eligible to receive such services and for whom such services have been authorized by the MassHealth agency or its designee.(F)Multiple-patient Care and CSN Services. The MassHealth agency pays for one nurse to provide CSN services in the same household and during the same time period to more than one member, but not more than three members, if (1) the members have been determined by the MassHealth agency or its designee to meet the criteria listed at 130 CMR 438.410(A) and (B);(2) the members receive services in the same household and during the same time period;(3) the MassHealth agency or its designee has determined that it is appropriate for one nurse to provide nursing services to the members simultaneously; and(4) the CSN agency has received a separate prior authorization from the MassHealth agency or its designee for each member as described at 130 CMR 438.411.(G)Complex Care Assistant 60-day Supervisory Visits. The MassHealth agency only pays for the 60-day complex care assistant supervisory visit described at 130 CMR 438.415(C)(5)(c). The 60-day nurse reassessment visit may be made in conjunction with the supervisory visit.Adopted by Mass Register Issue 1459, eff. 1/1/2022.Amended by Mass Register Issue 1478, eff. 9/16/2022.Amended by Mass Register Issue 1500, eff. 7/21/2023.Amended by Mass Register Issue 1529, eff. 8/30/2024.