Commonwealth of Massachusetts
Executive Office of Health and Human Services
Division of Medical Assistance
600 Washington Street
Boston, MA  02111
www.mass.gov/dma	
	MassHealth
	Adult Day Health Bulletin 10
	August 2002

	TO:	Adult Day Health Providers Participating in MassHealth

	FROM:	Wendy E. Warring, Commissioner

	RE:	Changes in Clinical Assessment for Adult Day Health Services  

Background	To be eligible for MassHealth, individuals must meet financial standards.  To be covered for certain MassHealth services, members or applicants must meet clinical criteria.  The Division or its agent determines clinical eligibility for adult day health services based upon documentation submitted by the provider and the member’s physician.

New Forms	This bulletin provides you with copies of the newly revised forms:
•	the Request for Services (formerly called the MassHealth Long 
	Term Care Assessment form); and
•	the Minimum Data Set for Home Care (MDS-HC).

These forms are the basis for approving referrals for long term care placement, conversions to MassHealth, and dementia‑specific reimbursement covered under the Home and Community-Based Services Waiver, in addition to adult day health.  

Begin using these forms as soon as you receive them.  As of September 1, 2002, the assessment agent will not accept the old forms.

Supplies of the Forms	You may photocopy the forms as needed.  To obtain supplies of the
forms, use the information below to mail or fax your request.  Include your provider number, address, telephone number, the exact title of the publication, and the date of issuance.

	MassHealth Forms Distribution
P.O. Box 9101
Somerville, MA 02145
Fax:  703-917-4937

	
Additional		In addition to the MDS-HC and  the Request for Services, the adult day 
Documentation	health provider must supply the Division’s assessment agent with any 
additional information requested by the local Aging Service Access Point (ASAP) to process referrals and annual screenings under the Home and Community-Based Services Waiver.

Clinical Assessment	Each provider must complete the MDS-HC form and the Request for 
Services.  The provider must then mail these forms to the appropriate ASAP.

Who May Complete	The program registered nurse is the assessment coordinator.  The 
the MDS-HC 	assessment coordinator’s signature certifies the accuracy and
Assessment	completeness of the MDS-HC assessment.  

The program registered nurse must complete the MDS-HC; however, a  licensed social worker (LSW, LCSW or LICSW) may complete the following sections of the MDS-HC: AA – Name and Identification Numbers, BB – Personal Items, CC – Referral Items, B – Cognitive Patterns, C – Communication/Hearing Patterns, E – Mood and Behavior Patterns, F – Social Functioning, G – Informal Support Services, and
O – Environmental Assessment.

Each individual who completes a portion of the MDS-HC should sign and certify the sections he or she completed in Section R (Assessment Information: signatures, title, sections, date).

ICD-9 Codes	The MDS-HC assessment requires the use of ICD-9‑CM Codes for medical diagnoses.  ICD-9‑CM code books are available at local medical supply stores and some local bookstores.  ICD-9‑CM codes are also available on the Internet.

Future Trainings	Periodic trainings will be held for new providers.  Please contact the
	Division for dates and locations.

Questions	If you have any questions about this bulletin, please contact the MassHealth Provider Services Department at 617-628-4141 or 1‑800‑325-5231.