Commonwealth of Massachusetts
Executive Office of Health and Human Services
Offi c e of Med ic aid
600 Washington Street Boston, MA 02111 www.mass.gov/dma

MASSHEALTH
TRANSMITTAL LETTER NF-49 January 2004
TO:      Nursing Facilities Participating in MassHealth FROM:      Beth Waldman, Director, Office of Medicaid 
RE:      Nursing Facility Manual (Senior Care Options)
Effective January 2, 2004, MassHealth members aged 65 and older will have the option of enrolling in a coordinated health plan called Senior Care Options (SCO). SCO is a comprehensive health plan that covers all of the services covered under Medicare and MassHealth, through a senior care organization and its network of providers. Enrollment in SCO is voluntary.
MassHealth members who are enrolled in SCO will not be covered for any services, including nursing-facility services, provided outside the senior care organization and its network of providers. Members who are enrolled in SCO will be so identified through the MassHealth Recipient Eligibility Verification System (REVS). It is, therefore, important, as always, to check REVS before providing services. If a MassHealth member seeking care from you is enrolled in SCO, you should contact the senior care organization with which the member is enrolled before providing services. The telephone number of the senior care organization is given on REVS.
This letter transmits revisions to MassHealth’s nursing facility regulations. At 130 CMR 456.408 (Conditions for Payment), MassHealth is adding the following paragraph:
(C) 130 CMR 456.408(A) and (B) do not apply to MassHealth members enrolled with a senior care organization. Enrollment in a senior care organization is voluntary and subject to change. Providers are responsible for verifying member status on a daily basis. For more information, see 130 CMR 450.117(D).
Additional revisions to reflect SCO have been made to the administrative and billing regulations, and were transmitted by Transmittal Letter ALL-122.
These regulations are effective January 2, 2004.
NEW MATERIAL
(The pages listed here contain new or revised language.)
Nursing Facility Manual
Pages 4-5 and 4-6
OBSOLETE MATERIAL
(The pages listed here are no longer in effect.)
Nursing Facility Manual
Pages 4-5 and 4-6 — transmitted by Transmittal Letter NF-34

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
NURSING FACILITY MANUAL	SUBCHAPTER NUMBER AND TITLE
4 PROGRAM REGULATIONS (130 CMR 456.000)	PAGE
4-5	

	TRANSMITTAL LETTER
NF-49	DATE
01/02/04	
(C) 130 CMR 456.408(A) and (B) do not apply to MassHealth members enrolled with a senior care organization. Enrollment in a senior care organization is voluntary and subject to change. Providers are responsible for verifying member status on a daily basis. For more information, see 130 CMR 450.117(D).
456.409:  Services Requirement for Medical Eligibility
To be considered medically eligible for nursing-facility services, the member or applicant must require one skilled service listed in 130 CMR 456.409(A) daily or the member must have a medical or mental condition requiring a combination of at least three services from 130 CMR 456.409(B) and (C), including at least one of the nursing services listed in 130 CMR 456.409(C).
(A) Skilled Services.   Skilled services must be performed by or under the supervision of a registered nurse or therapist. Skilled services consist of the following:
(1)	intravenous, intramuscular, or subcutaneous injection, or intravenous feeding;
(2)	nasogastric-tube, gastrostomy, or jejunostomy feeding;
(3)	nasopharyngeal aspiration and tracheostomy care, however, long-term care of a tracheotomy tube does not, in itself, indicate the need for skilled services;
(4)	treatment and/or application of dressings when the physician has prescribed irrigation, the application of medication, or sterile dressings of deep decubitus ulcers, other widespread skin disorders, or care of wounds, when the skills of a registered nurse are needed to provide safe and effective services (including, but not limited to, ulcers, burns, open surgical sites, fistulas, tube sites, and tumor erosions);
(5)	administration of oxygen on a regular and continuing basis when the member's medical condition warrants skilled observation (for example, when the member has chronic obstructive pulmonary disease or pulmonary edema);
(6)	skilled-nursing observation and evaluation of an unstable medical condition (observation must, however, be needed at frequent intervals throughout the 24 hours; for example, for arteriosclerotic heart disease with congestive heart failure);
(7)	skilled nursing for management and evaluation of the member's care plan when underlying conditions or complications require that only a registered nurse can ensure that essential unskilled care is achieving its purpose. The complexity of the unskilled services that are a necessary part of the medical treatment must require the involvement of skilled nursing personnel to promote the member's recovery and safety;
(8)	insertion, sterile irrigation, and replacement of catheters, care of a suprapubic catheter, or, in selected residents, a urethral catheter (a urethral catheter, particularly one placed for convenience or for control of incontinence, does not justify a need for skilled-nursing care). However, the insertion and maintenance of a urethral catheter as an adjunct to the active treatment of disease of the urinary tract may justify a need for skilled-nursing care. In such instances, the need for a urethral catheter must be documented and justified in the member's medical record (for example, cancer of the bladder or a resistant bladder infection);
(9)	gait evaluation and training administered or supervised by a registered physical therapist at least five days a week for members whose ability to walk has recently been impaired by a neurological, muscular, or skeletal abnormality following an acute condition (for example, fracture or stroke). The plan must be designed to achieve specific goals within a specific time frame. The member must require these services in an institutional setting;
(1)	
Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
NURSING FACILITY MANUAL	SUBCHAPTER NUMBER AND TITLE
4 PROGRAM REGULATIONS (130 CMR 456.000)	PAGE
4-6	

	TRANSMITTAL LETTER
NF-49	DATE
01/02/04	
(10)	certain range-of-motion exercises may constitute skilled physical therapy only if they are part of an active treatment plan for a specific state of a disease that has resulted in restriction of mobility (physical-therapy notes showing the degree of motion lost and the degree to be restored must be documented in the member's medical record);
(11)	hot pack, hydrocollator, paraffin bath, or whirlpool treatment will be considered skilled services only when the member's condition is complicated by a circulatory deficiency, areas of desensitization, open wounds, fractures, or other complications; and
(12)	physical, speech/language, occupational, or other therapy that is provided as part of a planned program that is designed, established, and directed by a qualified therapist. The findings of an initial evaluation and periodic reassessments must be documented in the member's medical record. Skilled therapeutic services must be ordered by a physician and be designed to achieve specific goals within a given time frame.
(B)	Assistance with Activities of Daily Living. Assistance with activities of daily living includes
the following services:
(1)	bathing when the member requires either direct care or attendance or constant supervision during the entire activity;
(2)	dressing when the member requires either direct care or attendance or constant supervision during the entire activity;
(3)	toileting, bladder or bowel, when the member is incontinent of bladder or bowel function day and night, or requires scheduled assistance or routine catheter or colostomy care;
(4)	transfers when the member must be assisted or lifted to another position;
(5)	mobility/ambulation when the member must be physically steadied, assisted, or guided in ambulation, or be unable to propel a wheelchair alone or appropriately and requires the assistance of another person; and
(6)	eating when the member requires constant intervention, individual supervision, or direct physical assistance.
(C)	Nursing Services. Nursing services, including any of the following procedures performed at
least three times a week, may be counted in the determination of medical eligibility:
(1)	any physician-ordered skilled service specified in 130 CMR 456.409(A);
(2)	positioning while in bed or a chair as part of the written care plan;
(3)	measurement of intake or output based on medical necessity;
(4)	administration of oral or injectable medications that require a registered nurse to monitor the dosage, frequency, or adverse reactions;
(5)	staff intervention required for selected types of behavior that are generally considered dependent or disruptive, such as disrobing, screaming, or being physically abusive to oneself or others; getting lost or wandering into inappropriate places; being unable to avoid simple dangers; or requiring a consistent staff one-to-one ratio for reality orientation when it relates to a specific diagnosis or behavior as determined by a mental-health professional;
(6)	physician-ordered occupational, physical, speech/language therapy or some combination of the three (time-limited with patient-specific goals);