T hese Guidelines for Medical Necessity Determination (Guidelines) identify the clinical information that MassHealth uses to determine medical necessity for home health agency services. These Guidelines are based on generally accepted standards of practice, review of medical literature, and federal and state policies and laws applicable to Medicaid programs.
MassHealth Home Health Agency Services providers (“Providers”) should consult MassHealth regulations at 130 CMR 403.000 and 101 CMR 350.00 for information about coverage, limitations, service conditions, and prior-authorization (PA) requirements. Providers serving members enrolled in a MassHealth-contracted accountable care partnership plan (ACPP), managed care organization (MCO), One Care organization, Senior Care Options (SCO) plan, or Program of All-inclusive Care for the Elderly (PACE) should refer to the ACPP’s, MCO’s, One Care organization’s, SCO’s, or PACE’s medical policies, respectively, for covered services.
MassHealth requires PA after a certain number of visits (see Section III) for the following home health services provided in the member’s home: intermittent skilled nursing visits, medication administration visits, physical therapy, occupational therapy, speech/language therapy, and home health aide services. MassHealth reviews requests for PA on the basis of medical necessity. If MassHealth approves the request, payment is still subject to all general conditions of MassHealth, including member eligibility, other insurance, and program restrictions.