Overview
Under Chapter 118E of the Massachusetts General Laws, the Executive Office of Health and Human Services, through the Division of Medical Assistance, administers the state’s Medicaid program, known as MassHealth. MassHealth provides access to healthcare services to approximately 1.9 million low- and moderate-income children, families, seniors, and people with disabilities annually. In fiscal year 2017, MassHealth paid more than $15 billion to healthcare providers, of which approximately 50% was funded by the Commonwealth. Medicaid expenditures represent approximately 39% of the Commonwealth’s total annual fiscal year 2017 budget of approximately $39 billion.
Cozy Corner Adult Day Health, located in Plymouth, became a certified MassHealth adult day health (ADH) provider on March 9, 2009. According to its website, Cozy Corner’s mission is to “provide quality health care to adults who require medical care or supervision during the day.” During the audit period, Cozy Corner provided ADH services to 47 different MassHealth members.
MassHealth pays for ADH services provided to eligible MassHealth members. It paid Cozy Corner $955,587 for ADH services provided to MassHealth members during the audit period, as detailed in the table below.
MassHealth Payments Received by Cozy Corner
|
Calendar Year |
MassHealth Payments |
Number of Claims |
Members Served |
|---|---|---|---|
|
2016 |
$502,809 |
11,934 |
34 |
|
2017 |
452,778 |
10,936 |
41 |
|
Total |
$955,587 |
22,870 |
|
ADH Services
MassHealth covers ADH services for eligible MassHealth members who need assistance with activities of daily living (ADLs) such as eating, toileting, bathing, walking, and taking medication. According to MassHealth regulations, to provide ADH services, an ADH provider must obtain documentation from the member’s own physician that includes the following:
- written physician orders detailing the member’s need for ADH services
- recent medical history
- results of a physical exam
- all medications and treatments prescribed
- special dietary needs
- any limitations the member may have in participating in ADH activities
- recommendations for therapy services, such as speech or physical therapy
The ADH provider uses this information to develop a member care plan that includes a treatment plan based on the member’s physician orders.
Additionally, the ADH provider must obtain written clinical authorizations from MassHealth approving the member to receive ADH services. The ADH provider must obtain both physician orders and MassHealth clinical authorizations before the member’s first day of service.
According to the Massachusetts Adult Day Services Association website, there are approximately 149 ADH programs in the Commonwealth, many of which are certified by MassHealth to provide ADH services to its members. These MassHealth-certified ADH providers bill MassHealth for ADH services either by the unit (in 15-minute increments) or for an entire six-hour day. ADH providers bill for one of two levels of ADH care:
- basic care, paid at $58.83 per day or $2.45 per 15-minute interval
- complex care, paid at $74.50 per day or $3.10 per 15-minute interval
In addition, ADH providers can bill MassHealth for transporting members to and from their facilities according to the applicable rate schedules established by the state Executive Office of Health and Human Services. Cozy Corner receives a rate of $17.56 per trip for transporting its members to and from its facility in Plymouth.
To avoid paying for duplicate services, MassHealth does not reimburse ADH providers for ADL services for (1) members residing in facilities such as nursing homes or home health agencies that provide the same services at the same time or (2) members receiving ADL services at the same time from personal care attendants.
Aging Services Access Points
Section 4B of Chapter 19A of the General Laws established Aging Services Access Points (ASAPs). According to the Executive Office of Elder Affairs’ website, ASAPs are “private non-profit agencies with governing boards that serve and represent 51% of people age 60 and older.” The Executive Office of Elder Affairs contracts with ASAPs to provide services by region for Massachusetts residents, including clinical assessments for MassHealth members seeking ADH services. These assessments are performed by ASAP nurses and represent independent clinical authorizations on behalf of MassHealth that verify MassHealth members’ medical need for ADH services. ASAPs receive referrals from ADH providers when new MassHealth members seek ADH services, for which ASAPs perform clinical assessments.
Upon completion of clinical assessments, ASAP nurses give ADH providers determination letters approving or denying members’ ADH services. ADH providers cannot provide any ADH services to members until they receive these letters.
ASAPs also pay ADH providers for services provided to MassHealth members enrolled in certain MassHealth plans, such as senior care organization and accountable care organization plans.
During our audit period, there were 26 ASAPs in the Commonwealth, and Cozy Corner primarily used the services of the ASAP Old Colony Elder Services in Brockton.
| Date published: | March 15, 2019 |
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