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Overview of the Audit of the Office of Medicaid (MassHealth)—Review of Claims Paid for Services Provided by Norwood Adult Day Health Center

This section describes the makeup and responsibilities of the Office of Medicaid (MassHealth)—Review of Claims Paid for Services Provided by Norwood Adult Day Health Center.

Table of Contents

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 healthcare providers more than $15 billion, of which approximately 50% was funded by the Commonwealth. Medicaid expenditures represented approximately 39% of the Commonwealth’s total annual fiscal year 2017 budget of approximately $39 billion.

Norwood Adult Day Health Center (NADHC) in Norwood, known as Norfolk Adult Day Health before 2015, became a certified MassHealth adult day health (ADH) provider in 1998. NADHC is one of three ADH locations owned and operated by HealthCare Options, Inc., which is located at 10 Emory Street in Attleboro. The other two ADH locations owned by HealthCare Options are Harmony Adult Day Health Center in Lakeville and Mansfield Adult Day Health Center in Mansfield. HealthCare Options is the billing agent for the three locations and is responsible for billing MassHealth for all the ADH services the three locations provide. HealthCare Options is owned by Community Health Services, Inc. of Attleboro, also known as Community VNA. According to Community VNA’s website, NADHC “provides services and resources that enhance the community’s capacity to achieve optimal health, wellness and quality of life.”

MassHealth pays for ADH services provided to eligible MassHealth members. It paid NADHC $1,854,494 for ADH services provided to MassHealth members during the audit period, as shown below.

MassHealth Payments Received by NADHC

Calendar Year

MassHealth Payments

Number of Claims

Members Served

2016

$953,866

29,235

80

2017

900,628

27,890

132

Total

$1,854,494

57,125

150*

*    This is the unduplicated total number of members served.

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. MassHealth-certified ADH providers bill MassHealth for ADH services either by the unit (in 15-minute increments) or for entire six-hour days. 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. In 2016, NADHC received $13.16 per trip for transporting its members to and from its facility. On July 1, 2017, this rate increased to $15.41 per trip.

To avoid paying for duplicate services, MassHealth does not reimburse ADH providers for ADL-related services for members while they are (1) living in facilities, such as nursing homes or home health agencies, that provide the same services or (2) receiving ADL services 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.

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 NADHC primarily used the services of the ASAP HESSCO Elder Services in Sharon.

Date published: June 6, 2019
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