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Overview of the Office of Medicaid (MassHealth)—Review of Claims Paid for Day Habilitation Services Provided by United Cerebral Palsy

This section describes the makeup and responsibilities of the Office of Medicaid (MassHealth)—Review of Claims Paid for Day Habilitation Services Provided by United Cerebral Palsy.

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 for 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 fiscal year 2017 budget of approximately $39 billion.

United Cerebral Palsy (UCP) in Watertown became a certified MassHealth day habilitation (DH) provider in 1983. According to its website, UCP’s mission is “advancing the independence, full citizenship and productivity of people with disabilities.”

MassHealth pays for DH services provided to eligible MassHealth members. It paid UCP $4,505,326 for DH services provided to 111 MassHealth members during the audit period, as shown below.

MassHealth Payments Received by UCP

Calendar Year

MassHealth Payments

Number of Claims

Members Served

2015
(April 1–December 31)

$1,227,776

293,785

82

2016

1,595,525

384,220

91

2017

1,099,817

266,850

71

2018
(January 1–July 31)

582,208

141,208

58

Total

$4,505,326

1,086,063

111*

*    This is the unduplicated total number of members served.

DH Services

MassHealth covers DH services for eligible MassHealth members based on a member service plan that sets forth measurable goals and objectives and prescribes an integrated program of activities and therapies necessary to reach them. According to Section 419.434 of Title 130 of the Code of Massachusetts Regulations,1 to be considered for admission to the DH program,

  1. The member must have mental retardation or a developmental disability. . . .
  2. The member must need and be expected to benefit from, day habilitation services designed to improve his or her level of independent functioning.
  3. The member must have a personal physician or medical clinic that may be contacted for consultations, examinations, and emergencies.
  4. Within 12 months before admission, the member must have had a comprehensive evaluation by a referring provider that includes the following:
  1. a written assessment of his or her social skills;
  2. a written assessment of his or her medical, mental, functional, and developmental status; and
  3. a home assessment that includes a family history and the person’s developmental history and a description of adaptation to the home environment.
  1. The member must have a record of all past and present immunizations and diagnostic tests.
  2. Members residing in nursing facilities must have been recommended for specialized services as a result of a preadmission screening.

A service-needs assessment must be completed. This is a compilation of evaluations by qualified professionals who determine the member’s functioning level, needs, and strengths and make specific recommendations for DH services to address identified needs. The DH provider uses this information to develop a member service plan that includes a treatment plan to achieve goals.

Additionally, for a DH provider to be paid, the DH services must be medically necessary as determined by MassHealth, must be prescribed in the member service plan, and must be authorized by the member’s physician or primary care clinician.

A severity profile must be submitted to MassHealth as a condition for payment for DH services provided to a member. This form records the member’s functional level and is used to determine the applicable MassHealth rate category for a member receiving DH services.

According to MassHealth data, there are approximately 128 DH programs in the Commonwealth, many of which are certified by MassHealth to provide DH services to its members. MassHealth-certified DH providers bill MassHealth for DH services either by the unit (in 15-minute increments) or for entire six-hour days. DH providers bill for three categories of member function:

  • low need, paid at $70.08 per day or $2.92 per 15-minute interval
  • moderate need, paid at $79.20 per day or $3.30 per 15-minute interval
  • high need, paid at $102.72 per day or $4.28 per 15-minute interval

1.    Effective September 7, 2018, MassHealth revised Section 419 of Title 130 of the Code of Massachusetts Regulations. For the purpose of our audit, OSA used the prior regulations that were in effect during the audit period. 

Date published: September 19, 2019

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