This MassHealth regulation governs reimbursement and operational requirements for psychiatric inpatient hospital services under the Massachusetts Medicaid program. It establishes provider eligibility criteria, admission criteria (including separate criteria for members under and over age 21), treatment planning, discharge planning, recordkeeping, and billing requirements for both private and state-operated psychiatric inpatient hospitals. Facilities must be licensed by the Massachusetts Department of Mental Health (or equivalent out-of-state authority), accredited by the Joint Commission, and comply with all applicable MassHealth administrative and billing regulations.
View official sourceCommonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title Table of Contents Page iv Psychiatric Inpatient Hospital Manual Transmittal Letter PIH-23 Date 06/16/17 4. PROGRAM REGULATIONS 425.401: Introduction ....................................................................................................................... 4-1 425.402: Definitions ........................................................................................................................ 4-1 425.403: Eligible Members .............................................................................................................. 4-3 425.404: Exclusion of MassHealth Managed Care Members ........................................................... 4-3 425.405: Provider Eligibility ............................................................................................................ 4-3 425.406: Admission Criteria for Members Younger than 21 Years of Age ..................................... 4-4 425.407: Admission Criteria for Members 21 Years of Age or Older ............................................. 4-4 425.408: Payment Methodology ...................................................................................................... 4-5 425.409: Nonreimbursable Services ................................................................................................ 4-5 425.410: Service Limitations ........................................................................................................... 4-6 425.411: Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Services ..................... 4-6 425.412: Child and Adolescent Needs and Strengths (CANS) Certification .................................... 4-6 425.413: Child and Adolescent Needs and Strengths (CANS) Data Reporting ................................ 4-6 (130 CMR 425.414 Reserved) 425.415: Notification and Right of Appeal ..................................................................................... 4-7 425.416: Treatment Plan ................................................................................................................. 4-7 425.417: Conditions for Continuing Care ....................................................................................... 4-8 425.418: Discharge Planning .......................................................................................................... 4-8 (130 CMR 425.419 Reserved) 425.420 Reimbursable Administrative Days ................................................................................. 4-10 425.421 Nonreimbursable Administrative Days ............................................................................ 4-10 (130 CMR 425.422 Reserved) 425.423: Recordkeeping Requirements .......................................................................................... 4-12 425.424: Confidentiality ................................................................................................................. 4-13 456.601: Personal Needs Allowance Account ................................................................................. 4-15 456.602: Management of the PNA Account .................................................................................... 4-15 456.603: Autonomy of PNA Accounts ............................................................................................ 4-15 456.604: PNA Recordkeeping Requirements .................................................................................. 4-15 456.605: Petty Cash in the Facility .................................................................................................. 4-16 456.606: Assurance of Financial Security........................................................................................ 4-16 456.607: Availability of the PNA Records to Division Personnel ................................................... 4-17 456.608: Member Signature ............................................................................................................ 4-17 456.609: Notification of Account Balance ....................................................................................... 4-17 456.610: Availability of the PNA Records to Members .................................................................. 4-17 456.611: PNA Funds of a Member Transferred to Another Facility ................................................ 4-17 456.612: PNA Funds of a Member Discharged to the Community ................................................. 4-17 456.613: Member Is Transferred to a Hospital and Does Not Return to the Facility ....................... 4-18 456.614: Death of a Member ........................................................................................................... 4-18 456.615: Annual Accounting to the Division of the PNA Balance .................................................. 4-19 Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title Table of Contents Page vi Psychiatric Inpatient Hospital Manual Transmittal Letter PIH-23 Date 06/16/17 Appendix A. Directory ................................................................................................................. A-1 Appendix C. Third-Party-Liability Codes ..................................................................................... C-1 Appendix D. Supplemental Instructions for Claims with Other Insurance .................................... D-1 Appendix T. CMSP-Covered Codes ............................................................................................. T-1 Appendix U. DPH-Designated Serious Reportable Events That Are Not Provider Preventable Conditions ........................................................................................... U-1 Appendix V. MassHealth Billing Instructions for Provider Preventable Conditions .................... V-1 Appendix W. EPSDT Services Medical and Dental Protocols and Periodicity Schedules ............ W-1 Appendix X. Family Assistance Copayments and Deductibles .................................................... X-1 Appendix Y. EVS Codes and Messages ....................................................................................... Y-1 Appendix Z. EPSDT/PPHSD Screening Services Codes .............................................................. Z-1 Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 4. Program Regulations (130 CMR 425.000) Page 4-1 Psychiatric Inpatient Hospital Manual Transmittal Letter PIH-23 Date 06/16/17 425.401: Introduction 130 CMR 425.000 contains regulations governing psychiatric inpatient hospital services under MassHealth. All psychiatric inpatient hospitals participating in MassHealth must comply with the MassHealth regulations, including, but not limited to, MassHealth regulations at 130 CMR 425.000 and 130 CMR 450.000: Administrative and Billing Regulations. 425.402: Definitions The following terms used in 130 CMR 425.000 will have the meanings given in 130 CMR 425.402 unless the context clearly requires a different meaning. Administrative Day — a day of inpatient hospitalization on which a member's care needs can be met in a less intensive setting than a psychiatric inpatient hospital, as defined in 130 CMR 425.402, and on which a member is clinically ready for discharge, but an appropriate institutional or noninstitutional setting is not readily available. Case Manager an area-based coordinator of services employed by the Department of Mental Health (DMH) or, where appropriate, the Department of Children and Families (DCF), the Department of Youth Services (DYS), or the Department of Developmental Services (DDS). Child and Adolescent Needs and Strengths (CANS) — a tool that provides a standardized way to organize information gathered during behavioral-health clinical assessments. A Massachusetts version of the tool has been developed and is intended to be used as a treatment decision support tool for behavioral-health providers serving MassHealth members younger than 21 years of age. Day of Discharge – the day on which a member leaves the hospital regardless of the hour. The day of death is also considered the day of discharge. A leave of absence is not considered a discharge. Inpatient Psychiatric Treatment — treatment that encompasses multidisciplinary assessments and multimodal interventions. Twenty-four-hour skilled nursing care, daily medical care, provided by either a board certified psychiatrist, Psychiatric-Mental Health Clinical Nurse Specialist, or Psychiatric-Mental Health Nurse Practitioner, under supervision of a board certified psychiatrist, and a structured treatment milieu are required. Mental Illness — mental and emotional disorders as defined in the current International Classification of Diseases, Clinical Modification (ICD-CM) or the American Psychiatric Association's Diagnostic and Statistical Manual (DSM), and manifested by impaired functioning in behavior, feeling, thinking, or judgment to the extent that the affected person, or someone else, can observe that the person affected is unable to fulfill reasonable personal and social expectations. Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 4. Program Regulations (130 CMR 425.000) Page 4-2 Psychiatric Inpatient Hospital Manual Transmittal Letter PIH-23 Date 06/16/17 Multidisciplinary Treatment Team a team of mental-health professionals employed by or under contract with a psychiatric inpatient hospital that provides services to members in the facility. The team must include, at a minimum, a board-eligible or board-certified psychiatrist and one of the following: (1) an independent licensed clinical social worker; (2) a licensed registered nurse with specialized psychiatric training or at least one year's experience treating mentally ill individuals; (3) an occupational therapist who is licensed and who has specialized psychiatric training or at least one year's experience treating mentally ill individuals; or (4) a psychologist who has a master's degree in clinical psychology, or a closely related field such as counseling psychology, or who has been certified either by the state in which the psychiatric inpatient hospital is located or by that state's psychological association. Private Psychiatric Inpatient Hospital — any private psychiatric facility that is (1) licensed by the Massachusetts Department of Mental Health (if in-state), or by the governing or licensing agency in its state (if out-of-state); (2) accredited by the Joint Commission; and (3) is primarily engaged in treating persons, whose principal diagnosis is based on the current ICD-CM or the current DSM. "Primarily engaged in treating" means that over a six-month period inpatient care has been provided to a patient population of which over 50% consistently have a principal diagnosis that is psychiatric. Psychiatric Inpatient Hospital — a private psychiatric inpatient hospital or a state-operated psychiatric inpatient hospital. Screening Team — an independent team that certifies the need for services for members younger than 21 years of age. The team includes, but may not be limited to, a physician, and must (1) be competent in diagnosing and treating mental illness in children; and (2) have knowledge of the member’s condition. State-operated Psychiatric Hospital – a hospital that is accredited by a recognized accreditation body such as the Joint Commission and is operated by the Department of Mental Health pursuant to M.G.L. c. 19 and c. 123. Treatment Plan — a documented written plan developed for each member by the hospital multidisciplinary treatment team with the goal of improving the member's condition to the extent that inpatient care is no longer necessary. Working Days — Monday through Friday, except for holidays. Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 4. Program Regulations (130 CMR 425.000) Page 4-3 Psychiatric Inpatient Hospital Manual Transmittal Letter PIH-23 Date 06/16/17 425.403: Eligible Members (A) (1) MassHealth Members. MassHealth covers psychiatric inpatient hospital services only when provided to eligible MassHealth members, subject to the restrictions and limitations described in the MassHealth regulations. 130 CMR 450.105: Coverage Types specifically states, for each MassHealth coverage type, which services are covered and which members are eligible to receive those services. (2) Recipients of the Emergency Aid to the Elderly, Disabled and Children Program. For information on covered services for recipients of the Emergency Aid to the Elderly, Disabled and Children Program, see 130 CMR 450.106: Emergency Aid to the Elderly, Disabled and Children Program. (B) For information on verifying member eligibility and coverage type, see 130 CMR 450.107: Eligible Members and the MassHealth Card. 425.404: Exclusion of MassHealth Managed Care Members 130 CMR 425.000 does not apply to members participating in a MassHealth managed care plan. Participation in a MassHealth managed care plan is subject to change. Providers are responsible to verify member status on a daily basis. For more information, see 130 CMR 450.117: Managed Care Participation. 425.405: Provider Eligibility Payment for the services described in 130 CMR 425.000 will be made only to psychiatric inpatient hospitals participating in MassHealth on the date of service. (A) In State. To participate in MassHealth, an in-state psychiatric inpatient hospital must (1) be a state-operated psychiatric inpatient hospital; or (2) be a private psychiatric inpatient hospital meeting all of the following criteria: (a) has a signed provider agreement that specifies a payment methodology with the MassHealth agency; and (b) is licensed as a hospital by the Massachusetts Department of Mental Health (DMH); (c) is accredited by the Joint Commission; (d) participates in the Medicare program. (B) Out of State. To participate in MassHealth, an out-of-state private psychiatric inpatient hospital must (1) obtain a MassHealth provider number; (2) be licensed by the governing or licensing agency in its state; (3) be accredited by the Joint Commission; (4) participate in that state's Medicaid program; and (5) participate in the Medicare program. See 130 CMR 425.410: Service Limitations for limitations on services covered when provided in an out-of-state psychiatric hospital. Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 4. Program Regulations (130 CMR 425.000) Page 4-4 Psychiatric Inpatient Hospital Manual Transmittal Letter PIH-23 Date 06/16/17 (B) Out of State. To participate in MassHealth, an out-of-state private psychiatric inpatient hospital must (1) obtain a MassHealth provider number; (2) be licensed by the governing or licensing agency in its state; (3) be accredited by the Joint Commission; (4) participate in that state's Medicaid program; and (5) participate in the Medicare program. See 130 CMR 425.410: Service Limitations for limitations on services covered when provided in an out-of-state psychiatric hospital. 425.406: Admission Criteria for Members Younger than 21 Years of Age (A) A screening team must screen a member younger than 21 years of age prior to admission to a psychiatric inpatient hospital or prior to conversion to MassHealth, as defined in 130 CMR 425.402. The screening team will determine and certify whether the admission is medically necessary. (B) To demonstrate the necessity of a psychiatric inpatient hospital admission for a member younger than 21 years of age, the following conditions must be met: (1) the member must have mental illness; (2) the member must meet one or more of the following criteria: (a) be dangerous to himself or herself; (b) be dangerous to others; or (c) be unable to care for himself or herself; and (3) the moment-to-moment medical observation or clinical management required cannot be provided in a less restrictive setting. (C) Court-ordered admissions are exempt from the admission criteria stated in 130 CMR 425.406(A) and (B). 425.407: Admission Criteria for Members 21 Years of Age or Older A member 21 years of age or older must meet all of the following conditions of medical necessity: (A) demonstrate symptomatology consistent with a diagnosis listed in the current edition of the DSM, and that such symptomatology requires and will respond to therapeutic intervention; (B) be cleared for treatment in a nonmedical, nonsurgical treatment environment; (C) require 24-hour medical, psychiatric, and nursing services that can appropriately be provided only at an acute level-l of hospital care; Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 4. Program Regulations (130 CMR 425.000) Page 4-5 Psychiatric Inpatient Hospital Manual Transmittal Letter PIH-23 Date 06/16/17 (D) have a psychiatric condition that results in serious dysfunction, such as increased suicidal gestures, assaultiveness, or sudden inability to provide self-care, that endangers the member or others; and (E) present conditions that can reasonably be expected to improve to the extent that psychiatric inpatient hospital services will no longer be needed or further regression of the member’s condition will be prevented. 425.408: Payment Methodology (A) In State. Payments to in-state private psychiatric inpatient hospitals for services furnished to MassHealth members will equal the rate established in the signed provider contract with the MassHealth agency. (B) Out of State. Payment to out-of-state private psychiatric inpatient hospitals will be the Massachusetts state-wide average per diem rate or administrative day rate established by the MassHealth agency for in-state private psychiatric inpatient hospitals. 425.409: Nonreimbursable Services The following services are not reimbursable: (A) drugs and durable medical equipment prescribed for take-home use that are readily available from pharmacies or medical providers; (B) the cost of any treatment or testing of a member or of a specimen from a member who is not an inpatient in the psychiatric inpatient hospital; (C) room-and-board services on the day of discharge (unless the day of discharge is also the day of admission); (D) leave-of-absence days; (E) research or the provision of experimental or unproven procedures; (F) private hospital rooms, except when medically necessary; and (G) services furnished by the emergency room or outpatient department on the day of admission, during the inpatient stay, or on the day of discharge. Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 4. Program Regulations (130 CMR 425.000) Page 4-6 Psychiatric Inpatient Hospital Manual Transmittal Letter PIH-23 Date 06/16/17 425.410: Service Limitations (A) Members younger than 21 years of age must be prescreened by a screening team or be admitted under court order, pursuant to M.G.L. c. 123, §§ 7, 8, 12(a), and 12(b). (B) Out-of-state psychiatric inpatient hospital services are covered only as provided in 130 CMR 450.109: Out-of-state Services. 425.411: Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Services The MassHealth agency pays for all medically necessary psychiatric inpatient hospital services for EPSDT-eligible members in accordance with 130 CMR 450.140: Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Services: Introduction et seq. 425.412: Child and Adolescent Needs and Strengths (CANS) Certification The following clinicians are eligible to administer the Child and Adolescent Needs and Strengths (CANS) in psychiatric inpatient hospitals and must be certified every two years, according to the process established by the Executive Office of Health and Human Services (EOHHS): (A) psychiatrists and psychiatric residents; (B) Child/Adolescent or Adult Psychiatric-Mental Health Clinical Nurse Specialist–Board Certified (PMHCNS-BC) or Psychiatric Mental Health Nurse Practitioner-Board Certified (PMHNP-BC); (C) psychologists who have a specialization in clinical or counseling psychology; (D) social workers who have a master’s degree in social work from an accredited educational institution; and (E) counselors who have a master’s degree in counseling education, counseling psychology, or rehabilitation psychology from an accredited educational institution. 425.413: Child and Adolescent Needs and Strengths (CANS) Data Reporting For each Child and Adolescent Needs and Strengths (CANS) conducted, the hospital must report data collected during the assessment to the MassHealth agency, in the manner and format specified by the MassHealth agency. (130 CMR 425.414 Reserved) Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 4. Program Regulations (130 CMR 425.000) Page 4-7 Psychiatric Inpatient Hospital Manual Transmittal Letter PIH-23 Date 06/16/17 425.415: Notification and Right of Appeal (A) The MassHealth agency or its agent will send a written notification of approval or denial to the member and to the medical practitioner or facility who submitted the request for psychiatric inpatient hospital services. If authorization for psychiatric inpatient hospital services is denied, the notification will inform the member and the medical practitioner or facility of the reason for the denial, the member's right to appeal, and the appeal process. (B) Following the decision of the MassHealth agency or its agent to deny services in a psychiatric inpatient hospital, a member may appeal by requesting a fair hearing from the MassHealth agency. The request for a fair hearing must be made, in writing, within 30 days after receipt of the notice of the denial. The appeal procedure and fair hearing will be administered and conducted by the Board of Hearings in accordance with the regulations set forth in 130 CMR 610.000: MassHealth: Fair Hearing Rules. 425.416: Treatment Plan (A) The hospital multidisciplinary treatment team must develop and implement a written treatment plan for each member. For members younger than 21 years of age, the treatment plan must be developed in conjunction with any case managers the member may have from DMH, DCF, DYS, or DDS. The treatment plan must (1) be developed and reviewed with the fullest possible participation of the member, his or her designated representative or guardian, if any, and individuals in whose care the member will be released after discharge; (2) be based on the findings of an initial assessment; (3) be based on a diagnostic evaluation that includes examination of the medical, psychological, social, behavioral, and developmental aspects of the member's situation and that reflects the need for psychiatric inpatient hospital care; (4) state long- and short-range goals; (5) state, with specific and measurable terms and time frames, treatment objectives that include changes that must occur in order to discharge the patient; (6) prescribe an integrated program of therapies, activities, and experiences designed to meet the treatment objectives; (7) specifically identify the psychiatric symptoms that require psychiatric inpatient hospital care rather than treatment in a less-restrictive setting; (8) be developed and implemented within three calendar days of admission; (9) include an initial determination of the member's expected length of stay in the facility and the anticipated discharge plan, that is coordinated with outpatient and community providers. (10) include written documentation in the member’s record that the member, his or her legal guardian, and family members are given the opportunity to participate in the development and modification of the treatment plan and the psychiatric treatment itself, through participation in family therapy as clinically indicated, and to attend treatment plan meetings as clinically appropriate and according to the bounds of consent; and (11) when appropriate, include indications of the need for DMH Continuing Care Services or for services from other state agencies, or both. Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 4. Program Regulations (130 CMR 425.000) Page 4-8 Psychiatric Inpatient Hospital Manual Transmittal Letter PIH-23 Date 06/16/17 (B) The treatment plan for each member must be reviewed, and revised if necessary, by the hospital interdisciplinary review team every seven days from the date of admission to determine that psychiatric services being provided are required on an inpatient basis. If the member's length of stay is less than seven days, the review must be performed at the time of discharge. (C) The treatment plan must be documented in the member's medical record, as set forth in 130 CMR 425.423. 425.417: Conditions for Continuing Care (A) To continue to qualify for psychiatric inpatient hospital services, members must continue to meet the admission criteria described in 130 CMR 425.406 or 425.407, whichever is applicable, or meet one of the conditions in 130 CMR 425.417(B). Members who are younger than 21 years of age must also be reviewed by a screening team prior to the 30th day after admission and every 30 days thereafter. (B) Additional Conditions. The following additional conditions qualify a member 21 years of age or older to continue to receive psychiatric inpatient hospital services, even if the member does not qualify under 130 CMR 425.417(A): (1) the persistence of conditions that necessitated admission, despite therapeutic efforts, or the emergence of additional problems consistent with the admissions criteria in 130 CMR 425.406 or 425.407; (2) a severe reaction to medication; or (3) a need for stabilization of psychiatric conditions, integration of gains, or preparation for transition to outpatient care or a residential setting. 425.418: Discharge Planning (A) The psychiatric inpatient hospital must assign, in writing, the responsibility for all member discharge planning to one department (such as social services or continuing care). (B) Admission data, including but not limited to age and diagnosis, must be screened by discharge-planning staff within 24 hours of admission in accordance with written criteria that identify pertinent patient characteristics and any high-risk diagnoses. Discharge-planning activities must then commence within three working days of admission for every member expected to require post-hospital care or services. Admission data must be noted in the member's record by the discharge-planning department. The written criteria used to screen members must be available to the MassHealth agency. Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 4. Program Regulations (130 CMR 425.000) Page 4-9 Psychiatric Inpatient Hospital Manual Transmittal Letter PIH-23 Date 06/16/17 (C) The hospital's discharge-planning staff and interdisciplinary review team must coordinate and document, in writing, a plan for each member who requires post-hospital care. Such plan must be prepared by the hospital's interdisciplinary review team, in conjunction with any primary care provider, DMH, DCF, DYS, or DDS case managers, and must ensure continuity of care with the member's family, school, and community upon discharge. The plan must also specify the services and care required by the member and the frequency, intensity, and duration of such services, including available family and community support. The plan must be updated if the member's condition changes significantly. The hospital must ensure that a clinician certified in accordance with 130 CMR 425.412 completes a CANS during the discharge planning process for members younger than 21 years of age. (D) The hospital must have a written policy that allows discharge-planning staff access to all members and their medical records. If such access is clinically contraindicated, the member's psychiatrist must sign a statement specifying the reason for the contraindication and the hospital must maintain the statement in the member's medical and discharge-planning records. (E) Unless clinically contraindicated, the hospital's discharge-planning staff or interdisciplinary review team must contact the member’s family to involve them in planning the member's discharge. To this end, family members must be informed of the discharge options and community resources available to the member and provided with lists of community resources in the area. (F) Each visit to a member or meeting with the family by a member of the discharge-planning staff must be noted in the member's discharge-planning record. The notation must include the date of the meeting, all discharge options discussed, any problems raised and plans for addressing them, all agreements reached with the member, and additional steps required for the discharge-planning staff to prepare the member for discharge. (130 CMR 425.419 Reserved) Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 4. Program Regulations (130 CMR 425.000) Page 4-10 Psychiatric Inpatient Hospital Manual Transmittal Letter PIH-23 Date 06/16/17 425.420: Reimbursable Administrative Days (A) The MassHealth agency pays a private psychiatric inpatient hospital for a continued length of stay of up to 30 administrative days, as defined in 130 CMR 425.402. For members younger than 21 years of age and members 65 years of age and older, the MassHealth agency may pay a private psychiatric inpatient hospital for administrative days exceeding the 30-day limit where the hospital can demonstrate, to the satisfaction of the MassHealth agency or its agent, that the hospital has (1) experienced extraordinary difficulty in placing the member, including the specific reasons for such extraordinary difficulty; and (2) exhaustively explored all potential appropriate placements. (B) An administrative day, as defined in 130 CMR 425.402, is reimbursable only if a hospital is making regular efforts to move the member to a less intensive level of care. These efforts must be documented according to the procedures described in 130 CMR 450.205: Recordkeeping and Disclosure. The regulations covering discharge-planning standards described in 130 CMR 425.418 must be followed, but they do not preclude additional, effective discharge-planning activities. (C) Examples of situations that may require hospital stays at an administrative-day level include, but are not limited to, the following. (1) A member is awaiting transfer to a nursing facility or any other institutional placement, and no appropriate nursing-facility bed is available. (2) A member is awaiting arrangement of residential, social, psychiatric, or medical services by a public or private agency. (3) A member is awaiting results of a report of abuse or neglect made to any public agency charged with the investigation of such reports. (4) A member in the custody of the Department of Children and Families is awaiting foster care when other temporary living arrangements are unavailable or inappropriate. (5) A member cannot be treated or maintained at home because the primary caregiver is absent due to a medical or psychiatric crisis, and a substitute caregiver is not available. 425.421: Nonreimbursable Administrative Days Administrative days are not reimbursable when (A) an appropriate placement is currently available, but the hospital has not transferred or discharged the member because of the hospital's administrative or operational delays; (B) the MassHealth agency or its agent determines that appropriate noninstitutional or institutional placement or services are available within a reasonable distance of the member's noninstitutional (customary) residence and the member, the member's family, or any person legally responsible for the member refuses the placement or services; or Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 4. Program Regulations (130 CMR 425.000) Page 4-11 Psychiatric Inpatient Hospital Manual Transmittal Letter PIH-23 Date 06/16/17 (C) the MassHealth agency or its agent determines that appropriate noninstitutional or institutional placement or services are available within a reasonable distance of the member's noninstitutional (customary) residence and advises the hospital of the determination, and the hospital or the physician refuses or neglects to discharge the member. (130 CMR 425.422 Reserved) Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 4. Program Regulations (130 CMR 425.000) Page 4-12 Psychiatric Inpatient Hospital Manual Transmittal Letter PIH-23 Date 06/16/17 425.423: Recordkeeping Requirements (A) A record must be established and maintained for each member that is consistent with current professional standards. The record must include the following documents, if applicable: (1) the screening certification from a screening team, as described in 130 CMR 425.406, or appropriate court documentation for court-ordered admissions, pursuant to M.G.L. c. 123, §§ 7, 8, 12a, and 12b; (2) the treatment plan, as described in 130 CMR 425.416; (3) documentation from the hospital interdisciplinary review team supporting the need for continuing care, as described in 130 CMR 425.417; (4) the discharge plan, as described in 130 CMR 425.418; and (5) for members younger than 21 years of age, a copy of the CANS completed during the discharge planning process. (B) No information from the medical record may be released to other providers without a signed authorization form from the member, or his or her legal guardian. (C) Psychiatric inpatient hospitals must adhere to all laws and regulations relating to recordkeeping requirements, including but not limited to the confidentiality regulations in 130 CMR 425.424 and the recordkeeping and disclosure requirements of 130 CMR 450.205: Recordkeeping and Disclosure. (D) A member's records must be maintained by the psychiatric inpatient hospital for a period of six years following the date of discharge. (E) If any litigation, claim, negotiation, audit, or other action involving the records is commenced prior to the expiration of the applicable retention period, all records must be retained until completion of the action and resolution of all issues resulting therefrom, or until the end of the applicable retention period, whichever is later. Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 4. Program Regulations (130 CMR 425.000) Page 4-13 Psychiatric Inpatient Hospital Manual Transmittal Letter PIH-23 Date 06/16/17 425.424: Confidentiality (A) Psychiatric inpatient hospitals must comply with all state and federal laws and regulations relating to confidentiality and privacy. (B) At all times, psychiatric inpatient hospitals must recognize the MassHealth agency's ownership of personal data (as defined in M.G.L. c. 66A, § 1) and other information deemed confidential by the Commonwealth. (C) If any employee or subcontractor of a psychiatric inpatient hospital is involved with a member's personal data or other confidential information, the psychiatric inpatient hospital must inform the employee or subcontractor of the laws and regulations relating to confidentiality. REGULATORY AUTHORITY 130 CMR 425.000: M.G.L. c. 118E, §§ 7 and 12 Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 4. Program Regulations (130 CMR 425.000) Page 4-14 Psychiatric Inpatient Hospital Manual Transmittal Letter PIH-23 Date 06/16/17 This page is reserved. Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 4. Program Regulations (130 CMR 456.600) Page 4-15 Psychiatric Inpatient Hospital Manual Transmittal Letter PIH-9 Date 12/11/98 456.601: Personal Needs Allowance Account MassHealth members have the right to manage their own financial affairs and the nursing facility must not require residents to deposit their personal funds with the facility. However, upon written request by a member, the facility must hold, safeguard, manage, and account for the member’s personal funds deposited with the facility as specified in 130 CMR 456.601 through 456.615. 456.602: Management of the PNA Account If requested by the member, a facility must assume responsibility for the PNA funds of a member. To do so, the facility must obtain and maintain on file a statement of authorization signed by the member or the member’s authorized representative, such as a guardian, conservator, relative, or other responsible person acting on the member’s behalf. The “other responsible person” must not be an employee of the facility or related to an employee of the facility in any way. Once a facility is trustee of a member’s PNA account, it is responsible for the safekeeping of this money and must repay the member for any lost or stolen funds or for any money that cannot be accurately accounted for. 456.603: Autonomy of PNA Accounts (A) If the facility assumes responsibility for a member’s funds, the facility must deposit funds in excess of $50 into a PNA account, that is, an interest-bearing trustee account separate from any of the facility’s operating accounts. (B) The facility must ensure that PNA accounts are not available for any purpose except the personal needs of the member. The funds must not be lent or be used as collateral for a loan for anyone including the facility. 456.604: PNA Recordkeeping Requirements (A) The facility must establish and maintain a system of recordkeeping that ensures a complete and separate accounting of the PNA funds according to generally accepted accounting principles. The system must prevent any commingling of the members’ PNA funds with facility funds or with the funds of any other person other than another resident of the facility. If the facility does not manage the PNA funds for any member, it is not required to maintain such records. (B) (1) The facility must ensure a separate accounting of each member’s PNA funds, maintain a written record of all financial transactions involving the PNA funds, and allow the member or the member’s authorized representative access to the accounting record. (2) The bank-account statements and the general ledger must be in agreement and reconcilable at all times. All bank statements, canceled checks, and supporting documentation relating to the PNA account must be kept in the facility for at least four years from the date of the transaction. Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 4. Program Regulations (130 CMR 456.600) Page 4-16 Psychiatric Inpatient Hospital Manual Transmittal Letter PIH-9 Date 12/11/98 (3) All checks or cash received on behalf of the member must be deposited into the PNA account no later than 30 days after the receipt of the money by the facility. (4) The facility must maintain for each member with a PNA account a record of receipts and disbursements separate from other members’ records. The facility must clearly label all PNA receipts and disbursements in the general ledger. (5) At a minimum, all receipts and disbursements must be recorded in the ledger as follows: Receipts Disbursements 1. Date of entry 1. Date of entry 2. Amount 3. Source 2. Specific description (Avoid “misc.,” “personal needs,” etc.) 4. Balance 3. Amount 4. Signature of member or person receiving disbursement 5. Invoice number or date (6) General ledger records must be updated at least once a month. (7) The facility must ensure that funds are available to members in the form of actual cash or check for no less than 10 hours a week and on no less than three days a week. The facility must inform the members of the times when they may receive their money. (8) All money disbursed to or on behalf of a member must be at the request of the member or the member’s representative. The nursing facility may not make any disbursements on behalf of a member for a service that is covered by either Medicare or MassHealth. (9) If a facility disburses money to a member by means of a check, or if the member signs petty cash vouchers, the facility does not need to obtain a signature in the ledger. (10) The facility does not need to itemize cash disbursements to members. (11) The facility must provide the member or the member’s representative every three months and upon the member’s request with an accounting of all financial transactions made on the member’s behalf. 456.605: Petty Cash in the Facility The facility may, if it chooses, maintain a petty cash fund in order to make direct cash distributions to residents. The total of this petty-cash fund must not exceed an amount equal to $5 per member for whom the facility manages a PNA account; however, a maximum of $250 is allowable regardless of the number of members. 456.606: Assurance of Financial Security The facility must purchase a surety bond to assure the security of all personal funds of members deposited with the facility. The facility must keep this bond at the facility. Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 4. Program Regulations (130 CMR 456.600) Page 4-17 Psychiatric Inpatient Hospital Manual Transmittal Letter PIH-13 Date 02/01/00 456.607: Availability of PNA Records to Division Personnel All PNA records, including the accompanying bank statements, canceled checks, and supporting documentation, must be kept in the facility at all times and must be available to Division of Medical Assistance personnel upon request. The request may be made by telephone, in person, or by mail. 456.608: Member Signature If the member cannot sign his or her own name, a staff member or business employee of the facility may sign as witness that the member has received cash from his or her PNA account. 456.609: Notification of Account Balance (A) The facility must notify each member for whom it has established a PNA account when the balance reaches a total of $1800, which is $200 less than the maximum countable assets allowed per member. The notification must state that, if the member’s countable assets exceed the maximum allowable amount of $2000, the member may lose MassHealth eligibility. (B) If the member’s balance exceeds the maximum allowable amount, the member may apply the excess to the cost of care in the facility. 456.610: Availability of PNA Records to Members The facility must, within one working day of a request, allow the member or the member’s authorized representative to examine the PNA records of the member. 456.611: PNA Funds of a Member Transferred to Another Facility If a member is transferred to another facility, all of the member's funds held in trust by the facility must be sent to the new facility within 10 days of the transfer date. 456.612: PNA Funds of a Member Discharged to the Community If a member has been discharged from the facility to the community, he or she must receive his or her bank book back from the facility or receive a check for the balance of his or her PNA account. The amount of the check must reflect the cash held on behalf of the member by the facility plus the bank balance. Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 4. Program Regulations (130 CMR 456.600) Page 4-18 Psychiatric Inpatient Hospital Manual Transmittal Letter PIH-13 Date 02/01/00 456.613: Member Is Transferred to a Hospital and Does Not Return to the Facility If a member is transferred to a hospital and does not return to the facility, the balance of the PNA account must be sent to the member at his or her new address within 10 days after he or she leaves the facility. 456.614: Death of a Member (A) Upon the death of a MassHealth member, the facility must: (1) render an accounting of the member’s PNA funds. The funds must remain at the facility for 30 days after the death of a member to allow for the appointment of an administrator or executor of the estate and for the payment of burial expenses; and (2) notify the next of kin or the person who served as the member’s representative in official business with the facility of any remaining funds, determine whether or not an executor or administrator has been or will be appointed, and explain to the next of kin or the member’s representative how to obtain the funds from the facility. (a) If there is an outstanding balance due on a funeral bill, the funeral home may submit an itemized funeral bill to the facility and the facility may pay the bill from the PNA funds. (b) If an executor or administrator is appointed within 30 days after the death of a member, the facility must send the balance of the PNA account and a final accounting of the member’s account to the administrator or executor of the member's estate. If any payment has been made to the funeral home under 130 CMR 456.414(A)(2)(a), the final accounting must reflect that payment. (B) If any funds still remain in the PNA account after 30 days, the facility must (1) send a check for the balance and a final accounting of the member’s account to the Division of Medical Assistance; and (2) notify the next of kin or the member’s representative of the amount of the funds and the address to which they are being sent and tell them they may apply for the funds, if they are appointed executor or administrator of the member’s estate. (C) A final accounting of the PNA funds must include any transactions that occurred during the previous three months and for the 30 days following the member’s death. If there are no PNA funds, the facility is not required to submit the final accounting; however, the facility must maintain all member records according to 130 CMR 456.604. (D) The facility must include with the returned PNA balance and the accounting the following information: (1) the member's name and social security number; (2) the member’s date of birth and date of death; (3) the name, address, and relationship of the next of kin or the member’s representative; (4) the name, address, and MassHealth provider number of the facility; and (5) the name and address of the funeral director. Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 4. Program Regulations (130 CMR 456.600) Page 4-19 Psychiatric Inpatient Hospital Manual Transmittal Letter PIH-13 Date 02/01/00 456.615: Annual Accounting to the Division of the PNA Balance (A) Annually, at least by each June 1, an accounting must be made to the Division of the balance of each PNA account. If the facility is not a trustee for any member’s money, it must report this fact by each June 1 to the Division. The accounting to the Division must be submitted on the Statement of MassHealth Member’s Personal Needs Account (PNA-1) and must be dated and signed under the pains and penalty of perjury by the administrator of the facility and mailed to the Division. (B) The accounting must consist of the following: (1) the member's name; (2) the member's social security number; (3) the amount of petty cash held in the facility for the member; (4) the balance held in any individual bank account for the member; (5) the balance held in the trustee account for the member; (6) any other money being held by the facility for the member; and (7) if funds are held in an aggregate trustee bank account, then a copy of the bank statement for that account must be submitted with the accounting. Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 4. Program Regulations (130 CMR 456.600) Page 4-20 Psychiatric Inpatient Hospital Manual Transmittal Letter PIH-13 Date 02/01/00 This page is reserved.