Common use of Family Assistance Enrollees CarePlus Clause in Contracts

Family Assistance Enrollees CarePlus. Transportation to and from the Adult Day Health program is arranged and reimbursed by the Adult Day Health program. In order to be eligible for Adult Day Health Services, the Enrollee must be at least 18 years of age or older and require assistance with at least one (1) ADL or one (1) skilled service and meet the eligibility criteria outlined in 130 CMR 404.407. Adult Xxxxxx Care - services ordered by a physician and delivered to an Enrollee in a home environment that meets the qualified setting as described in 130 CMR 408.435 Services are based upon an individual plan of care and include assistance with Activities of Daily Living (ADLs), Instrumental Activities of Daily Living (IADLs), and other personal care as needed, nursing services and oversight, and care management. Assistance with ADLs, IADLs and other personal care is provided by a qualified caregiver that lives with the Enrollee in the home environment. Nursing services and oversight and care management are provided by a multidisciplinary team. In order to be eligible for Adult Xxxxxx Care services, the Enrollee must be at least 16 years of age or older an require assistance with at least one (1) ADL and meet the eligibility criteria outlined in 130 CMR 408.417. ✓ Chronic, Rehabilitation Hospital, or Nursing Facility Services – Both 1. Services provided at either a nursing facility, chronic or rehabilitation hospital, or any combination thereof, over 100 days per Contract Year per Enrollee; provided, however, that (A) for Enrollees receiving Hospice services, the Contractor shall cover skilled nursing facility services without limitation, and (B) for Enrollees in Family Assistance such coverage is limited to six months consistent with MassHealth policy; and 2. Any stay of any duration in a Commonwealth-designated COVID-19 nursing facility. ✓ ✓ Day Habilitation – services provided in a community based day program setting that is open at least Monday through Friday for six hours per day and includes daily programming based on activities and therapies necessary to meet individual goals and objectives. Goals and objectives are outlined on a day habilitation service plan and are ✓ Coverage Types Service MassHealth Standard & CommonHealth Enrollees MassHealth Family Assistance Enrollees CarePlus designed to help an Enrollee reach his/her optimal level of physical, cognitive, psychosocial and occupational capabilities. In order to be eligible for Day Habilitation services, the Enrollee must be at least 18 years of age or older; have a diagnosis of mental retardation and/or developmental disability; and meet the eligibility criteria outlined in 130 CMR 419.434. Dental - preventive and basic services for the prevention and control of dental diseases and the maintenance of oral health for children and adults as described in 130 CMR 420.000. ✓ ✓ ✓ Digital Therapy Products – Digital therapy products designated by EOHHS. Such digital therapy products, even though such products are Non-ACO Covered Services, must be listed on Contractor’s formulary in the same manner as listed on the MassHealth Drug List, with the same prior authorization status, point of sale (POS) rules, age restrictions, step therapy, quantity limit and diagnostic restrictions as MassHealth FFS. Claims for digital therapy products designated by EOHHS, which are Non-ACO Covered Services, must be processed through Contractor’s on-line pharmacy claims processing system and be paid to the pharmacy at $0 pay, with $0 cost share for members. ✓ ✓ ✓ Group Adult Xxxxxx Care - services ordered by a physician delivered to an Enrollee in a group housing residential setting such as assisted living, elderly, subsidized or supportive housing. Group Adult Xxxxxx Care services are based upon an individual plan of care and include: assistance with Activities of Daily Living (ADLs), Instrumental Activities of Daily Living (IADLs), and other personal care as needed, nursing services and oversight and care management. Assistance with ADLs, IADLs and other personal care is provided by a direct care worker that is employed or contracted by the Group Adult Xxxxxx Care Provider, Nursing services and oversight and care management are provided by a multidisciplinary team. In order to be eligible for Group Adult Xxxxxx Care services, the Enrollee must be at least 22 years of age or older and require assistance with at least one (1) ADL. ✓ Isolation and Recovery Site Services – services received by an Enrollee in an Isolation and Recovery site that are paid for by EOHHS using the payment methodologies described in Administrative Bulletin AB 20-30 or as set forth in the Acute Hospital RFA. ✓ ✓ ✓ Coverage Types Service MassHealth Standard & CommonHealth Enrollees MassHealth Family Assistance Enrollees CarePlus Personal Care Attendant – physical assistance with Activities of Daily Living (ADLs) such as: bathing, dressing/grooming, eating, mobility, toileting, medication administration, and passive range of motion exercise for Enrollees who have a chronic or permanent disability requiring physical assistance with two (2) or more ADLs. If an Enrollee is clinically eligible for PCA, an Enrollee may also receive assistance with Instrumental Activities of Daily Living (IADLs), including household management tasks, meal preparation, and transportation to medical providers. ✓ Private Duty Nursing/Continuous Skilled Nursing – a nursing visit of more than two continuous hours of nursing services. This service can be provided by a home health agency, continuous skilled nursing agency, or Independent Nurse. ✓ Transitional Support Services (TSS) for Substance Use Disorders (Level 3.1) – 24- hour short term intensive case management and psycho-educational residential programming with nursing available for members with substance use disorders who have recently been detoxified or stabilized and require additional transitional stabilization prior to placement in a residential or community based program. Enrollees with Co-Occurring Disorders receive coordination of transportation and referrals to mental health providers to ensure treatment for their co-occurring psychiatric conditions. Pregnant women receive coordination of their obstetrical care. ✓ ✓ ✓ Transportation (non-emergent, to in-state location or location within 50 miles of the Massachusetts border) - ambulance (land), chair car, taxi, and common carriers that generally are pre-arranged to transport an Enrollee to a covered service that is located in-state or within a 50-mile radius of the Massachusetts border. ✓ ✓ Vision Care (non-medical component) - prescription and dispensing of ophthalmic materials, including eyeglasses and other visual aids, excluding contacts. ✓ ✓ ✓ Appendix C Exhibit 3: ACO Covered Behavioral Health Services ✓ Denotes a covered service Coverage Types ACO ACO MassHealth MassHealth Service Standard & Family CarePlus CommonHealth Assistance Enrollees Enrollees Inpatient Services - 24-hour services, delivered in a licensed or state-operated hospital setting, that provide clinical intervention for mental health or substance use diagnoses, or both. This service does not include continuing inpatient psychiatric care delivered at a facility that provides such services, as further specified by EOHHS. (See details below)

Family Assistance Enrollees CarePlus. Transportation to and from the Adult Day Health program is arranged and reimbursed by the Adult Day Health program. In order to be eligible for Adult Day Health Services, the Enrollee must be at least 18 years of age or older and require assistance with at least one (1) ADL or one (1) skilled service and meet the eligibility criteria outlined in 130 CMR 404.407. Adult Xxxxxx Care - services ordered by a physician and delivered to an Enrollee in a home environment that meets the qualified setting as described in 130 CMR 408.435 Services are based upon an individual plan of care and include assistance with Activities of Daily Living (ADLs), Instrumental Activities of Daily Living (IADLs), and other personal care as needed, nursing services and oversight, and care management. Assistance with ADLs, IADLs and other personal care is provided by a qualified caregiver that lives with the Enrollee in the home environment. Nursing services and oversight and care management are provided by a multidisciplinary team. In order to be eligible for Adult Xxxxxx Care services, the Enrollee must be at least 16 years of age or older an require assistance with at least one (1) ADL and meet the eligibility criteria outlined in 130 CMR 408.417. ✓ Chronic, Rehabilitation Hospital, or Nursing Facility Services – Both 1. Services provided at either a nursing facility, chronic or rehabilitation hospital, or any combination thereof, over 100 days per Contract Year per Enrollee; provided, however, that (A) for Enrollees receiving Hospice services, the Contractor shall cover skilled nursing facility services without limitation, and (B) for Enrollees in Family Assistance such coverage is limited to six months consistent with MassHealth policy; and 2. Any stay of any duration in a Commonwealth-designated COVID-19 nursing facility. ✓ ✓ Day Habilitation – services provided in a community based day program setting that is open at least Monday through Friday for six hours per day and includes daily programming based on activities and therapies necessary to meet individual goals and objectives. Goals and objectives are outlined on a day habilitation service plan and are ✓ Coverage Types Service MassHealth Standard & CommonHealth Enrollees MassHealth Family Assistance Enrollees CarePlus designed to help an Enrollee reach his/her optimal level of physical, cognitive, psychosocial and occupational capabilities. In order to be eligible for Day Habilitation services, the Enrollee must be at least 18 years of age or older; have a diagnosis of mental retardation and/or developmental disability; and meet the eligibility criteria outlined in 130 CMR 419.434. Dental - preventive and basic services for the prevention and control of dental diseases and the maintenance of oral health for children and adults as described in 130 CMR 420.000. ✓ ✓ ✓ Digital Therapy Products – Digital therapy products designated by EOHHS. Such digital therapy products, even though such products are Non-ACO Covered Services, must be listed on Contractor’s formulary in the same manner as listed on the MassHealth Drug List, with the same prior authorization status, point of sale (POS) rules, age restrictions, step therapy, quantity limit and diagnostic restrictions as MassHealth FFS. Claims for digital therapy products designated by EOHHS, which are Non-ACO Covered Services, must be processed through Contractor’s on-line pharmacy claims processing system and be paid to the pharmacy at $0 pay, with $0 cost share for members. ✓ ✓ ✓ Group Adult Xxxxxx Care - services ordered by a physician delivered to an Enrollee in a group housing residential setting such as assisted living, elderly, subsidized or supportive housing. Group Adult Xxxxxx Care services are based upon an individual plan of care and include: assistance with Activities of Daily Living (ADLs), Instrumental Activities of Daily Living (IADLs), and other personal care as needed, nursing services and oversight and care management. Assistance with ADLs, IADLs and other personal care is provided by a direct care worker that is employed or contracted by the Group Adult Xxxxxx Care Provider, Nursing services and oversight and care management are provided by a multidisciplinary team. In order to be eligible for Group Adult Xxxxxx Care services, the Enrollee must be at least 22 years of age or older and require assistance with at least one (1) ADL. ✓ Isolation and Recovery Site Services – services received by an Enrollee in an Isolation and Recovery site that are paid for by EOHHS using the payment methodologies described in Administrative Bulletin AB 20-30 or as set forth in the Acute Hospital RFA. ✓ ✓ ✓ Coverage Types Service MassHealth Standard & CommonHealth Enrollees MassHealth Family Assistance Enrollees CarePlus Personal Care Attendant – physical assistance with Activities of Daily Living (ADLs) such as: bathing, dressing/grooming, eating, mobility, toileting, medication administration, and passive range of motion exercise for Enrollees who have a chronic or permanent disability requiring physical assistance with two (2) or more ADLs. If an Enrollee is clinically eligible for PCA, an Enrollee may also receive assistance with Instrumental Activities of Daily Living (IADLs), including household management tasks, meal preparation, and transportation to medical providers. ✓ Coverage Types Service MassHealth Standard & CommonHealth Enrollees MassHealth Family Assistance Enrollees CarePlus Private Duty Nursing/Continuous Skilled Nursing – a nursing visit of more than two continuous hours of nursing services. This service can be provided by a home health agency, continuous skilled nursing agency, or Independent Nurse. ✓ Transitional Support Services (TSS) for Substance Use Disorders (Level 3.1) – 24- hour short term intensive case management and psycho-educational residential programming with nursing available for members with substance use disorders who have recently been detoxified or stabilized and require additional transitional stabilization prior to placement in a residential or community based program. Enrollees with Co-Occurring Disorders receive coordination of transportation and referrals to mental health providers to ensure treatment for their co-occurring psychiatric conditions. Pregnant women receive coordination of their obstetrical care. ✓ ✓ ✓ Transportation (non-emergent, to in-state location or location within 50 miles of the Massachusetts border) - ambulance (land), chair car, taxi, and common carriers that generally are pre-arranged to transport an Enrollee to a covered service that is located in-state or within a 50-mile radius of the Massachusetts border. ✓ ✓ Vision Care (non-medical component) - prescription and dispensing of ophthalmic materials, including eyeglasses and other visual aids, excluding contacts. ✓ ✓ ✓ Appendix C Exhibit 3: ACO Covered Behavioral Health Services ✓ Denotes a covered service Coverage Types ACO ACO MassHealth MassHealth Service Standard & Family CarePlus CommonHealth Assistance Enrollees Enrollees Inpatient Services - 24-hour services, delivered in a licensed or state-operated hospital setting, that provide clinical intervention for mental health or substance use diagnoses, or both. This service does not include continuing inpatient psychiatric care delivered at a facility that provides such services, as further specified by EOHHS. (See details below)

Family Assistance Enrollees CarePlus. Transportation to and from the Adult Day Health program is arranged and reimbursed by the Adult Day Health program. In order to be eligible for Adult Day Health Services, the Enrollee must be at least 18 years of age or older and require assistance with at least one (1) ADL or one (1) skilled service and meet the eligibility criteria outlined in 130 CMR 404.407. Adult Xxxxxx Care - services ordered by a physician and delivered to an Enrollee in a home environment that meets the qualified setting as described in 130 CMR 408.435 Services are based upon an individual plan of care and include assistance with Activities of Daily Living (ADLs), Instrumental Activities of Daily Living (IADLs), and other personal care as needed, nursing services and oversight, and care management. Assistance with ADLs, IADLs and other personal care is provided by a qualified caregiver that lives with the Enrollee in the home environment. Nursing services and oversight and care management are provided by a multidisciplinary team. In order to be eligible for Adult Xxxxxx Care services, the Enrollee must be at least 16 years of age or older an require assistance with at least one (1) ADL and meet the eligibility criteria outlined in 130 CMR 408.417. ✓ Certain Bundled COVID-19 Testing – Bundled COVID-19 testing when billed under the A0999 code by a provider who has executed a special conditions contract with EOHHS. ✓ ✓ ✓ Chapter 766 – home assessments and participation in team meetings. ✓ ✓ Chronic, Rehabilitation Hospital, or Nursing Facility Services – Both 1. Services provided at either a nursing facility, chronic or rehabilitation hospital, or any combination thereof, over 100 days per Contract Year per Enrollee; provided, however, that (A) for Enrollees receiving Hospice services, the Contractor shall cover skilled nursing facility services without limitation, and (B) for Enrollees in Family Assistance such coverage is limited to six months consistent with MassHealth policy; and 2. Any stay of any duration in a Commonwealth-designated COVID-19 nursing facility. ✓ ✓ Coverage Types Service MassHealth Standard & CommonHealth Enrollees MassHealth Family Assistance Enrollees CarePlus Day Habilitation – services provided in a community based day program setting that is open at least Monday through Friday for six hours per day and includes daily programming based on activities and therapies necessary to meet individual goals and objectives. Goals and objectives are outlined on a day habilitation service plan and are ✓ Coverage Types Service MassHealth Standard & CommonHealth Enrollees MassHealth Family Assistance Enrollees CarePlus designed to help an Enrollee reach his/her optimal level of physical, cognitive, psychosocial and occupational capabilities. In order to be eligible for Day Habilitation services, the Enrollee must be at least 18 years of age or older; have a diagnosis of mental retardation and/or developmental disability; and meet the eligibility criteria outlined in 130 CMR 419.434. ✓ Dental - preventive and basic services for the prevention and control of dental diseases and the maintenance of oral health for children and adults as described in 130 CMR 420.000. ✓ ✓ ✓ Digital Therapy Products – Digital therapy products designated by EOHHS. Such digital therapy products, even though such products are Non-ACO Covered Services, must be listed on Contractor’s formulary in the same manner as listed on the MassHealth Drug List, with the same prior authorization status, point of sale (POS) rules, age restrictions, step therapy, quantity limit and diagnostic restrictions as MassHealth FFS. Claims for digital therapy products designated by EOHHS, which are Non-ACO Covered Services, must be processed through Contractor’s on-line pharmacy claims processing system and be paid to the pharmacy at $0 pay, with $0 cost share for members. ✓ ✓ ✓ Group Adult Xxxxxx Care - services ordered by a physician delivered to an Enrollee in a group housing residential setting such as assisted living, elderly, subsidized or supportive housing. Group Adult Xxxxxx Care services are based upon an individual plan of care and include: assistance with Activities of Daily Living (ADLs), Instrumental Activities of Daily Living (IADLs), and other personal care as needed, nursing services and oversight and care management. Assistance with ADLs, IADLs and other personal care is provided by a direct care worker that is employed or contracted by the Group Adult Xxxxxx Care Provider, Nursing services and oversight and care management are provided by a multidisciplinary team. In order to be ✓ Coverage Types Service MassHealth Standard & CommonHealth Enrollees MassHealth Family Assistance Enrollees CarePlus eligible for Group Adult Xxxxxx Care services, the Enrollee must be at least 22 years of age or older and require assistance with at least one (1) ADL. ✓ Isolation and Recovery Site Services – services received by an Enrollee in an Isolation and Recovery site that are paid for by EOHHS using the payment methodologies described in Administrative Bulletin AB 20-30 or as set forth in the Acute Hospital RFA. ✓ ✓ ✓ Coverage Types Service MassHealth Standard & CommonHealth Enrollees MassHealth Family Assistance Enrollees CarePlus Keep Teens Healthy - services provided pursuant to EOHHS’s “Keep Teens Healthy” provider agreement. ✓ ✓ Personal Care Attendant – physical assistance with Activities of Daily Living (ADLs) such as: bathing, dressing/grooming, eating, mobility, toileting, medication administration, and passive range of motion exercise for Enrollees who have a chronic or permanent disability requiring physical assistance with two (2) or more ADLs. If an Enrollee is clinically eligible for PCA, an Enrollee may also receive assistance with Instrumental Activities of Daily Living (IADLs), including household management tasks, meal preparation, and transportation to medical providers. ✓ Private Duty Nursing/Continuous Skilled Nursing – a nursing visit of more than two continuous hours of nursing services. This service can be provided by a home health agency, continuous skilled nursing agency, or Independent Nurse. ✓ Telehealth Network Provider Services – all services set forth in this Appendix C delivered via telehealth, when such services are rendered by a Telehealth Network Provider in the MassHealth provider network ✓ ✓ ✓ Transitional Support Services (TSS) for Substance Use Disorders (Level 3.1) – 24- hour short term intensive case management and psycho-educational residential programming with nursing available for members with substance use disorders who have recently been detoxified or stabilized and require additional transitional stabilization prior to placement in a residential or community based program. Enrollees with Co-Occurring Disorders receive coordination of transportation and referrals to mental health providers to ensure treatment for their co-occurring psychiatric conditions. Pregnant women receive coordination of their obstetrical care. ✓ ✓ ✓ Coverage Types Service MassHealth Standard & CommonHealth Enrollees MassHealth Family Assistance Enrollees CarePlus Transportation (non-emergent, to in-state location or location within 50 miles of the Massachusetts border) - ambulance (land), chair car, taxi, and common carriers that generally are pre-arranged to transport an Enrollee to a covered service that is located in-state or within a 50-mile radius of the Massachusetts border. ✓ ✓ Vision Care (non-medical component) - prescription and dispensing of ophthalmic materials, including eyeglasses and other visual aids, excluding contacts. ✓ ✓ ✓ Appendix C C‌ Exhibit 3: ACO Covered Behavioral Health Services ✓ Denotes a covered service Coverage Types ACO Service ACO MassHealth MassHealth Service Standard & CommonHealth Enrollees ACO MassHealth Family CarePlus CommonHealth Assistance Enrollees Enrollees CarePlus Inpatient Services - 24-hour services, delivered in a licensed or state-operated hospital setting, that provide clinical intervention for mental health or substance use diagnoses, or both. This service does not include continuing inpatient psychiatric care delivered at a facility that provides such services, as further specified by EOHHS. (See details below)