SECTION 1. Section 7 of Chapter 118G is hereby amended by inserting, in the first sentence after the words "health care services" the following:- for the purposes of this clause adult day health providers shall be considered institutional providers;
SECTION 2. Chapter 118G is hereby amended by inserting a new section
17A as follows:-
Section 17A. In establishing rates for adult day health providers, the executive office shall establish separate rates for the Basic and Complex levels of service. The Basic level of service rate shall be paid for any program participant who meets the requirements of 130 CMR
404.407 or requires skilled services that must be provided in a structured setting because of the intensity, duration, or frequency of need for these services. Skilled services are services ordered by a physician with the professional disciples of nursing, physical and occupational, or speech therapy. A recipient must require these services to achieve maximum use of his physical or mental capabilities, to prevent his physical or mental deterioration, or to maintain his optimal
level of functioning. Skilled services include, but are not limited to, the professional health-care management of the following:
(a) Impairments in the cardiovascular, respiratory, endocrine, musculoskeletal, neurological, gastrointestinal, or genitor-urinary systems, which require a plan of skilled care with documentation of assessment, intervention, teaching, and evaluation of clinical outcomes;
(b) Orthotic or prosthetic devices that necessitate professional assessment, teaching, and intervention; the presence of an orthotic or prosthetic device does not, in itself, determine the need for skilled care; however, other related medical conditions or specific medical complications may necessitate skilled care, and must be documented in the recipient's medical record;
(c) Treatment or prevention of actual or potential deterioration in skin, cardiac, or respiratory status that requires professional assessment, teaching, intervention and evaluation;
(d) Administration of prescribed topical, oral, and injectable medications;
(e) Specialized treatments, such as oxygen therapy and respiratory therapy, or
(f) Impairments in mobility that require assessment, teaching, and evaluation in the use of a cane, walker, or other prescribed durable medical equipment.
Sensory loss or impairment is not, in itself, an indication that the recipient requires care in an adult day health setting. In determining the appropriate site and level of care for a recipient, sensory impairment must be considered with all other factors that affect the amount, duration, and scope of services necessary.
Mental-state or cognitive impairment is not, in itself, an indication that the recipient requires care in an adult day health setting, nor does it indicate the need for a specific level of care. A recipient who exhibits mental-state or cognitive impairment such as confusion, disorientation to time, place or person, memory loss, or defective judgment - such as an impairment in the ability to judge personal safety and function in a non-supervised setting or impairment in the ability to
perceive or communicate health changes - may require care in an adult day health setting. In determining the appropriate care for a recipient, mental-state or cognitive impairment must be considered with all other factors that affect the amount, duration, and scope of services
Any participant who meets the eligibility criteria for nursing home placement pursuant to 130 CMR 456.409, and has been diagnosed with dementia shall be eligible for participation in the complex level of care.
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