Section 4B. The department shall manage the home care program established in section 4 with respect to clinical screening, service authorization activities and case management for Medicaid community-based long-term care made available to eligible elderly persons pursuant to chapter 118E and the regulations promulgated thereunder; provided, however, that the programs and activities authorized by this section shall be administered and coordinated in accordance with the single state agency requirement under 42 CFR Part 431 and other applicable requirements of Title XIX of the Social Security Act, or its successor title. The primary goal of the coordinated system of care shall be to assist elders in maintaining their residences in the community-consistent with their clinical and psychosocial needs in the most cost-effective manner possible. As used in this section, the word “Medicaid” shall mean medical care and assistance provided to eligible persons pursuant to said chapter 118E and said Title XIX or its successor title, the term “executive office” shall mean the executive office of health and human services and the term “community long-term care” shall mean those Medicaid services determined by the department in consultation with the secretary of health and human services.
The coordinated system of care shall be administered by agencies under contract with the department that shall be known as aging services access points, hereinafter referred to as ASAPs. ASAPs shall be designated by the department and may be operated nonprofit agencies, home care providers as defined in clause (c) of the third paragraph of section 4, a combination of home care corporations acting jointly or by state agencies. Pursuant to the terms of those contracts, ASAPs shall coordinate services on behalf of Medicaid eligible elders; provided, however, that the department shall maintain exclusive responsibility for determining the financial or categorical eligibility of elders for Medicaid and the secretary of health and human services shall establish rates and methods of payment for Medicaid services delivered pursuant to this section. Administrative payments to ASAPs for Medicaid-funded functions including, but not limited, to screenings, assessments, case management and coordination of care shall be established by the department in consultation with the secretary of health and human services. Administrative payments for home care-funded services under said section 4 shall be established by the department in consultation with the secretary of health and human services. The department, in consultation with the secretary of health and human services, may develop a capitation system of payment for services in which ASAPs shall be at financial risk for any Medicaid services authorized and purchased on behalf of an eligible person that exceed the amount of said capitation payments.
The department shall establish performance and outcome goals for Medicaid and home care-related functions of ASAPs and may establish such goals for any other responsibilities contracted to ASAPs for managing the coordinated system. Continuation of the contracts authorized by this section shall be dependent on the achievement of the Medicaid-related performance and outcome goals, as determined by the department.
ASAPs shall be responsible for: (1) providing information and referral services to elders; provided, however, that referrals for terminally ill elders shall include referrals to licensed and certified hospices for determination of eligibility, appropriateness and consumer interest in services; (2) conducting intake, comprehensive needs assessments, preadmission screening and clinical eligibility determinations for elders seeking institutional and community care services from Medicaid or the home care program, which in the case of hospice clients, shall adhere to Medicare and Medicaid conditions of participation pursuant to 42 C.F.R. 418 and 114.3 C.M.R. 43.00; (3) developing a comprehensive service plan based on the needs of an elder, provided, however, that a medical plan of care for an elder shall be developed by a licensed or certified health care provider; (4) arranging, coordinating, authorizing and purchasing community long-term care services called for in the comprehensive service plan; and (5) monitoring the outcomes of and making periodic adjustments to a service plan in consultation with service and health care providers. The establishment of a comprehensive service plan for an elder shall not establish an entitlement to services for that eligible person for services beyond that established by law or beyond the amounts appropriated therefor.
ASAP responsibilities for Medicaid-related functions shall be those established by the department. When renewing the annual terms of a contract the subsequent fiscal year, the department shall seek to promote continuity in the the coordinated system of care consistent with this section; provided, however, that substantive changes to the terms and conditions of an annual agreement, including changes to the functional responsibilities of ASAP’s as defined in this section, shall be negotiated after the department’s written findings that such changes are necessary as a result of changes in federally reimbursable services, rates of federal reimbursement rates or state fiscal demands or that the division is prepared to implement a more comprehensive, cost-effective and coordinated system of long-term care than that established in this section. The written finding required by this paragraph shall be submitted to the executive office, the secretary of administration and finance and the legislature’s joint committee on human services and elderly affairs.
ASAPs shall not provide direct services except for case management; information and referral, and protective services as defined in regulations of the home care program established pursuant to 651 C.M.R. 3.00 et seq. and nutrition services established pursuant to 651 CMR 4.00 et seq. and the Older Americans Act, as amended, 42 U.S.C. 3021 et seq. Except for the direct services provided by ASAPs pursuant to this section, no ASAP shall have a direct or indirect financial ownership interest in an entity that provides institutional or community long-term care services on a compensated basis. The department may grant a waiver of the restrictions in this paragraph upon a finding that public necessity and convenience require such a waiver.
Overall management, administration and oversight activities related to the screening and authorization of community long-term care services and related case management services shall be the responsibility of the department. The department shall actively explore with interested parties programmatic options that would decrease the reliance of nursing facilities on Medicaid funding and shall promote increased residential and community long-term care program options for elders needing long-term care services. The department shall also explore future coordinated systems of service delivery options as identified in the coordinated aging, rehabilitation and disability services project.