Medicaid revises policy on home health aides & DME in response to advocacy letter

In August 2018 legal advocates wrote to the Medicaid director identifying several ways that current MassHealth regulations and policies on home health aide services and durable medical equipment (DME) are out of compliance with federal Medicaid regulations and harming our clients. We outlined the legal issues, the harm and asked for the agency to take corrective action. This began a series of meetings extending into 2019.. (Advocacy letter attached)

In October 2018, the agency issued a DME provider bulletin to clarify that DME suitable for use in the "home" includes community settings as defined in federal Medicaid regulations and that DME that would not be covered under a Medicare local coverage determination (LCD) cannot be denied for that reason but  requires an individualized assessment under the MassHealth medical necessity definition. The DME Bulletin is attached, as is later correspondence in Feb and Mar 2019 about training needed regarding the Oct 2018 Bulletin.

In June 2019, the agency issued a Home Health Agency (HHA) bulletin adding a new basis for individuals to qualify for a home health aide services when help is needed with at least 2 activities of daily living (ADLs) but there is no related need for skilled nursing or skilled therapy services. This is new and takes effect July 1, 2019. There is no change to the rules and procedures for obtaining a home health aide when someone also has a skilled nursing or therapy need. The HHA Bulletin is attached.

DLC has already seen the change in decisions affecting standing wheel chairs --which still require a strong showing of medical necessity--but are no longer denied based on the state rule deferring to Medicare local coverage determinations.

Starting July 1 2019 there will be expanded access to home health aides for help with ADLs (with no skilled nursing or therapy need). It will require prior approval & must be renewed every 90 days. Many of our clients will do better with PCAs. But help with ADLs from home health aides  will be an important resource for some of our clients such as elderly & disabled poverty level adult immigrants who cannot obtain Standard or CommonHealth because they do not have a "Qualified" immigration status but can obtain Family Assistance. Family Assistance does not cover PCAs but does cover the Home Health Agency services including the expanded home health aide benefit.

We want to monitor implementation. If advocates have clients with home health aide services denied or reduced based on lack of a skilled need or DME denied based on a Medicare coverage determination, please communicate with Vicky Pulos vpulos@mlri.org.  If MassHealth members have these problems, please use Find Legal Aid to find legal represenation for them.