Early Intervention Services

 Commonwealth of Massachusetts SUBCHAPTER NUMBER AND TITLE PAGE Division of Medical Assistance TABLE OF CONTENTS iv Provider Manual Series

TRANSMITTAL LETTER DATE EARLY INTERVENTION PROGRAM MANUAL EIP-13 10/03/97

4. PROGRAM REGULATIONS

440.401: Introduction ............................................................................................................. 4-1 440.402: Definitions ............................................................................................................... 4-1 440.403: Eligible Members..................................................................................................... 4-3 440.404: Provider Eligibility .................................................................................................. 4-3 (130 CMR 440.405 through 440.410 Reserved) 440.411: Staff Qualifications .................................................................................................. 4-4 440.412: Reimbursable Services ............................................................................................ 4-4 440.413: Nonreimbursable Services ...................................................................................... 4-5 440.414: Coordination of Services ......................................................................................... 4-5 440.415: Recordkeeping Requirements ................................................................................. 4-6 ( .416 through 440.420 Reserved) 440.421: Payment Limitations: Duration and Frequency ..................................................... 4-7 440.422: Rates of Payment .................................................................................................... 4-7

Commonwealth of Massachusetts SUBCHAPTER NUMBER AND TITLE PAGE Medical Assistance Program 4 PROGRAM REGULATIONS 4-1 Provider Manual Series ( .000) EARLY INTERVENTION PROGRAM TRANSMITTAL LETTER DATE MANUAL EIP-13 10/03/97

440.401: Introduction

All early intervention program providers participating in MassHealth must comply with the regulations of the Division governing MassHealth, including but not limited to Division regulations set forth in .000 and CMR 450.000. The general operation of early intervention programs is governed by the Massachusetts Department of Public Health, through its Early Intervention Operational Standards.

440.402: Definitions

The following terms used in .000 shall have the meanings given in this section unless the context clearly requires a different meaning.

Biological Risk Infant — an infant with a history of prenatal, perinatal, neonatal, or early developmental events or conditions suggestive of biological insults to the development of the central nervous system that, either singly or collectively, increase the probability of later atypical development.

Caregiver — an individual (such as, but not limited to, a parent or foster parent) who assumes primary responsibility for the day-to-day care of a child.

Center-Based Individual Visit — a face-to-face meeting, at an early intervention program's site, of one member or one member's caregiver, or both, with professional program staff for the purpose of furthering the member's developmental progress.

Child-Focused Group Session — a face-to-face meeting, at an early intervention program's site, of a group of members with a professional program staff for the purpose of furthering the members' developmental progress.

Early Intervention Program — a program that is certified by the Massachusetts Department of Public Health as an Early Intervention Program and that provides social, medical, educational, therapeutic, and developmental services for children aged three years or younger who are at biological, environmental, or established risk, and their families.

Environmental Risk Infant — an infant who is biologically sound but whose early life, including maternal and family care, health care, nutrition, opportunities for expression of adaptive behaviors, and patterns of physical and social stimulation, is so limiting that there is a likelihood of delayed development.

Established Risk Infant — an infant whose early development is influenced by diagnosed medical disorders of known etiology that cause developmental delay. Also within this category are children who during the infancy period, or more commonly in the second year of life, begin to manifest developmental delays or deviations, for known or unknown reasons.

Commonwealth of Massachusetts SUBCHAPTER NUMBER AND TITLE PAGE Medical Assistance Program 4 PROGRAM REGULATIONS 4-2 Provider Manual Series ( .000)

EARLY INTERVENTION PROGRAM TRANSMITTAL LETTER DATE MANUAL EIP-13 10/03/97

Evaluation/Assessment — the process of determining eligibility for early intervention services. Evaluation consists of administration of a normed developmental evaluation instrument by a multidisciplinary team and a determination of family and child-risk factors to document eligibility. Evaluation of eligibility is performed on referral to the early intervention program and on an annual basis. Assessment is the process of identifying the child's and family's strengths and needs, and the nature and extent of the early intervention services that are needed. Evaluation and assessment may be conducted simultaneously or as separate events during the process of a child's enrollment in early intervention.

Home Visit — a face-to-face meeting of the member, the member’s caregiver, or both, with professional program staff at the member's home, a child-care setting, or other off-site setting, for the purpose of furthering the member's developmental progress.

Individualized Family Service Plan (IFSP) — a document produced collaboratively by program staff and family members that contains the agreed-upon early intervention services. The IFSP is based on a multidisciplinary assessment.

Intake/Screening — an initial face-to-face meeting of a member and a member's caregiver with professional program staff to initiate the process of evaluation of eligibility and enrollment in the early intervention program. Initial information regarding the member's medical and developmental history relating to the member's possible eligibility for early intervention is collected. In the instances when probable eligibility is not determined by the referral information, a developmental screening tool may be administered to determine probable eligibility.

Operational Standards — the Early Intervention Operational Standards developed by the Massachusetts Department of Public Health to govern the general operation of early intervention programs in Massachusetts.

Parent-Focused Group Session — a face-to-face meeting of a group of members' parents/ caregivers (not a child-care worker) with professional program staff, for the purpose of support, education, and guidance.

Working Hour — one hour worked on an intake/screening or an evaluation/assessment by one professional staff member. (For example, if three professionals work together for one hour to complete an assessment/evaluation, the evaluation/assessment lasts three working hours.)

Commonwealth of Massachusetts SUBCHAPTER NUMBER AND TITLE PAGE Medical Assistance Program 4 PROGRAM REGULATIONS 4-3 Provider Manual Series ( .000)

EARLY INTERVENTION PROGRAM TRANSMITTAL LETTER DATE MANUAL EIP-13 10/03/97

440.403: Eligible Members

(A) MassHealth Members. The Division covers early intervention program services only when provided to eligible MassHealth members who meet all of the criteria in 130 CMR 440.403(A)(1) through (3), subject to all other restrictions and limitations described in the Division’s regulations. The Division’s regulations at 130 CMR 450.105 specifically state which services are covered and which members are eligible to receive those services. (1) The member is considered to be subject to a biological, environmental, or established risk. (2) Failure to receive early intervention services is expected to impede the member's development. (3) The member is aged three years or younger. An exception may be made if the member is in the process of transferring from the program. The Division will continue to pay as follows for services delivered to such a member: (a) if the member was born on or before April 1, for three months after the member's third birthday; and (b) if the member was born after April 1, until September 1 of the year of the member's third birthday or until three months after the member's third birthday, whichever is longer.

(B) Recipients of the Emergency Aid to the Elderly, Disabled and Children Program. For information on which services are covered for recipients of the Emergency Aid to the Elderly, Disabled and Children Program, see 130 CMR 450.106.

440.404: Provider Eligibility

(A) In State. To participate in MassHealth, an early intervention program located in Massachusetts must fulfill the following requirements. (1) Evidence of the program's compliance with the Operational Standards must be submitted to the Division. This evidence, supplied by the provider as a result of an on-site review of the program, must consist of a letter on Department of Public Health stationery stating that the program is in compliance with the Operational Standards and has been reviewed by the Department of Public Health. The letter must include the date of the review. (2) The provider must complete the MassHealth Provider Application. (3) After completion of the application process, the provider must enter into a provider agreement with the Division. Payments will not be made for services provided prior to the effective date of the provider agreement. Continuation of the agreement will be subject to the Division's receipt each year of documentation from the Department of Public Health as specified in .404(A)(1) above.

(B) Out of State. The Division does not pay for early intervention services provided outside the Commonwealth of Massachusetts, except as specified in 130 CMR 450.109.

( .405 through 440.410 Reserved)

Commonwealth of Massachusetts SUBCHAPTER NUMBER AND TITLE PAGE Medical Assistance Program 4 PROGRAM REGULATIONS 4-4 Provider Manual Series ( .000)

EARLY INTERVENTION PROGRAM TRANSMITTAL LETTER DATE MANUAL EIP-13 10/03/97

440.411: Staff Qualifications

The Division will pay for early intervention services only when they are furnished by those professional program staff members designated in .412 who possess the qualifications listed below.

(A) A nurse must possess a bachelor’s degree in nursing from an accredited program or a diploma in nursing from an accredited program and a current registration by the Massachusetts Board of Registration in Nursing.

(B) An occupational therapist must be a graduate of an occupational therapy curriculum approved by the American Occupational Therapy Association, and be licensed by the Massachusetts Board of Registration in Allied Health Professions.

(C) A physical therapist must be a graduate of a physical therapy curriculum approved by the American Physical Therapy Association, and be licensed by the Massachusetts Board of Registration in Allied Health Professions.

(D) A psychologist must possess a master’s degree from an accredited program in psychology, educational psychology, counseling psychology, or developmental psychology.

(E) A social worker must at a minimum be licensed as a licensed clinical social worker (LCSW) by the Massachusetts Board of Registration for Social Work.

(F) A speech and language pathologist must be licensed by the Massachusetts Board of Registration in Allied Health Professionals and either possess a Certificate of Clinical Competence (CCC) granted by the American Speech, Language, and Hearing Association, or be in the clinical fellowship the year prior to being granted a Certificate of Clinical Competence.

440.412: Reimbursable Services

(A) The Division pays early intervention programs for the following services only when they are furnished by a nurse, an occupational therapist, a physical therapist, a speech and language pathologist, a social worker, or a psychologist: (1) a home visit; (2) a center-based individual visit; (3) a child-focused group session; and (4) a parent-focused group session.

Commonwealth of Massachusetts SUBCHAPTER NUMBER AND TITLE PAGE Medical Assistance Program 4 PROGRAM REGULATIONS 4-5 Provider Manual Series ( .000)

EARLY INTERVENTION PROGRAM TRANSMITTAL LETTER DATE MANUAL EIP-13 10/03/97

(B) The Division pays early intervention programs for the following services only when they are furnished by a nurse, an occupational therapist, a physical therapist, a speech and language pathologist, a social worker, or a psychologist; or a developmental educator working with one of the above: (1) an evaluation/assessment; and (2) an intake/screening.

440.413: Nonreimbursable Services

The Division does not pay early intervention programs for the following:

(A) research or experimental treatment;

(B) educational services;

(C) recreational services;

(D) nutritional counseling;

(E) respite services;

(F) home- or center-based visits not conducted by a nurse, an occupational therapist, a physical therapist, a speech and language pathologist, a social worker, or a psychologist; and

(G) any visits, screenings, group sessions, or assessments that are missed by a member or canceled.

440.414: Coordination of Services

The Division pays for early intervention services only when the following conditions are met.

(A) Case Coordinator. The program must assign to each member a service coordinator who is responsible for the following: (1) coordinating services provided to the member; and (2) coordinating the development of the member’s individualized family service plan.

Commonwealth of Massachusetts SUBCHAPTER NUMBER AND TITLE PAGE Medical Assistance Program 4 PROGRAM REGULATIONS 4-6 Provider Manual Series ( .000)

EARLY INTERVENTION PROGRAM TRANSMITTAL LETTER DATE MANUAL EIP-13 10/03/97

(B) Physician or Clinic Care. The program must ensure that the member is under the routine care of a physician or clinic and that, if the member has not been examined by this clinic or physician more recently than six months before admission to the program, the member is examined within 90 days after admission. Such examination must, if appropriate, meet the requirements of the EPSDT Medical Protocol and Periodicity Schedule. If the member is enrolled in managed care, such examination must be delivered in accordance with the requirements of 130 CMR 508.000. If the program is unable to fulfill this requirement, it must submit to the Division documentation of its attempts to do so.

(C) Translation Services. An early intervention program must be responsive to the needs of the non-English-speaking population living within its service area. If interpretive assistance is not readily available, the case coordinator or the program must establish contact with appropriate community agencies that can aid the program by helping members and their families with language or cultural barriers.

440.415: Recordkeeping Requirements

Early intervention programs must maintain, for at least four years after the member leaves the program, records for each member that include at least all the information required by the Department of Public Health in its Operational Standards and the following:

(A) the member’s name, address, and MassHealth identification number;

(B) the name and address of the member’s caregiver;

(C) the name of the service coordinator;

(D) the name and address of the member’s primary physician, clinic, or coordinated health site (see Part 1 of the billing instructions in Subchapter 5 of the Early Intervention Program Manual);

(E) a schedule of visits, group sessions, assessments, progress reviews, and other services that have been or will be provided;

(F) an attendance record;

(G) a report for each reimbursable service provided, listing the date, duration, and type of service, the program staff involved, the ratio of staff to participants, and the work accomplished; and

(H) copies of any correspondence and reports of any consultations about the member’s treatment with the member’s family or friends or other individuals not employed by the program.

( .416 through 440.420 Reserved)

Commonwealth of Massachusetts SUBCHAPTER NUMBER AND TITLE PAGE Medical Assistance Program 4 PROGRAM REGULATIONS 4-7 Provider Manual Series ( .000)

EARLY INTERVENTION PROGRAM TRANSMITTAL LETTER DATE MANUAL EIP-13 10/03/97

440.421: Payment Limitations: Duration and Frequency

(A) Home Visit. Payment for a home visit is limited to two hours per visit. Payment will be made for no more than two home visits on a single day.

(B) Center-Based Individual Visit. Payment for a center-based individual visit is limited to two hours per visit.

(C) Child-Focused Group Session. Payment for a child-focused group session is limited to two and one-half hours per session.

(D) Parent-Focused Group Session. Payment for a parent-focused group session is limited to two hours per session and one session per week.

(E) Services Provided on the Same Day. The Division does not pay for more than one visit or session with the same service code provided to the same member on the same day with the exception of the home visit limitation as noted in .421(A).

(F) Evaluation/Assessment. An evaluation must be conducted upon the member’s enrollment in the program and then annually to determine continued eligibility. An assessment may be conducted periodically to determine the child’s strengths and needs. Payment is limited to 10 working hours per 12-month period for evaluation/assessment.

(G) Intake/Screening. Payment for a screening is limited to two working hours.

440.422: Rates of Payment

(A) The Massachusetts Division of Health Care Finance and Policy determines the maximum allowable fees for reimbursable services provided by early intervention programs. Payment is subject to the conditions, exclusions, and limitations set forth in the regulations in 130 CMR 440.000. Payment for a service provided by an early intervention program is the lowest of the following: (1) the provider’s usual and customary fee; or (2) the maximum allowable fee listed in the fee schedule in Subchapter 6 of the Early Intervention Program Manual.

(B) Maximum allowable fees for early intervention services include payment for administrative operations and for all aspects of service delivery. Providers may not bill separately for services such as, but not limited to, the following: (1) registration; (2) telephone contacts; (3) information and referral services; (4) recordkeeping; (5) travel costs incurred by program staff during home visits and consultations; (6) supervisory services; and (7) translation services.

Commonwealth of Massachusetts SUBCHAPTER NUMBER AND TITLE PAGE Medical Assistance Program 4 PROGRAM REGULATIONS 4-8 Provider Manual Series ( .000)

EARLY INTERVENTION PROGRAM TRANSMITTAL LETTER DATE MANUAL EIP-13 10/03/97

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