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Determining clinical assessment & eligibility for MassHealth programs

Are you feeling discouraged by the amount of help you need daily? Are you helping  someone to manage the monitoring or treatment of a chronic medical condition? Do you or your loved one need help with bathing and dressing or transfers and mobility? People who are over sixty or who have a disability and have unmet needs should look to LifePath to find the help they need. LifePath offers may options for independence. This article describes a specialized program for those with a high level of need.

MassHealth designates authority to determine a consumer’s clinical eligibility for various MassHealth programs, called Clinical Assessment & Eligibility (CAE), to Aging Service Access Points (ASAPs). LifePath is the ASAP for Franklin County as well as the four Worcester County towns of Athol, Petersham, Phillipston, and Royalston.

Andi Baker, RN, Clinical Services Nurse Manager at LifePath, leads the CAE determinations for admissions to programs both in the community and in nursing facilities. “[CAE] referrals come from a variety of sources: the community, the hospital, case managers in-house,” says Baker. Sometimes referrals are made as a part of a discharge plan from a facility so that MassHealth consumers may return home with services already put into place.

Consumers must be both financially and clinically eligible to qualify for and remain in a program. CAE determinations are performed for MassHealth members or applicants. Consumers with higher incomes may still qualify under a “waivered” program in which the consumer’s income is counted separately from their spouse’s or in which the consumer is very frail. Massachusetts has “waivers” that allow persons who meet nursing facility level of care access to home and community services.

Clinical determinations begin with a review of current medical information provided by a hospital, physician, or nursing facility. In the community or a nursing facility, a nursing on-site assessment is performed to interview the consumer directly and determine his/her particular needs and abilities. Family members and other involved caregivers can be important sources of information in this process. Clinical eligibility criteria are dictated by Commonwealth of Massachusetts regulations.

For those who qualify, CAE can provide clinical approval for MassHealth payment of nursing facility services and for community-based programs such as Adult Day Health and the Home and Community-Based Services Waiver (Frail Elder Waiver).

LifePath RNs also conduct initial assessment and redeterminations for non-MassHealth programs such as the Enhanced Community Options Program (ECOP) and personal care services under the Home Care Program. Each program has its own assessment, documentation, and determination components.

For more information about Clinical Assessment and Eligibility, contact us.