reglab/statecodes huggingface dataset:
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 448.000 - Community Behavioral Health Center Services › Section 448.414 - Supervision, Training, and Other Staff Requirements

Current through Register 1525, July 5, 2024
(A)
Supervision
.
(1)
Unlicensed or Not Independently Licensed Staff Supervision
			 Requirements
. All professionals who are unlicensed, who are in a
			 profession without licensure, or who are not independently licensed or
			 certified as a peer supervisor must receive direct and continuous supervision.
			 Direct and continuous supervision may be provided using telehealth
			 technology.
(2)
Independently Licensed and Certified Peer Supervisor
			 Staff
. All independently licensed professionals and certified peer
			 supervisors will receive supervision in accordance with center policy.
			 Supervision may be provided using telehealth technology.
(3) The supervising clinician is primarily
			 responsible for the care of the member. For any care delivered by a
			 professional under supervision, there will be documentation in the clinical
			 chart that the chart was reviewed by the supervising clinician.
(4) All supervision must be documented in
			 files accessible for review by the MassHealth agency. Supervision notes will,
			 at a minimum, contain information regarding frequency of supervision, format of
			 supervision, supervisor's signature and credentials, and general content of
			 supervision session.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 448.000 - Community Behavioral Health Center Services › Section 448.415 - Qualifications of Professional and Paraprofessional Staff Members Authorized to Render Billable Community Behavioral Health Center Services

Current through Register 1525, July 5, 2024
A center may only bill for medically necessary services
				provided by a professional or paraprofessional staff member qualified as
				follows.
(A)
Psychiatrists
			 and Medical Professionals
.
(1) At
			 least one staff psychiatrist must meet the requirements set forth in
			 130
			 CMR 448.413.
(2) Additional psychiatrists must be licensed
			 physicians in at least their second year of a psychiatric residency program
			 accredited by the Accreditation Council for Graduate Medical
			 Education.
(3) Psychiatrists and
			 prescribers will have the appropriate Drug Enforcement Administration (DEA) and
			 Department of Public Health (DPH) registrations for the prescribing of
			 controlled substances.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 448.000 - Community Behavioral Health Center Services › Section 448.416 - Coordination of Medical Care

Current through Register 1525, July 5, 2024
A community behavioral health center must coordinate behavioral
				health disorder treatment with medical care for MassHealth members. If a member
				has not received a physical exam within 12 months of the date of intake, the
				community behavioral health center will advise the member that one is needed.
				If the member does not have an existing relationship with a physician, the
				community behavioral health center will assist the member in contacting the
				MassHealth agency's customer service toll-free line to receive help in
				selecting a physician. If the member declines a physical examination, the
				member's record will document the member's preference and any stated reason for
				that preference. The center will have agreements with other providers where
				necessary to ensure member access to medically necessary medical and behavioral
				health services not provided by the center.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 448.000 - Community Behavioral Health Center Services › Section 448.417 - Schedule of Operations and Appointments

Current through Register 1525, July 5, 2024
(A)
Standard Hours Schedule of Operations
. The center must
			 offer appointment and treatment availability Monday through Friday during the
			 hours of 8:00 A.M. to 8:00 P.M. and on Saturdays and Sundays during the hours
			 of 9:00 A.M. to 5:00 P.M. Required appointment availability excludes state and
			 federal holidays.
(B)
After Hours Schedule of Operations
. Outside of the
			 standard hours of operation, the center must provide after-hours coverage to
			 triage needs and personnel must be available to offer referral to qualified
			 professionals, emergency services, or other mechanisms for effectively
			 responding to a crisis, in accordance with the requirements set forth at
			 130
			 CMR 448.412(A)(6).
(C)
Urgent and Crisis Services
			 Schedule of Operations
. The center must provide clinic coverage
			 24-hours per day, seven days per week to respond to members with an urgent need
			 or in crisis.
(1) Clinic coverage must include
			 live telephonic access to qualified professionals and, if indicated,
			 arrangements for further care and assistance in real-time to an appropriate
			 provider.
(2) Each center must
			 maintain a current roster of all on-call clinicians available to speak with
			 members. A pre-recorded message will not fulfill this requirement. The
			 after-hours triage phone line shall provide a direct connection to the center's
			 AMCI/YMCI.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 448.000 - Community Behavioral Health Center Services › Section 448.418 - Utilization Review Plan

Current through Register 1525, July 5, 2024
The community behavioral health center must have a utilization
				review plan that meets the following conditions.
(A) A utilization review committee will be
			 formed, composed of the clinical director or the clinical director's designee
			 and two other professional staff members who meet all the qualifications for
			 their discipline, as outlined in
			 130
			 CMR 448.415. The composition of the
			 utilization review committee will be reported to MassHealth as set forth in
			 130
			 CMR 448.406.
(B) The utilization review committee will
			 review each member's case in accordance with the Department of Public Health
			 regulations at
			 105
			 CMR 140.540:
Case Review
and
			 following the member's discharge from services at the center.
(C) The utilization review committee will
			 verify for each case that
(1) the diagnosis
			 is, or has been, adequately documented;
(2) the treatment plan is, or was,
			 appropriate and specifies the methods and duration of the projected treatment
			 program;
(3) the treatment plan is
			 being, or has been, carried out;
(4) the treatment plan is being, or has been,
			 modified as indicated by the member's changing status;
(5) there is, or was, adequate follow-up when
			 a member misses appointments or drops out of treatment;
(6) there is, or was, progress toward
			 achievement of short and long-term goals; and
(7) for members younger than 21 years old,
			 the CANS has been completed at the initial behavioral health assessment and
			 updated at least every 90 days thereafter.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 448.000 - Community Behavioral Health Center Services › Section 448.420 - Written Policies and Procedures

Current through Register 1525, July 5, 2024
Each community behavioral health center must have and observe
				written policies and procedures that include
(A) a description of the geographical area
			 served;
(B) an intake
			 policy;
(C) admission procedures,
			 including criteria for client admission and procedures for multidisciplinary
			 review of each individual referral;
(D) treatment procedures, including, but not
			 limited to, development of the treatment plan, case assignment, case review,
			 discharge planning, and follow-up on members who leave the center voluntarily
			 or involuntarily;
(E) a medication
			 policy that includes prescription data, administration data, monitoring data,
			 and procedures for induction and bridging of MOUD;
(F) a referral policy, including procedures
			 for ensuring uninterrupted and coordinated member care upon transfer;
(G) procedures for walk-in members, and
			 clinical emergencies during operating and nonoperating hours;
(H) recordkeeping policies, including what
			 information must be included in each record, and procedures to ensure
			 confidentiality;
(I) personnel and
			 management policies, including policies for hiring, training, evaluation,
			 supervision and termination protocol for all staff;
(J) a utilization review plan; and
(K) explicit fee policies with respect to
			 billing third party payers and cancellation procedures.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 448.000 - Community Behavioral Health Center Services › Section 448.421 - Administration

Current through Register 1525, July 5, 2024
(A)
Organization
. Each center will establish an
			 organization chart showing major operating service programs of the center, with
			 staff divisions, administrative personnel in charge of each service program,
			 and their lines of authority, responsibility, and communication.
(B)
Fiscal
			 Management
. Each center will establish a system of business
			 management to ensure accurate accounting for sources and uses of funds, and
			 proper expenditure of funds within established budgetary constraints and grant
			 restrictions.
(C)
Data
			 Management
. Each center will develop and maintain a statistical
			 information system to collect member, service utilization, and fiscal data
			 necessary for the effective operation of the center.
(D)
Personnel
			 Management
. Each center will establish and maintain personnel
			 policies and personnel records for each employee.
(E)
Staff Development and
			 Supervision
.
(1) Each staff
			 member must receive supervision appropriate to the person's skills and level of
			 professional development. Supervision will be documented and will occur within
			 the context of a formalized relationship with the supervisor and in accordance
			 with 130 CMR
			 448.414(A).
(2) Documentation of supervision will be
			 maintained by the supervisor.
(3)
			 Each center will establish and implement procedures for staff training and
			 evaluation. These procedures will require all staff who will be certified to
			 administer the CANS, as described in
			 130
			 CMR 448.414, to complete the certification
			 process established by EOHHS.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 448.000 - Community Behavioral Health Center Services › Section 448.422 - Outreach

Current through Register 1525, July 5, 2024
(A) Services
			 rendered in a member's home, place of residence, or an appropriate,
			 mutually-agreed-upon community-based location by clinicians who are employed by
			 the community behavioral health center may be billed by the center when
			 provided in accordance with the requirements of
			 130 CMR
			 448.000. All services provided in community-based
			 settings must be provided in accordance with all provisions in
			 130 CMR
			 448.000.
(B) All community behavioral health center
			 services must be billed with a Place of Service (POS) code denoting the
			 location in which the treatment was delivered.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 448.000 - Community Behavioral Health Center Services › Section 448.423 - Service Limitations

Current through Register 1525, July 5, 2024
(A)
Diagnostic and Treatment Services
. The MassHealth
			 agency pays for diagnostic and treatment services only when a professional
			 staff member, as defined by
			 130
			 CMR 448.415, personally provides these
			 services to the member or the member's family or personally consults with a
			 professional outside of the center. The services must be provided to the member
			 on an individual basis and are not reimbursable if they are an aspect of
			 service delivery, as defined in
			 130
			 CMR 448.408(B).
(B)
Multiple Visits on a Same
			 Date of Service
. Services provided through an encounter rate will
			 be paid by the MassHealth agency pursuant to
			 101 CMR
			 305.00:
Rates for Community Behavioral Health
			 Centers
. The MassHealth agency pays only one encounter bundled rate
			 for each member on one date of service. The MassHealth agency will pay for
			 Adult Mobile Crisis Intervention, Youth Mobile Crisis Intervention, Adult
			 Community Crisis Stabilization, Youth Community Crisis Stabilization, Certified
			 Peer Specialists services, Peer Recovery Coach services, Recovery Support
			 Navigator services, Community Support Program services, and Psychological
			 Testing on the same date of service as the encountered bundled rate. The
			 MassHealth agency will only pay for one of the following on a single date of
			 service: Structured Outpatient Addiction Program, Enhanced Structured
			 Outpatient Addiction Program, Intensive Outpatient Program, or the encounter
			 bundled rate.
(C)
Multiple Therapies
. The MassHealth agency pays for
			 more than one mode of therapy used for a member during one week when it is
			 clinically justified, and when any single approach has been shown to be
			 necessary but insufficient. The need for multiple therapies must be documented
			 in the member's record.
(D)
Case Consultation
.
(1) The MassHealth agency pays only for a
			 case consultation that involves a personal meeting with a professional of
			 another agency. Personal meetings may be conducted
via
audio-only telephonic, audio-video, or in person meetings.
(2) The MassHealth agency pays for case
			 consultation only when written communication and other non-reimbursable forms
			 of communication clearly will not suffice. Such circumstances must be
			 documented in the member's record. Such circumstances are limited to situations
			 in which both the center and the other party are actively involved in treatment
			 or management programs with the member (or family members) and where a lack of
			 direct communication would impede a coordinated treatment program.
(3) The MassHealth agency does not pay a
			 center for court testimony.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 450.000 - Administrative and Billing Regulations › Section 450.102 - Purpose of 130 CMR 400.000 through 499.000

Current through Register 1525, July 5, 2024
130 CMR 400.000 through 499.000 contain the MassHealth agency's
				regulations specific to provider participation in, and the medical services and
				benefits available under, MassHealth and the Emergency Aid to the Elderly,
				Disabled and Children Program.
				130 CMR 450.000 applies to
				all MassHealth providers and services. The MassHealth agency also promulgates
				other regulations, and publishes other documents affecting these programs,
				including other chapters in 130 CMR, statements of policy and procedure,
				conditions of participation, guidelines, billing and claims submission
				instructions, provider bulletins, and other documents referenced in 130 CMR. In
				addition, the regulations in 130 CMR frequently refer to federal regulations,
				to regulations of the Massachusetts Department of Public Health and other
				agencies, and to rates and fee schedules established by the Massachusetts
				Executive Office of Health and Human Services.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 450.000 - Administrative and Billing Regulations › Section 450.103 - Promulgation of 130 CMR

Current through Register 1525, July 5, 2024
(A) All regulations
			 of the MassHealth agency are promulgated in accordance with M.G.L. c. 30A. In
			 the event of any conflict between the MassHealth agency's regulations and
			 applicable federal laws and regulations, the MassHealth agency's regulations
			 will be construed so far as possible to make them consistent with such federal
			 laws and regulations.
(B) Without
			 limiting the generality of 130 CMR 450.103(A), the MassHealth agency's
			 regulations will be construed so far as possible to make them consistent with
			 the federal Health Insurance Portability and Accountability Act (HIPAA),
			 including federal regulations promulgated thereunder. To implement and comply
			 with HIPAA, the MassHealth agency may issue billing and claims submission
			 instructions, provider bulletins, companion guides, or other materials, which
			 will be effective and controlling notwithstanding any MassHealth agency
			 regulations to the contrary.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 450.000 - Administrative and Billing Regulations › Section 450.105 - Coverage Types

Current through Register 1525, July 5, 2024
A member is eligible for services and benefits according to the
				member's coverage type. Each coverage type is described below. Payment for the
				covered services listed in 130 CMR 450.105 is subject to all conditions and
				restrictions of MassHealth, including all applicable prerequisites for payment.
				See individual program regulations for information on covered services and
				specific service limitations, including age restrictions applicable to certain
				services.
(A)
MassHealth
			 Standard
.
(1)
Covered
			 Services
. The following services are covered for MassHealth
			 Standard members (
see
130 CMR
			 505.002:
MassHealth Standard
and
			 130 CMR
			 519.002:
MassHealth
			 Standard
).
(a) abortion
			 services;
(b) acupuncture
			 services;
(c) adult day health
			 services;
(d) adult foster care
			 services;
(e) ambulance
			 services;
(f) ambulatory surgery
			 services;
(g) audiologist
			 services;
(h) behavioral health
			 services;
(i) certified nurse
			 midwife services
(j) certified
			 nurse practitioner services;
(k)
			 certified registered nurse anesthetist services;
(l) Chapter 766: home assessments and
			 participation in team meetings;
(m)
			 chiropractor services;
(n) clinical
			 nurse specialist services;
(o)
			 community health center services;
(p) day habilitation services;
(q) dental services;
(r) durable medical equipment and
			 supplies;
(s) early intervention
			 services;
(t) family planning
			 services;
(u) hearing aid
			 services;
(v) home health
			 services;
(w) hospice
			 services;
(x) independent nurse
			 (private duty nursing) services;
(y) inpatient hospital services;
(z) laboratory services;
(aa) nursing facility services;
(bb) orthotic services;
(cc) outpatient hospital services;
(dd) oxygen and respiratory therapy
			 equipment;
(ee) personal care
			 services;
(ff) pharmacy
			 services;
(gg) physician
			 services;
(hh) physician assistant
			 services;
(ii) podiatrist
			 services;
(jj) prosthetic
			 services;
(kk) psychiatric clinical
			 nurse specialist services;
(ll)
			 rehabilitation services;
(mm) renal
			 dialysis services;
(nn) speech and
			 hearing services;
(oo) therapy
			 services: physical, occupational, and speech/language;
(pp) transportation services;
(qq) urgent care clinic services;
(rr) vision care; and
(ss) X-ray/radiology services.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 450.000 - Administrative and Billing Regulations › Section 450.106 - Emergency Aid to the Elderly, Disabled and Children Program

Current through Register 1525, July 5, 2024
(A)
Covered
			 Services
. The following services are covered for EAEDC recipients:
(1) physician services specified in
			 130 CMR
			 433.000:
Physician
			 Services
;
(2) community
			 health center services specified in
			 130
			 CMR 405.000:
Community Health Center
			 Services
;
(3) prescription
			 drugs (those drugs that require a prescription under federal or state law)
			 specified in
			 130 CMR
			 406.000:
Pharmacy Services
;
(4) insulins (the only over-the-counter drugs
			 that are covered) and diabetic supplies;
(5) infusion (intravenous) therapy, including
			 chemotherapy, pain management, antibiotics, chelation, and cardiac
			 management;
(6) oxygen and
			 respiratory therapy services specified in
			 130 CMR 427.000:
Oxygen and Respiratory Therapy Equipment
;
(7) substance use disorder treatment services
			 as specified in
			 130 CMR 418.000:
Substance Abuse Treatment Services
if provided in public
			 detoxification and outpatient substance use disorder treatment centers;
			 and
(8) diagnostics and testing
			 (such as laboratory, radiology, magnetic resonance imaging, or psychological
			 testing) necessary for the determination or redetermination of eligibility for
			 the EAEDC Program, upon referral from a physician or a community health
			 center.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 450.000 - Administrative and Billing Regulations › Section 450.107 - Eligible Members and the MassHealth Card

Current through Register 1525, July 5, 2024
(A)
Eligibility
			 Determination
. MassHealth eligibility is determined in accordance
			 with
			 130 CMR 501.000 through
			 130 CMR 522.000.
			 Eligibility for the EAEDC Program is determined pursuant to
			 106 CMR
			 320.000 through
			 321.000,
			 701.000 through
			 701.600,
			 705.000 through
			 705.950, and
			 706.000 through
			 706.710.
(B)
Eligibility Verification
			 System
. The MassHealth agency uses the Eligibility Verification
			 System (EVS) for day-specific eligibility verification, and to communicate a
			 member's MassHealth eligibility, coverage type, managed care status,
			 restrictions, and other insurance information to health-care
			 providers.
(C)
MassHealth Card
. The MassHealth agency issues a
			 plastic identification card for most MassHealth members. The MassHealth card
			 contains information necessary to access EVS. Members for whom the MassHealth
			 agency pays health insurance premiums only may not have a MassHealth
			 card.
(D)
Temporary
			 MassHealth Eligibility Card
. When necessary, the MassHealth agency
			 or the Department of Transitional Assistance will issue a temporary MassHealth
			 card to the cardholder for use until a plastic MassHealth card is issued. The
			 temporary MassHealth card shows dates of eligibility, service restrictions, and
			 other insurance information. If a discrepancy occurs between information given
			 on a temporary MassHealth card and by EVS, the information on the temporary
			 card prevails. To be paid for a covered service that was provided based on
			 information given on a temporary card, a provider must produce a copy of the
			 temporary card, and have otherwise met all other prerequisites for
			 payment.
(E)
Provisional Eligibility
. The MassHealth agency will
			 provide eligibility while the applicant provides to the MassHealth agency any
			 outstanding verification, in accordance with
			 130 CMR
			 502.003:
Verification of Eligibility
			 Factors
.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 450.000 - Administrative and Billing Regulations › Section 450.108 - Selective Contracting

Current through Register 1525, July 5, 2024
(A)
Use
			 of Selective Contracts
. The MassHealth agency may provide some
			 services through selective contracts where such contracts are permitted by
			 federal and state law.
(B)
Termination of Provider Contracts
. The MassHealth
			 agency may terminate, in whole or in part, existing provider contracts where
			 selective contracts are in effect. In the event of any such termination, the
			 MassHealth agency notifies the affected providers in writing, at least 30 days
			 prior to termination. Such termination does not affect payments to providers
			 for services provided prior to the date of termination.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 450.000 - Administrative and Billing Regulations › Section 450.109 - Out-of-state Services

Current through Register 1525, July 5, 2024
(A) MassHealth
			 covers services provided in another state to a MassHealth member, subject to
			 all applicable limitations, including service coverage, prior authorization,
			 and provider enrollment, only in the following circumstances:
(1) medical services are needed because of a
			 medical emergency;
(2) medical
			 services are needed and the member's health would be endangered if the member
			 were required to travel to Massachusetts;
(3) it is the general practice for members in
			 a particular locality to use medical resources in another state; or
(4) the MassHealth agency determines on the
			 basis of medical advice, that the needed medical services, or necessary
			 supplementary resources, are more readily available in the other
			 state.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 450.000 - Administrative and Billing Regulations › Section 450.110 - Hospital-determined Presumptive Eligibility

Current through Register 1525, July 5, 2024
(A)
			 The MassHealth agency provides coverage for certain individuals for a limited
			 period of time, in accordance with
			 130 CMR
			 502.003(H):
Hospital-determined Presumptive Eligibility
if, on the basis
			 of attested information, a qualified hospital determines that the individual is
			 presumptively eligible. Coverage for members with time-limited presumptive
			 eligibility begins on the date on which a qualified hospital makes a
			 determination regarding presumptive eligibility and continues until
(1) the end of the month following the month
			 in which the hospital-determined presumptive eligibility, if the individual has
			 not submitted a complete application as described in
			 130 CMR
			 502.001:
Application for
			 Benefits
by that date, or
(2) an eligibility determination is made
			 based upon the individual's submission of a complete application as described
			 in
			 130 CMR
			 502.001:
Application for
			 Benefits
if the complete application was submitted prior to the end of
			 the month following the month of the hospital presumptive eligibility
			 determination.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 450.000 - Administrative and Billing Regulations › Section 450.112 - Advance Directives

Current through Register 1525, July 5, 2024
(A)
Provider Participation
. All hospitals, nursing
			 facilities, MCOs, Accountable Care Partnership Plans, SCOs, ICOs, home health
			 agencies, personal care agencies, hospices, and the MassHealth behavioral
			 health contractor must
(1) provide to all
			 adults 18 years of age or older, who are receiving medical care from the
			 provider, the following written information concerning their rights, which
			 information must reflect changes in state law as soon as possible, but no later
			 than 90 days after the effective date of the change to
(a) make decisions concerning their medical
			 care;
(b) accept or refuse medical
			 or surgical treatment; and
(c)
			 formulate advance directives (for example, living wills or durable powers of
			 attorney for health care, or health-care proxy designations);
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 450.000 - Administrative and Billing Regulations › Section 450.118 - Primary Care Clinician (PCC) Plan

Current through Register 1525, July 5, 2024
(A)
Role of Primary Care Clinician
. The PCC is the
			 principal source of care for members who are enrolled in the PCC Plan. All
			 services for which such a member is eligible, except those listed in 130 CMR
			 450.118(J), are payable only when provided by the member's PCC, or when the PCC
			 has referred the member to another MassHealth provider.
(B)
Provider
			 Eligibility
. Providers who wish to enroll as PCCs must be
			 participating providers in MassHealth, or physician assistants participating
			 pursuant to
			 130 CMR
			 433.434, must complete a PCC provider
			 application, which is subject to approval by the MassHealth agency, and must
			 meet the requirements of the PCC provider contract. The following provider
			 types may apply to the MassHealth agency to become PCCs:
(1) individual physicians who have current
			 admitting privileges to at least one MassHealth-participating Massachusetts
			 acute hospital that participates in MassHealth or who meet 130 CMR
			 450.118(F)(1), and who are board-eligible or board-certified in family
			 practice, pediatrics, internal medicine, obstetrics, gynecology, or
			 obstetrics/gynecology, or who meet 130 CMR 450.118(F)(2). A physician
			 specialist must agree to provide primary care services to PCC Plan
			 enrollees;
(2) independent
			 certified nurse practitioners who specialize in family practice, pediatrics,
			 internal medicine, obstetrics, gynecology or obstetrics/gynecology, and have an
			 arrangement with a MassHealth-participating physician for purposes of hospital
			 admissions and as needed to satisfy scope of practice requirements. Such
			 physician must meet the criteria of 130 CMR 450.118(B)(1). An independent
			 certified nurse practitioner specialist must agree to provide primary care
			 services to PCC Plan enrollees;
(3)
			 community health centers (freestanding or hospital-licensed) with at least one
			 physician on staff who meets the criteria of 130 CMR 450.118(B)(1);
(4) acute hospital outpatient departments
			 with at least one physician on staff who meets the criteria of 130 CMR
			 450.118(B)(1); and
(5) group
			 practices with at least one physician or independent certified nurse
			 practitioner who
(a) is enrolled and approved
			 by the MassHealth agency as a participating provider in that group;
(b) meets the requirements of 130 CMR
			 450.118(B)(1) or (2); and
(c) has
			 signed the PCC contract.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 450.000 - Administrative and Billing Regulations › Section 450.119 - Primary Care ACOs

Current through Register 1525, July 5, 2024
(A)
(1)
Role of Primary Care
			 ACO
. Each Primary Care ACO is contracted with the MassHealth
			 agency to coordinate and manage care for enrolled members.
(2)
Role of Primary Care ACO's
			 Participating Primary Care Provider (participating PCP)
. The
			 participating PCPs are the principal source of care for members who are
			 enrolled in a Primary Care ACO. All services for which such a member is
			 eligible, except those listed in 130 CMR 450.119(I), are payable only when
			 provided by the member's participating PCP, or when the participating PCP has
			 referred the member to another MassHealth provider.
(3)
Role of Primary Care ACO's
			 Referral Circle
. Each Primary Care ACO may establish a referral
			 circle of providers pursuant to its contract with the MassHealth
			 agency.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 450.000 - Administrative and Billing Regulations › Section 450.123 - Managed Care Compliance with Mental Health Parity

Current through Register 1525, July 5, 2024
(A) MCOs, Accountable Care Partnership Plans,
			 SCOs, and ICOs, and their behavioral health subcontractors or third party
			 administrators, if any, must comply with and implement relevant provisions of
			 the Paul Well stone and Pete Domenici Mental Health Parity and Addiction Equity
			 Act of 2008 (the Federal Mental Health Parity Law), and implementing
			 regulations and federal guidance, which requires parity between mental health
			 or substance use disorder benefits and medical/surgical benefits with respect
			 to financial requirements and treatment limitations.
(B)
Annual Certification of
			 Compliance with Federal Mental Health Parity Law
. Each MCO,
			 Accountable Care Partnership Plan, SCO, and ICO must annually review its
			 administrative and other practices, including the administrative and other
			 practices of any behavioral health subcontractors or third party
			 administrators, for compliance with the relevant provisions Federal Mental
			 Health Parity Law, regulations, and guidance.
(1) Each MCO, Accountable Care Partnership
			 Plan, SCO, and ICO must submit a certification signed by the chief executive
			 officer and chief medical officer stating that the entity has completed a
			 comprehensive review of the administrative practices of the entity for
			 compliance with the necessary provisions of State Mental Health Parity Laws and
			 Federal Mental Health Parity Law.
(2) If the MCO, Accountable Care Partnership
			 Plan, SCO, or ICO determines that all administrative and other practices were
			 in compliance with relevant requirements of the Federal Mental Health Parity
			 Law, the annual certification will affirmatively state that all relevant
			 administrative and other practices were in compliance with Federal Mental
			 Health Parity Law.
(3) If the MCO,
			 Accountable Care Partnership Plan, SCO, or ICO determines that any
			 administrative or other practices were not in compliance with relevant
			 requirements of the Federal Mental Health Parity Law, the annual certification
			 will state that not all practices were in compliance with Federal Mental Health
			 Parity Law, and will include a list of the practices not in compliance, and the
			 steps the entity has taken to bring these practices into compliance.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 450.000 - Administrative and Billing Regulations › Section 450.124 - Behavioral Health Services

Current through Register 1525, July 5, 2024
(A)
Behavioral Health Contractor
. Except as provided in
			 130
			 CMR 450.124(B) and (C), all
			 behavioral health services covered by the MassHealth agency's contract with the
			 behavioral health contractor (the Contractor) are authorized, provided, and
			 paid solely by the Contractor. Payment for such services is subject to the
			 terms of the Contractor's provider contracts including, but not limited to,
			 provisions governing service authorization and billing requirements. Any
			 provider seeking a contract with the Contractor should contact the Contractor
			 directly.
(B)
Emergency
			 Services
. Members may obtain emergency behavioral health services
			 from any qualified participating MassHealth provider as well as any provider
			 that has entered into an agreement with the Contractor. Providers should refer
			 to MassHealth bulletins for information and guidance on submission of claims
			 for emergency department behavioral health visits.
(C)
Services to Exempt
			 Members
. Services provided to the following MassHealth members are
			 not subject to
			 130
			 CMR 450.124:
(1) members who are enrolled in an MCO,
			 Accountable Care Partnership Plan, SCO, or ICO; and
(2) members who are excluded from
			 participating in managed care under
			 130
			 CMR 508.002:
MassHealth Members
			 Excluded from Participation in Managed Care
unless such member is
			 enrolled with the behavioral health contractor pursuant to
			 130
			 CMR 508.001(E).
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 450.000 - Administrative and Billing Regulations › Section 450.140 - Early and Periodic Screening, Diagnostic and Treatment (EPSDT) Services

Current through Register 1525, July 5, 2024
(A)
Legal Basis
.
(1) In accordance with federal law at
			 42 U.S.C.
			 1396d(a)(4)(b) and
			 1396d(r), and
			 42 CFR
			 441.50, and notwithstanding any limitations
			 implied or expressed elsewhere in MassHealth regulations or other publications,
			 the MassHealth agency has established a program of Early and Periodic
			 Screening, Diagnostic and Treatment (EPSDT) for MassHealth Standard and
			 MassHealth CommonHealth members younger than 21 years old, including those who
			 are parents.
(2) Any qualified
			 MassHealth provider may deliver EPSDT services. However, in delivering
			 well-child care, providers must follow the EPSDT Medical Protocol and
			 Periodicity Schedule.
(3) EPSDT
			 screening services include among other things, health, vision, dental, hearing,
			 behavioral health, developmental and immunization status screening
			 services.
(4) The regulations
			 governing the EPSDT program are set forth in
			 130
			 CMR 450.140 through
			 450.149.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 450.000 - Administrative and Billing Regulations › Section 450.142 - EPSDT Services: Medical Protocol and Periodicity Schedule and Dental Protocol and Periodicity Schedule

Current through Register 1525, July 5, 2024
(A)
Providers of Periodic and Interperiodic Visits
.
(1) Primary care providers must offer to
			 conduct periodic and medically necessary interperiodic visits to screen all
			 members younger than 21 years old (except members enrolled in MassHealth
			 Limited) in accordance with the Medical Schedule, and must provide or refer
			 such members to assessment, diagnosis, and treatment services.
(2) Hospitals and community health centers
			 that provide primary care services must offer to conduct periodic and medically
			 necessary interperiodic visits to screen all members younger than 21 years old
			 (except members enrolled in MassHealth Limited) in accordance with the Medical
			 Schedule, and must provide or refer such members to assessment, diagnosis and
			 treatment services.
(3) The health
			 assessments described in the Medical Schedule are payable when provided by a
			 physician, certified nurse practitioner, certified nurse midwife, hospital,
			 community health center, or physician assistant.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 450.000 - Administrative and Billing Regulations › Section 450.143 - EPSDT Services: Description of Medical Protocol and Periodicity Schedule Visits (EPSDT Visits)

Current through Register 1525, July 5, 2024
(A)
Initial EPSDT Visit
.
(1) An initial EPSDT visit must be provided
			 for every
(a) new member;
(b) member previously seen only for sick
			 care; and
(c) newborn previously
			 seen only in the hospital.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 450.000 - Administrative and Billing Regulations › Section 450.144 - EPSDT Services: Diagnosis and Treatment

Current through Register 1525, July 5, 2024
(A)
(1)
			 EPSDT diagnosis and treatment services consist of all medically necessary
			 services listed in 1905(a) of the Social Security Act (
			 42
			 U.S.C. 1396d(a) and (r) )
			 that are
(a) needed to correct or ameliorate
			 physical or mental illnesses and conditions discovered by a screening, whether
			 or not such services are covered under the State Plan; and
(b) payable for MassHealth Standard and
			 MassHealth CommonHealth members younger than 21 years old, if the service is
			 determined by the MassHealth agency to be medically necessary.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 450.000 - Administrative and Billing Regulations › Section 450.145 - EPSDT Services: Claims for Visits

Current through Register 1525, July 5, 2024
(A)
Initial EPSDT Visit
. A provider may bill for only one
			 initial EPSDT visit per member.
(B)
Periodic Visits
.
(1)
			 For each member from birth through two years of age, a provider may bill for
			 only one periodic visit per age level listed in the Medical Schedule.
(2) For each member aged two years through 20
			 years, a provider may bill for only one periodic visit every year.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 450.000 - Administrative and Billing Regulations › Section 450.146 - EPSDT Services: Claims for Laboratory Services, Audiometric Hearing Tests, Vision Tests, and Behavioral Health Screening (Physician, Physician Assistant, Certified Nurse Practitioner, Certified Nurse Midwife, Certified Clinical Nurse Specialist, and Community Health Center Providers Only)

Current through Register 1525, July 5, 2024
(A)
Laboratory
			 Services
. The laboratory services that are listed in Appendix Z:
EPSDT/PPHSD Screening Services Codes
of all MassHealth
			 provider manuals and included in the Medical Schedule are payable, in addition
			 to the initial, periodic or interperiodic visit, when they are performed and
			 interpreted in the office of the provider who performed the initial, periodic
			 or interperiodic visit.
(B)
Audiometric Hearing and Vision Tests
. Payments for the
			 audiometric hearing tests and the bilateral quantitative screening test of
			 visual acuity that are listed in Appendix Z of all MassHealth provider manuals
			 and included in the Medical Schedule, is not included in the fee for an
			 initial, periodic or interperiodic visit. Payment for these tests may be
			 claimed separately.
(C)
Behavioral Health Screening
. Payment for the
			 administration and scoring of one of the standardized behavioral health
			 screening tools that is listed in Appendix Z of all MassHealth provider manuals
			 and set forth in the Medical Schedule is not included in the fee for an
			 initial, periodic or interperiodic visit.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 450.000 - Administrative and Billing Regulations › Section 450.148 - EPSDT Services: Payment for Transportation

Current through Register 1525, July 5, 2024
Transportation may be available to members accessing EPSDT
				services. Providers must ask members if they need transportation assistance,
				and refer those members who do to MassHealth Customer Service for additional
				information about transportation.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 450.000 - Administrative and Billing Regulations › Section 450.149 - EPSDT Services: Recordkeeping Requirements

Current through Register 1525, July 5, 2024
(A)
Medical Records
.
(1) A provider must create and maintain a
			 record for every member receiving EPSDT services, in accordance with MassHealth
			 regulations governing medical records at
			 130 CMR
			 450.205.
(2) In addition, the medical record for each
			 member receiving EPSDT services must contain documentation of the screening
			 procedures listed in Appendix W:
EPSDT Services: Medical and Dental
			 Protocols and Periodicity Schedules
as well as the following:
(a) the results of all laboratory
			 tests;
(b) the name of each
			 referral provider; and
(c) the
			 results of any component of the Medical Schedule that was delivered by another
			 provider.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 450.000 - Administrative and Billing Regulations › Section 450.150 - Preventive Pediatric Health-care Screening and Diagnosis (PPHSD) Services for Certain MassHealth Members

Current through Register 1525, July 5, 2024
(A)
			 MassHealth has established a program of preventive pediatric health-care
			 screening and diagnosis services for MassHealth members younger than 21 years
			 old who are enrolled in MassHealth Family Assistance. MassHealth Standard and
			 MassHealth CommonHealth members are entitled to Early and Periodic Screening,
			 Diagnosis and Treatment (EPSDT) services pursuant to
			 130
			 CMR 450.140.
(B) Any qualified MassHealth provider may
			 deliver preventive pediatric health-care screening and diagnosis services.
(1) In delivering preventive pediatric
			 health-care screening and diagnosis services, providers must
(a) follow the procedures listed in the
			 Medical Schedule; and
(b) comply
			 with the regulations at
			 130
			 CMR 450.140 through 450.150.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 450.000 - Administrative and Billing Regulations › Section 450.200 - Conflict Between Regulations and Contracts

Current through Register 1525, July 5, 2024
If the MassHealth regulations about payment methods and
				conditions of provider participation conflict with a provider or managed care
				contract, such contract supersedes the regulation, unless the contract
				expressly states otherwise.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 450.000 - Administrative and Billing Regulations › Section 450.201 - Choice of Provider

Current through Register 1525, July 5, 2024
Pursuant to federal regulations set forth in
				42 CFR
				431.51, members have the right to choose
				providers from whom they may obtain medical services with certain exceptions
				that are specified in the MassHealth regulations, including, but not limited
				to,
				130 CMR 450.117(B)
				 and
				450.316.
				However, a member's right to choose a provider does not permit or require
				payment by the MassHealth agency to any person or institution not eligible for
				such payment under the MassHealth regulations in effect at the time a medical
				service is provided.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 450.000 - Administrative and Billing Regulations › Section 450.203 - Payment in Full

Current through Register 1525, July 5, 2024
(A) Federal and
			 state laws require that participation in MassHealth be limited to providers who
			 agree to accept, as payment in full, the amounts paid in accordance with the
			 applicable fees and rates or amounts established under a provider contract or
			 regulations applicable to MassHealth payment. (
See
42 CFR
			 447.15 and M.G.L. c. 118E, § 36.) No
			 provider may solicit, charge, receive, or accept any money, gift, or other
			 consideration from a member, or from any other person, for any item or medical
			 service for which payment is available under MassHealth, in addition to,
			 instead of, or as an advance or deposit against the amounts paid or payable by
			 the MassHealth agency for such item or service, except to the extent that the
			 MassHealth regulations specifically require or permit contribution or
			 supplementation by the member or by a health insurer.
(B) If the provider receives payment from a
			 member for any service payable under MassHealth without knowing that the member
			 was a MassHealth member at the time the service was provided, the provider
			 must, upon learning that the individual is a MassHealth member, immediately
			 return all sums solicited, charged, received, or accepted with respect to such
			 service.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 450.000 - Administrative and Billing Regulations › Section 450.204 - Medical Necessity

Current through Register 1525, July 5, 2024
The MassHealth agency does not pay a provider for services that
				are not medically necessary and may impose sanctions on a provider for
				providing or prescribing a service or for admitting a member to an inpatient
				facility where such service or admission is not medically necessary.
(A) A service is medically necessary if
(1) it is reasonably calculated to prevent,
			 diagnose, prevent the worsening of, alleviate, correct, or cure conditions in
			 the member that endanger life, cause suffering or pain, cause physical
			 deformity or malfunction, threaten to cause or to aggravate a handicap, or
			 result in illness or infirmity; and
(2) there is no other medical service or site
			 of service, comparable in effect, available, and suitable for the member
			 requesting the service, that is more conservative or less costly to the
			 MassHealth agency. Services that are less costly to the MassHealth agency
			 include, but are not limited to, health care reasonably known by the provider,
			 or identified by the MassHealth agency pursuant to a prior-authorization
			 request, to be available to the member through sources described in
			 130
			 CMR 450.317(C),
			 503.007:
Potential Sources of Health Care
, or 517.007:
Utilization of Potential Benefits
.