reglab/statecodes huggingface dataset:
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 405.000 - Community Health Center Services › Section 405.413 - Coordination of Services

Current through Register 1525, July 5, 2024
A CHC that provides any of the services listed in
				130 CMR
				405.409 or
				405.471
				must coordinate these services with all other services at the CHC. Such
				coordination includes at a minimum:
(A) one central medical record for each
			 member in which all health care services are recorded;
(B) medical accountability to the CHC's
			 professional services director;
(C)
			 administrative accountability to the CHC's manager;
(D) participation in the CHC's quality
			 assessment program (if the special group of services has its own plan for
			 quality assessment, this plan must be approved by the professional services
			 director who must also receive progress reports);
(E) regular participation in the CHC's staff
			 meetings and other appropriate activities by those professionals responsible
			 for directing special services; and
(F) familiarity with the CHC's policies,
			 procedures, staff, and scope of services by all personnel employed through
			 special programs.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 405.000 - Community Health Center Services › Section 405.414 - Translation Services

Current through Register 1525, July 5, 2024
A CHC must employ at least one practitioner or translator
				conversant in the primary language of each substantial population (10% or more
				of the total member population) of non-English-speaking members that regularly
				uses the CHC.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 405.000 - Community Health Center Services › Section 405.415 - Emergency Backup Services

Current through Register 1525, July 5, 2024
(A) A CHC must
			 provide either:
(1) 24-hour-a-day on-site
			 medical or emergency services or both; or
(2) an after-hours telephone service, and
			 have a written agreement with a provider of 24-hour-a-day medical or emergency
			 service or both.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 405.000 - Community Health Center Services › Section 405.416 - Quality Assessment Program

Current through Register 1525, July 5, 2024
(A) A CHC
			 must have in effect a program for internal quality assessment that is based on
			 written policies, standards, and procedures, and that includes the following:
(1) a review of the CHC's performance
			 including, but not limited to, adequacy of recordkeeping, referral procedures
			 and follow-up, medication review, quality of patient care, and identification
			 of deficient areas of performance;
(2) recommendations for correcting any
			 deficiencies identified in the review; and
(3) a review of any such corrective
			 action.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 405.000 - Community Health Center Services › Section 405.417 - Maximum Allowable Fees

Current through Register 1525, July 5, 2024
The Executive Office of Health and Human Services (EOHHS)
				determines the payment rate for CHC services in accordance with 101 CMR 304.00:
Rates for Community Health Centers
. For services payable to
				CHCs for which the maximum allowable fee is not listed in 101 CMR 304.00, EOHHS
				determines the payment rates in accordance with the applicable EOHHS pricing
				regulations that govern payment of those services.
Payment is subject to the conditions, exclusions, and
				limitations set forth in 130 CMR 405.000.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 405.000 - Community Health Center Services › Section 405.418 - Nonreimbursable Services

Current through Register 1525, July 5, 2024
(A) The MassHealth
			 agency does not pay a CHC for performing, administering, or dispensing
			 experimental, unproven, cosmetic, or otherwise medically unnecessary procedures
			 or treatments.
(B) The MassHealth
			 agency does not pay a CHC for the treatment of male or female infertility
			 (including, but not limited to, laboratory tests, drugs, and procedures
			 associated with such treatment); however, MassHealth does pay a CHC for the
			 diagnosis of male or female infertility.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 405.000 - Community Health Center Services › Section 405.422 - Obstetric Services: Introduction

Current through Register 1525, July 5, 2024
(A) The
			 MassHealth agency offers two methods of payment for obstetric services: the
			 fee-for-service method and the global-fee method. Fee for service requires
			 submission of claims for services as they are performed and is available for
			 covered obstetric services. The global-fee method is available only when the
			 conditions in
			 130 CMR
			 405.423 are met.
(B) The MassHealth agency will pay for a
			 delivery performed in a hospital by a physician or, in the case of a pelvic
			 delivery, by a certified nurse midwife who meets the requirements in
			 130 CMR
			 405.427 when the physician or certified nurse
			 midwife is a contractor or employee of the CHC. Such a delivery is covered
			 provided that such a contractor or employee is not receiving a salary from a
			 hospital or other institution to perform the same service. For each such
			 delivery, the CHC may claim payment for the services of only one practitioner
			 (that is, a CHC may not submit two claims for one delivery - one for a
			 physician and one for a certified nurse midwife).
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 405.000 - Community Health Center Services › Section 405.424 - Hysterectomy Services

Current through Register 1525, July 5, 2024
(A)
Nonpayable Services
. The MassHealth agency does not
			 pay for a hysterectomy provided to a member under the following conditions.
(1) The hysterectomy was performed solely for
			 the purpose of sterilizing the member.
(2) If there was more than one purpose for
			 the procedure, the hysterectomy would not have been performed but for the
			 purpose of sterilizing the member.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 405.000 - Community Health Center Services › Section 405.426 - Obstetric Services: Fee-for-service Method of Payment

Current through Register 1525, July 5, 2024
The fee-for-service method of payment is always available to a
				provider for obstetric services covered by MassHealth. If the global fee
				requirements in
				130 CMR
				405.423 are not met, the provider or
				providers may claim payment from the MassHealth agency only on a
				fee-for-service basis as specified in
				130 CMR
				405.426(A) and (B).
(A) If the pregnancy is terminated by an
			 event other than a delivery, each provider involved in performing obstetric
			 services for the member may claim payment only on a fee-for-service
			 basis.
(B) When additional services
			 (for example, ultrasound or special tests) are performed, the provider may
			 claim payment for these only on a fee-for-service basis.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 405.000 - Community Health Center Services › Section 405.427 - Certified Nurse-midwife Services

Current through Register 1525, July 5, 2024
(A)
Payable Services
. The CHC may bill for services
			 provided by a certified nurse midwife that relate to pregnancy, labor, birth,
			 and the immediate postpartum period when the nurse midwife is contractor or
			 employee of the CHC. The following conditions also apply.
(1) The services must be limited to the scope
			 of practice authorized by state law or regulation.
(2) The certified nurse midwife must meet the
			 educational and certification requirements mandated by state law or
			 regulation.
(3) The certified nurse
			 midwife must enter into a formal collaborative arrangement with a physician or
			 group of physicians as required by state law or regulation.
(4) The immediate postpartum period during
			 which certified nurse-midwife services may be provided is defined as a period
			 of time not to exceed six weeks after the date of delivery.
(5) Deliveries by a certified nurse midwife
			 must occur in facilities licensed by the Department of Public Health for the
			 operation of maternity and newborn services.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 405.000 - Community Health Center Services › Section 405.428 - Sterilization Services: Introduction

Current through Register 1525, July 5, 2024
(A)
Payable Services
. The MassHealth agency pays for a
			 sterilization service provided to an eligible member only if all of the
			 following conditions are met.
(1) The member
			 has voluntarily given informed consent for the sterilization procedure in the
			 manner and at the time described in
			 130 CMR
			 405.429, and such consent is documented in
			 the manner and form described in
			 130 CMR
			 405.430.
(2) The member is 18 years of age or older at
			 the time consent is obtained.
(3)
			 The member is not a mentally incompetent individual or an institutionalized
			 individual.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 405.000 - Community Health Center Services › Section 405.429 - Sterilization Services: Informed Consent

Current through Register 1525, July 5, 2024
A member's consent for sterilization will be considered
				informed and voluntary only if such consent is obtained in accordance with the
				requirements specified in
				130 CMR
				405.429(A) and (B), and such
				consent is documented as specified in
				130 CMR
				405.430.
(A)
Informed Consent
			 Requirements
.
(1) The person who
			 obtains consent (a physician, nurse, or counselor, for example) must orally
			 provide all of the following information and advice to the member requesting
			 sterilization:
(a) advice that the member is
			 free to withhold or withdraw consent for the procedure at any time before the
			 sterilization without affecting the right to future care or treatment and
			 without loss of any federal- or state-funded program benefits to which the
			 member might otherwise be entitled;
(b) a description of available alternative
			 methods of family planning and birth control;
(c) advice that the sterilization procedure
			 is considered irreversible;
(d) a
			 thorough explanation of the specific sterilization procedure to be
			 performed;
(e) a full description
			 of the discomforts and risks that may accompany or follow the procedure,
			 including an explanation of the type and possible effects of any anesthetic to
			 be used;
(f) a full description of
			 the benefits or advantages that may be expected as a result of the
			 sterilization; and
(g) advice that
			 the sterilization will not be performed for at least 30 days from the date
			 consent is given, except under the circumstances specified in
			 130 CMR
			 405.429(B)(1).
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 405.000 - Community Health Center Services › Section 405.430 - Sterilization Services: Consent Form Requirements

Current through Register 1525, July 5, 2024
Informed consent for sterilization must be documented by the
				completion of the MassHealth agency's Consent for Sterilization form in
				accordance with the following requirements. (Instructions for obtaining the
				Consent for Sterilization forms are located in Subchapter 5 of the
Community Health Center Manual
.)
(A)
Required Consent
			 Form
.
(1) One of the following
			 Consent for Sterilization forms must be used:
(a) CS-18 for members 18 through 20 years of
			 age; or
(b) CS-21 for members 21
			 years of age or older.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 405.000 - Community Health Center Services › Section 405.431 - Laboratory Services: Introduction

Current through Register 1525, July 5, 2024
The MassHealth agency only pays CHCs for those laboratory
				services listed in Subchapter 6 of the
Community Health Center
				Manual
. The MassHealth agency pays a CHC for laboratory services that
				are medically necessary for the diagnosis, treatment, and prevention of
				disease, and for the maintenance of the health of MassHealth members, subject
				to all the restrictions and limitations described in 130 CMR 405.000, and
				450.000:
Administrative and Billing Regulations
. In order for
				a CHC to be paid for any laboratory service, a written request for that service
				from an authorized prescriber must be present in the member's medical
				record.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 405.000 - Community Health Center Services › Section 405.432 - Laboratory Services: Eligibility to Provide Services

Current through Register 1525, July 5, 2024
A CHC may claim payment for the laboratory services listed in
				Subchapter 6 of the
Community Health Center Manual
only when
				all of the following conditions are met.
(A) The laboratory services are performed in
			 the CHC.
(B) The laboratory tests
			 are performed on properly and regularly calibrated equipment, and daily
			 controls are carried out.
(C) The
			 CHC has been certified by the Centers for Medicare & Medicaid Services
			 (CMS) for performing in-house clinical laboratory services, based on the
			 criteria set forth in the Clinical Laboratory Improvement Amendments (CLIA) of
			 1988, as it may be amended. In addition, the CHC's laboratory must maintain its
			 own quality-control program and successfully participate in one or more
			 proficiency testing programs that cover all Medicare-certified specialties and
			 subspecialties of the laboratory. The CHC must make the results of the
			 proficiency testing programs available to the MassHealth agency and the
			 Attorney General's Medicaid Fraud Division upon request or during an on-site
			 visit.
(D) If the CHC is located
			 in-state, the CHC has been approved by the Massachusetts Department of Public
			 Health to perform in-house clinical laboratory services. If the CHC is located
			 out-of-state, in addition to meeting the requirements of
			 130 CMR
			 405.404(B),
			 405.432(A)
			 through (C), and
			 450.109:
Out of State Services
, the CHC must also meet its own state's
			 requirements for performing in-house clinical laboratory services.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 405.000 - Community Health Center Services › Section 405.433 - Laboratory Services: Service Limitations

Current through Register 1525, July 5, 2024
(A)
			 The MassHealth agency will not pay a CHC for services listed as non-covered
			 services or for which payment limits apply in accordance with the
MassHealth Independent Clinical Laboratory Manual
at 130 CMR
			 401.000:
Independent Clinical Laboratory
.
(B) The MassHealth agency will not pay a CHC
			 for routine specimen collection and preparation for the purpose of clinical
			 laboratory analysis (for example, venipunctures; urine, fecal, and sputum
			 samples; Pap smears; cultures; and swabbing and scraping for removal of
			 tissue).
(C) The MassHealth agency
			 does not pay a CHC for the professional component of a clinical laboratory
			 service. The MassHealth agency will pay a CHC for the professional component of
			 an anatomical service, as provided in Subchapter 6 of the
Community
			 Health Center Manual
(for example, bone marrow analysis or analysis of
			 a surgical specimen).
(D) In no
			 event may a CHC bill or be paid separately for each of the tests included in a
			 profile or panel test (as defined herein) when a profile or panel test has
			 either been performed by that CHC or requested by an authorized person. A
			 profile or panel test is defined as any group of tests, whether performed
			 manually, automatedly, or semiautomatedly, that is ordered for a specified
			 member on a specified day and has at least one of the following
			 characteristics.
(1) The group of tests is
			 designated as a profile or panel by the CHC performing the tests.
(2) The group of tests is performed by the
			 CHC at a usual and customary fee that is lower than the sum of that CHC's usual
			 and customary fees for the individual tests in that group.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 405.000 - Community Health Center Services › Section 405.434 - Laboratory Services: Services Performed by Outside Laboratories

Current through Register 1525, July 5, 2024
(A) A CHC may not bill the MassHealth agency
			 for laboratory services provided outside the CHC. In this case, the testing
			 laboratory should bill the MassHealth agency directly for those
			 services.
(B) When sending a
			 specimen to an outside laboratory, the CHC must include the member's MassHealth
			 identification number and the CHC's MassHealth provider number.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 405.000 - Community Health Center Services › Section 405.441 - Radiology Services: Introduction

Current through Register 1525, July 5, 2024
The Mass Health Agency will pay for the radiology services in
				Subchapter 6 of the
Community Health Center Manual
only when
				the services are provided at the written request of a licensed physician or
				dentist. All radiology equipment used in providing these services must be
				inspected and approved by the Massachusetts Department of Public Health.
For radiology services furnished as part of a chiropractor
				service provided on-site at the CHC, such radiology services must be furnished
				and payment claimed by the CHC in compliance with the MassHealth Chiropractor
				regulations at 130 CMR 441.000:
Chiropractor Services
,
				including applicable radiology fee schedules and Subchapter 6 of the
Chiropractor Manual
.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 405.000 - Community Health Center Services › Section 405.442 - Radiology Services: Service Limitations

Current through Register 1525, July 5, 2024
(A)
Definitions
.
Global Fee
- the rate of payment for
				the two components of a radiology service: the professional component and the
				technical component.
Professional Component
- the component
				of a radiology service for interpreting a diagnostic test or image.
Technical Component
- the component of
				a radiology service for the cost of rent, equipment, utilities, supplies,
				administrative and technical salaries and benefits, and other overhead
				expenses.
(B)
Payment of the Global Fee
. The MassHealth agency will
			 pay a CHC the global fee for performing a radiology service at the CHC when one
			 of the following conditions is met.
(1) The
			 CHC owns or leases the equipment for providing the technical component of the
			 service, employs a technician to provide the technical component of the
			 service, and employs a board-certified or board-eligible radiologist to provide
			 the professional component of the service.
(2) The CHC employs a board-certified or
			 board-eligible radiologist to provide the professional component of the service
			 and the CHC subcontracts with a licensed Medicare-certified entity to provide
			 the technical component of the service.
(3) The CHC subcontracts with a licensed
			 Medicare-certified entity to provide the professional and technical component
			 of the service.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 405.000 - Community Health Center Services › Section 405.443 - Radiology Services: Payment Limitations

Current through Register 1525, July 5, 2024
(A)
			 The maximum allowable fees include payment for both the technical and
			 professional components of the radiology service. A CHC must not bill for
			 either the professional or technical component separately.
(B) Radiology services that are not listed in
			 Subchapter 6 of the
Community Health Center Manual
are not
			 reimbursable when furnished in a CHC. The CHC should refer a member to a
			 hospital for such services.
(C)
			 Some services listed in Subchapter 6 of the
Community Health Center
			 Manual
are designated "S.P.", an abbreviation for separate procedure.
			 Radiology services that are performed at separate sittings on the same or
			 different days are considered separate procedures. The CHC must not bill
			 separately for a service listed as an S.P. service when this service is
			 furnished as a portion of another radiology service at the same
			 sitting.
(D) A CHC must not bill
			 for a visit when a member is being seen for a radiology service only.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 405.000 - Community Health Center Services › Section 405.451 - Electrocardiogram (EKG) Services: Introduction

Current through Register 1525, July 5, 2024
The MassHealth agency will pay for an electrocardiogram (EKG)
				service only when the service is provided at the written request of a CHC staff
				physician who will interpret or review the interpretation of the EKG.
				Documentation of the physician's request must be kept in the member's medical
				record.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 405.000 - Community Health Center Services › Section 405.452 - Electrocardiogram (EKG) Services: Eligibility to Provide Services

Current through Register 1525, July 5, 2024
A CHC may claim payment for electrocardiogram (EKG) services
				only when both of the following conditions are met.
(A) The CHC owns or rents its own EKG
			 equipment.
(B) The EKG is taken at
			 the CHC or at the member's home.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 405.000 - Community Health Center Services › Section 405.453 - Electrocardiogram (EKG) Services: Payment Limitations

Current through Register 1525, July 5, 2024
(A) The maximum allowable fees include
			 payment for both the technical and professional components of the service. The
			 test must be performed at the CHC and interpreted by a physician employed by
			 the CHC.
(B) A CHC must not bill
			 for a visit when a member is being seen for an EKG only.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 405.000 - Community Health Center Services › Section 405.461 - Audiology Services: Introduction

Current through Register 1525, July 5, 2024
In order for a CHC to be paid for an audiology service other
				than a hearing test performed as part of an EPSDT services assessment
				(
see
130
				CMR 450.140 through
				450.149),
				a written request must be made by a physician, physician assistant, or
				certified nurse practitioner who has found some indication of a hearing
				problem. Documentation of the request and of the hearing problem must be kept
				in the member's medical record.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 405.000 - Community Health Center Services › Section 405.462 - Audiology Services: Eligibility to Provide Services

Current through Register 1525, July 5, 2024
(A) A CHC may claim payment for a basic
			 pure-tone (air and bone) evaluation by audiometer furnished to a member only
			 when the following conditions are met.
(1) The
			 CHC possesses on its premises a pure-tone audiometer, which must be calibrated
			 at least once every six months. Records of calibrations must be kept and made
			 available to the MassHealth agency upon request. The machine must be placed and
			 testing conducted in a quiet room.
(2) The person conducting hearing evaluations
			 is trained to perform hearing tests with an audiometer.
(3) The quality of the tester's work is
			 assessed at least twice a year by an audiologist licensed or certified in
			 accordance with
			 130 CMR
			 426.404:
Provider
			 Eligibility
. The audiologist may be a consultant to the CHC.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 405.000 - Community Health Center Services › Section 405.463 - Audiology Services: Payment Limitations

Current through Register 1525, July 5, 2024
(A)
			 Audiology services that are not listed in the
Community Health Center
			 Manual
Subchapter 6 are not reimbursable when furnished in a
			 CHC.
(B) A CHC must not bill for a
			 visit when a member is seen for audiology services only.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 405.000 - Community Health Center Services › Section 405.466 - Pharmacy Services: Participation in the 340B Drug-pricing Program for Outpatient CHC Pharmacies

Current through Register 1525, July 5, 2024
(A)
Notification of Participation
. Except for drugs that
			 cost $100,000 or more per utilizer per year (gross cost per utilizer per year)
			 that are designated as excluded from coverage for MassHealth members through
			 the 340B Drug Pricing Program, a CHC that is a 340B-covered entity may provide
			 drugs to MassHealth members through the 340B Drug Pricing Program provided that
			 it notifies the MassHealth agency in writing that the 340B-covered entity is
			 registered and approved by the federal Office of Pharmacy Affairs (OPA). Any
			 high cost drug designated for exclusion from coverage for MassHealth members
			 through the 340B Drug Pricing Program will be communicated by provider bulletin
			 or other written issuance from the MassHealth agency, and be consistent with
			 all requirements of M.G.L. c. 118E, §13L, and shall include an opportunity
			 for eligible providers to provide input regarding the designation. The
			 MassHealth agency may designate up to 25 drugs for exclusion from coverage for
			 MassHealth members through the 340B Drug Pricing Program. Any exclusion from
			 coverage for MassHealth members through the 340B Drug Pricing Program does not
			 apply to claims paid using the adjudicated payment amount per discharge (APAD)
			 or adjudicated payment per episode of care (APEC) methodology, other than for
			 drugs listed on the Acute Hospital Carve-Out Drugs List section of the
			 MassHealth Drug List.
(B)
Subcontracting for 340B Outpatient CHC Pharmacy
			 Services
.
(1) A CHC that is a
			 340B-covered entity may contract with a MassHealth pharmacy provider to
			 dispense 340B drugs for the 340B-covered entity's MassHealth patients. All such
			 subcontracts between the 340B-covered entity and a pharmacy provider must be in
			 writing, ensure continuity of care, specify that the CHC pays the pharmacy,
			 specify that such payment constitutes payment in full for 340B drugs provided
			 to MassHealth members, be consistent with all applicable provisions of
			 130 CMR
			 406.000:
Pharmacy Services
, and are
			 subject to approval by the MassHealth agency.
(2) The CHC is legally responsible to
			 MassHealth for the performance of any subcontractor. The CHC must ensure that
			 every pharmacy subcontractor is licensed by the Massachusetts Board of
			 Registration in Pharmacy and is a MassHealth pharmacy provider, and that
			 services are furnished in accordance with
			 130 CMR
			 406.000:
Pharmacy Services
and all
			 other applicable MassHealth requirements including, but not limited to, those
			 set forth in
			 130 CMR 450.000:
Administrative and Billing Regulations
.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 405.000 - Community Health Center Services › Section 405.467 - Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Services

Current through Register 1525, July 5, 2024
The MassHealth agency pays for all medically necessary
				community health care for EPSDT-eligible members in accordance with
				130
				CMR 450.140:
Early and Periodic
				Screening, Diagnosis and Treatment (EPSDT) Services: Introduction
,
				without regard to service limitations described in
				130
				CMR 405.000, and with prior
				authorization.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 405.000 - Community Health Center Services › Section 405.468 - Drugs Administered in the CHC (Provider-administered Drugs)

Current through Register 1525, July 5, 2024
(A) Drugs and biologicals dispensed in the
			 CHC are payable, subject to the exclusions and service limitations at 130 CMR
			 405.417, 405.418, and 130 CMR 406.413(B):
Drug Exclusions
and
			 (C):
Service Limitations
.
(B) The MassHealth agency does not pay
			 separately for drugs that are considered routine and integral to the delivery
			 of a service in the course of diagnosis or treatment. Such drugs are commonly
			 provided without charge or are included in the CHC's fee for the
			 service.
(C) The MassHealth agency
			 does not pay separately for any oral drugs dispensed in the office for which
			 the CHC has not requested and received prior authorization from the MassHealth
			 agency, with the exception of oral vaccines and oral radiopharmaceuticals,
			 which do not require prior authorization.
(D) Claims for drugs and biologicals that are
			 listed in Subchapter 6 of the
Community Health Center Manual
must include the name of the drug or biological, strength, dosage, and number
			 of Healthcare Common Procedure Coding System (HCPCS) units dispensed, National
			 Drug Code (NDC), NDC units, and NDC unit of measurement. In addition, for drugs
			 and/or biologicals that are listed as requiring individual consideration in
			 Subchapter 6 of the
Community Health Center Manual
, a copy of
			 the invoice showing the actual acquisition cost must be attached to the claim.
			 Claims without this information are denied.
(E) The MassHealth agency pays only for
			 prescription drugs that are approved by the U.S. Food and Drug Administration
			 and manufactured by companies that have signed rebate agreements with the U.S.
			 Secretary of Health and Human Services pursuant to
			 42 U.S.C.
			 1396r-8. Payment is calculated in accordance
			 with 101 CMR 331.00:
Prescribed Drugs
.
(F) The MassHealth agency does not pay for a
			 biological if the Massachusetts Department of Public Health distributes the
			 biological free of charge.
(G)
			 Payment for drugs may be claimed in addition to an office visit.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 405.000 - Community Health Center Services › Section 405.471 - Optional Reimbursable Services

Current through Register 1525, July 5, 2024
A CHC may elect to provide the following services on site or by
				referral, but it is not required to do so under 130 CMR 405.000. The CHC must
				notify the MassHealth agency in writing of each service listed in
				130 CMR 405.471(A)
				through (E) that the CHC will provide on-site
				and must enroll with MassHealth as that provider type. All services provided
				on-site must be furnished by practitioners qualified to provide the service
				that are employees or contactors of the CHC, and associated payment claimed by
				the CHC, in compliance with the applicable MassHealth regulations and
				subchapter 6 for each service, including applicable fee schedules. All services
				listed below that are provided by referral must be based on written agreements
				between the CHC and each referral provider to ensure continuity of care,
				exchange of relevant health information such as test results and records, and
				avoidance of service duplication. Each referral provider must be a
				participating provider in MassHealth, and payment for the services provided by
				the referral provider must be claimed by the referral provider in compliance
				with the applicable MassHealth regulations for such service. All referrals must
				include follow up to ensure that the referral process is successfully
				completed. Services the CHC may elect to provide include:
(A) adult day health services;
(B) adult foster care;
(C) day habilitation;
(D) psychiatric day treatment; and
(E) home health services.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 405.000 - Community Health Center Services › Section 405.472 - Tobacco-cessation Services

Current through Register 1525, July 5, 2024
(A)
Introduction
. MassHealth members are eligible to
			 receive tobacco cessation counseling services described in
			 130 CMR 405.472(B)
			  and pharmacotherapy treatment, including
			 nicotine replacement therapy (NRT), in accordance with 130 CMR 406.000:
Pharmacy Services
.
(B)
Tobacco-cessation Counseling
			 Services
.
(1) MassHealth covers a
			 total of 16 group and individual counseling sessions per member per 12-month
			 cycle, without prior authorization. These sessions may be any combination of
			 group and individual counseling. All individual counseling sessions must be at
			 least 30 minutes, except for intake sessions, which must be at least 45
			 minutes. Intake sessions are limited to two per member per 12-month cycle,
			 without prior authorization.
(a) Individual
			 counseling consists of face-to-face tobacco-cessation counseling services
			 provided to an individual member by a MassHealth-qualified provider of
			 tobacco-cessation services as set forth in
			 130 CMR 405.472(B) and
			 (C).
(b) Group tobacco treatment counseling
			 consists of a scheduled professional counseling session with a minimum of three
			 and a maximum of 12 members, and has a duration of at least 60 to 90
			 minutes.
(c) Individual and group
			 counseling also includes collaboration with and facilitating referrals to other
			 healthcare providers to coordinate the appropriate use of medications,
			 especially in the presence of medical or psychiatric comorbidities.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 405.000 - Community Health Center Services › Section 405.473 - Fluoride Varnish Services

Current through Register 1525, July 5, 2024
(A)
Eligible Members
. Members must be younger than 21
			 years old to be eligible for the application of fluoride varnish.
(B)
Qualified
			 Personnel
. Physicians, physician assistants, certified nurse
			 practitioners, registered nurses, licensed practical nurses, and medical
			 assistants may apply fluoride varnish subject to the limitation of state law.
			 To qualify to apply fluoride varnish, the individual must complete a
			 MassHealth-approved training on the application of fluoride varnish, maintain
			 proof of completion of the training, and provide such proof to the MassHealth
			 agency upon request.
(C)
Billing for a Medical Visit and Fluoride Varnish Treatment or
			 Procedure
. A CHC may bill for fluoride varnish services provided
			 by a physician or a qualified staff member as listed in
			 130
			 CMR 405.473(B)  under the
			 supervision of a physician. The CHC may bill for a medical visit in addition to
			 the fluoride varnish application only if fluoride varnish was not the sole
			 service, treatment, or procedure provided during the visit. The dental
			 enhancement fee may not be billed for a fluoride varnish application separately
			 or in addition to a medical visit.
(D)
Claims
			 Submission
. A CHC may submit claims for fluoride varnish services
			 that are provided by physicians, physician assistants, certified nurse
			 practitioners, registered nurses, licensed practical nurses, and medical
			 assistants according to
			 130
			 CMR 405.473(C).
See
Subchapter 6 of the
Community Health Center Manual
for service codes.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 405.000 - Community Health Center Services › Section 405.474 - Acupuncture Services

Current through Register 1525, July 5, 2024
(A)
Introduction
. MassHealth members are eligible to
			 receive acupuncture services in CHCs for the treatment of pain as described in
			 130
			 CMR 405.474(C).
See
130
			 CMR 433.454(C):
Medical Direction of Anesthesia Services
for use of
			 acupuncture as an anesthetic, and
			 130 CMR
			 418.000:
Substance Use Disorder Treatment
			 Services
for use of acupuncture for detoxification.
(B)
General
.
			 130
			 CMR 405.474 applies specifically to
			 physicians and other licensed practitioners of acupuncture in a CHC. The
			 requirements elsewhere in
			 130 CMR
			 405.000 that apply to a CHC, also apply to licensed
			 practitioners of acupuncture, such as service limitations, recordkeeping,
			 report requirements, and prior-authorization requirements.
(C)
Acupuncture for the Treatment
			 of Pain
. MassHealth provides a total of 20 sessions of acupuncture
			 for the treatment of pain per member per year without prior authorization. If
			 the member's condition, treatment, or diagnosis changes, the member may be able
			 to receive more sessions of medically-necessary acupuncture treatment with
			 prior authorization.
(D)
Provider Qualifications for Acupuncture
.
(1)
Qualified
			 Providers
. MassHealth pays a CHC for acupuncture services only
			 when the provider rendering the service is:
(a) a physician; or
(b) licensed in acupuncture by the
			 Massachusetts Board of Registration in Medicine under
			 243 CMR
			 5.00:
The Practice of
			 Acupuncture.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 405.000 - Community Health Center Services › Section 405.475 - Medical Nutrition Therapy

Current through Register 1525, July 5, 2024
(A)
Introduction
. MassHealth members are eligible to
			 receive medical nutrition therapy services described in
			 130
			 CMR 405.475(B).
See
Subchapter 6 of the
Community Health Center
			 Manual
for service code descriptions and billing
			 requirements.
(B) The MassHealth
			 agency pays for nutritional diagnostic therapy and counseling services for the
			 purpose of management of a medical condition. Medical nutrition therapy
			 services are payable when provided to eligible MassHealth members by the
			 following providers:
(1) physicians;
(2) dietitians/nutritionists licensed by the
			 Massachusetts Division of Professional Licensure, and the Board of Registration
			 of Dietitians and Nutritionists;
(3) mid-level practitioners credentialed by
			 the Commission on Dietetic Registration (CDR) (
e.g
., certified
			 nurse-midwives, certified nurse practitioners, registered nurses, and physician
			 assistants); or
(4) other
			 health-care providers licensed by the Massachusetts Division of Professional
			 Licensure, and the Board of Registration of Dietitians and Nutritionists, with
			 specific training in the provision of nutritional counseling as provided in
			 42 U.S.C.
			 1395x(vv)(2).
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 405.000 - Community Health Center Services › Section 405.476 - Diabetes Self-management Training

Current through Register 1525, July 5, 2024
(A)
Introduction
. MassHealth members are eligible to
			 receive diabetes self-management (DSMT) training services described in
			 130
			 CMR 405.476(B).
See
Subchapter 6 of the
Community Health Center
			 Manual
for service code descriptions and billing
			 requirements.
(B) The MassHealth
			 agency pays for DSMT and education, which may include medical nutrition
			 therapy, and are furnished to an individual with pre-diabetes or diabetes. DSMT
			 services are payable when provided to eligible MassHealth members by the
			 following providers:
(1) physicians;
(2) dietitians/nutritionists licensed by the
			 Massachusetts Division of Professional Licensure, and the Board of Registration
			 of Dietitians and Nutritionists;
(3) mid-level practitioners credentialed by
			 the National Certification Board of Diabetes Educators (NCBDE)
			 (
e.g
., nurse-midwives, nurse practitioners, registered nurses,
			 and physician assistants); or
(4)
			 other health-care practitioners with specific training in the provision of DSMT
			 as provided in 42 U.S.C.
			 1395x(qq)(2).
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 405.000 - Community Health Center Services › Section 405.496 - Utilization Management Program

Current through Register 1525, July 5, 2024
The MassHealth agency pays for procedures and hospital stays
				that are subject to the Utilization Management Program only if the applicable
				requirements of the program as described in
				130
				CMR 450.207 through
				450.209 are satisfied.
				Appendix E of the
Community Health Center Manual
describes the
				information that must be provided as part of the review
				process.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 406.000 - Pharmacy Services › Section 406.401 - Introduction

Current through Register 1525, July 5, 2024
All pharmacies participating in MassHealth must comply with the
				regulations governing MassHealth including, but not limited to, the regulations
				set forth in
				130 CMR
				406.000 and
				130 CMR
				450.000:
Administrative and Billing
				Regulations
.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 406.000 - Pharmacy Services › Section 406.403 - Eligible Members

Current through Register 1525, July 5, 2024
(A)
(1)
MassHealth
			 Members
. MassHealth covers pharmacy services only when provided to
			 eligible MassHealth members, subject to the restrictions and limitations
			 described in MassHealth regulations.
			 130
			 CMR 450.105:
Coverage Types
specifically states, for each MassHealth coverage type, which services are
			 covered and which members are eligible to receive those services.
(2)
Recipients of the Emergency
			 Aid to the Elderly, Disabled and Children Program
. For information
			 on covered services for recipients of the Emergency Aid to the Elderly,
			 Disabled and Children Program,
see
130
			 CMR 450.106:
Emergency Aid to the
			 Elderly, Disabled and Children Program
.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 406.000 - Pharmacy Services › Section 406.404 - Provider Eligibility

Current through Register 1525, July 5, 2024
(A)
All
			 Providers
. A pharmacy must be a participant in MassHealth on the
			 date of service in order to be eligible for payment.
(B)
In-state
			 Providers
. To be eligible for participation as a MassHealth
			 provider, a pharmacy must
(1) have a retail
			 establishment located and doing business in the Commonwealth of
			 Massachusetts;
(2) be licensed by
			 the Massachusetts Board of Registration in Pharmacy in accordance with M.G.L.
			 c. 112, and
			 247 CMR
			 6.00:
Registration, Management and Operation
			 of a Pharmacy or Pharmacy Department
or be licensed by the
			 Massachusetts Department of Public Health as a pharmacy in a clinic setting in
			 accordance with M.G.L. c. 111;
(3)
			 be licensed by the federal Drug Enforcement Administration (DEA) and possess a
			 DEA registration number (if a pharmacy is licensed to dispense only Schedule VI
			 drugs, the pharmacy may possess a Massachusetts Controlled Substance
			 Registration number instead of a DEA registration number); and
(4) agree to use the MassHealth Pharmacy
			 Online Processing System (POPS) in real-time mode to submit claims.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 406.000 - Pharmacy Services › Section 406.405 - Drugs and Medical Supplies Provided to Members Who Are Temporarily Outside of Massachusetts

Current through Register 1525, July 5, 2024
When provided out of state, drugs and medical supplies are
				reimbursable only if the member is temporarily out of state and requires drugs
				or medical supplies under the circumstances described in
				130
				CMR 450.109:
Out-of-state
				Services
.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 406.000 - Pharmacy Services › Section 406.411 - Prescription Requirements

Current through Register 1525, July 5, 2024
(A)
Legal Prescription Requirements
. The MassHealth agency
			 pays for prescription drugs, over-the-counter drugs, and items on the Non-drug
			 Product List only if the pharmacy has in its possession a prescription that
			 meets all requirements for a legal prescription under all applicable federal
			 and state laws and regulations. Each prescription for drugs in Schedules II
			 through V must contain the prescriber's unique DEA number. For Schedule VI
			 drugs, if the prescriber has no DEA registration number, the prescriber's
			 Massachusetts Controlled Substance Registration number must appear on the
			 prescription.
(B)
Emergencies
. When the pharmacist determines that an
			 emergency exists, the MassHealth agency will pay the pharmacy for at least a
			 72-hour, nonrefillable supply of the drug in compliance with state and federal
			 regulations. Emergency dispensing to a MassHealth member who is enrolled in the
			 Controlled Substance Management Program (CSMP) must comply with
			 130
			 CMR 406.442(C)(2).
(C)
Refills
.
(1) The MassHealth agency does not pay for
			 prescription refills that exceed the specific number authorized by the
			 prescriber.
(2) The MassHealth
			 agency pays for a maximum of 11 monthly refills, except in circumstances
			 described at
			 130
			 CMR 406.411(C)(3), or where
			 the MassHealth Drug List specifically limits the number of refills, duration of
			 the prescription, or both.
(3) The
			 MassHealth agency pays for more than 11 refills within a 12-month period if
			 such refills are for less than a 30-day supply and have been prescribed and
			 dispensed in accordance with
			 130
			 CMR 406.411(D).
(4) The MassHealth agency does not pay for
			 any refill dispensed after one year from the date of the original
			 prescription.
(5) The absence of an
			 indication to refill by the prescriber renders the prescription
			 nonrefillable.
(6) The MassHealth
			 agency does not pay for any refill without an explicit request from a member or
			 caregiver for each filling event. The possession by a provider of a
			 prescription with remaining refills authorized does not in itself constitute a
			 request to refill the prescription.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 406.000 - Pharmacy Services › Section 406.412 - Covered Drugs and Medical Supplies

Current through Register 1525, July 5, 2024
(A)
Drugs
. The MassHealth Drug List specifies the drugs
			 that are payable under MassHealth. In addition, the following rules apply.
(1)
Prescription
			 Drugs
. The MassHealth agency pays only for prescription drugs that
			 are approved by the U.S. Food and Drug Administration and manufactured by
			 companies that have signed rebate agreements with the U.S. Secretary of Health
			 and Human Services pursuant to
			 42 U.S.C.
			 1396r-8. Payment is calculated in accordance
			 with 101 CMR
			 331.00:
Prescribed Drugs
.
(2)
Over-the-counter
			 Drugs
. Payment by the MassHealth agency for over-the-counter drugs
			 is calculated in accordance with
			 101 CMR
			 331.00:
Prescribed Drugs
.
(3)
Compounded
			 Drugs
. MassHealth pays for compounded drugs specified in the
			 MassHealth Drug List. Payment for compounded drugs is calculated in accordance
			 with 101 CMR
			 331.00:
Prescribed Drugs
.