Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 410.000 - Outpatient hospital services › Section 410.435 - Abortion Services: Certification for Payable Abortion Form

Current through Register 1525, July 5, 2024
All providers (
i.e
., physicians, physician
				assistants, nurse practitioners, or nurse midwives and hospital outpatient
				departments) must complete a Certification for Payable Abortion (CPA-2) form
				and retain the form in the member's record. (Instructions for obtaining the
				Certification for Payable Abortion form are in Subchapter 5 of the Outpatient
				Hospital Manual.) To identify those abortions that meet federal reimbursement
				standards, the MassHealth agency must secure on the CPA-2 form the
				certifications described in 130 CMR 410.435(A) through (C), when applicable.
				For all medically necessary abortions not included in 130 CMR 410.435(A)
				through (C), the certification described in 130 CMR 410.435(D) is required on
				the CPA-2 form. The provider must indicate on the CPA-2 form which of the
				following circumstances is applicable, and must complete that portion of the
				form with the appropriate signatures.
(A)
Life of the Pregnant
			 Individual Would Be Endangered
. The attending provider must
			 certify that, in their professional judgment, the life of the pregnant
			 individual would be endangered if the pregnancy were carried to term.
(B)
Severe and Long-lasting
			 Damage to the Pregnant Individual's Physical Health
. The attending
			 provider and another provider must each certify that, in their professional
			 judgment, severe and long-lasting damage to the pregnant individual's physical
			 health would result if the pregnancy were carried to term. At least one of the
			 providers must also certify that they are not an "interested provider," defined
			 herein as one whose income is directly or indirectly affected by the fee paid
			 for the performance of the abortion; or who is the spouse of, or another
			 relative who lives with, a provider whose income is directly or indirectly
			 affected by the fee paid for the performance of the abortion.
(C)
Victim of Rape or
			 Incest
. The provider is responsible for retaining signed
			 documentation from a law enforcement agency or public health service certifying
			 that the person upon whom the procedure was performed was a victim of rape or
			 incest that was reported to the agency or service within 60 days of the
			 incident. (A public health service is defined as either an agency of the
			 federal, state, or local government that provides health or medical services,
			 or a rural health clinic, provided that the agency's principal function is not
			 the performance of abortions.) The documentation must include the date of the
			 incident, the date the report was made, the name and address of the victim and
			 of the person who made the report (if different from the victim), and a
			 statement that the report included the signature of the person who made the
			 report.
(D)
Other
			 Medically Necessary Abortions
. The attending provider must certify
			 that, in their medical judgment, for reasons other than those described in 130
			 CMR 410.435(A) through (C), the abortion performed was necessary in light of
			 all factors affecting the pregnant individual's health.