Commonwealth of Massachusetts Executive Office of Health and Human Services Office of Medicaid www.mass.gov/masshealth MassHealth Transmittal Letter AIH-49 December 2013 TO: Acute Inpatient Hospitals Participating in MassHealth FROM: Kristin L. Thorn, Medicaid Director RE: Acute Inpatient Hospital Manual (Revisions to MassHealth Regulations-Affordable Care Act) This letter transmits revisions to the acute inpatient hospital program regulations in Subchapter 4 of the Acute Inpatient Hospital Manual. The revised regulations implement a change in coverage for diagnosis of infertility. This change was prompted by requirements of the Affordable Care Act regarding coverage of Essential Health Benefits. These regulations are effective January 1, 2014. MassHealth Website This transmittal letter and attached pages are available on the MassHealth website at www.mass.gov/masshealth. Questions If you have any questions about the information in this transmittal letter, please contact MassHealth Customer Service at 1-800-841-2900, email your inquiry to providersupport@mahealth.net, or fax your inquiry to 617-988-8974. NEW MATERIAL (The pages listed here contain new or revised language.) Acute Inpatient Hospital Manual Pages 4-4a – 4-4b OBSOLETE MATERIAL (The pages listed here are no longer in effect.) Acute Inpatient Hospital Manual Pages 4-4a – 4-4b — transmitted by Transmittal Letter AIH-43 Commonwealth of Massachusetts MassHealth Provider Manual Series Acute Inpatient Hospital Manual Subchapter Number and Title 4. Program Regulations (130 CMR 415.000) Page 4-4a Transmittal Letter AIH-49 Date 01/01/14 (B) the cost of any treatment or testing provided to a member who is an inpatient at another hospital, whether of the member or of a specimen from the member. Payment will be made to the hospital where the member is an inpatient and not to the provider where this treatment or testing occurs; (C) leaves of absence; (D) research or the provision of experimental, unproven, or otherwise medically unnecessary procedures or treatments, specifically including, but not limited to, sex-reassignment surgery, thyroid cartilage reduction and any other related surgeries and treatments, including pre- and post- sex-reassignment surgery hormone therapy. Notwithstanding the preceding sentence, the MassHealth agency will continue to pay for post-sex-reassignment surgery hormone therapy for which it had been paying immediately prior to May 15, 1993; (E) cosmetic surgery; (F) the provision of whole blood (however, administrative and processing costs associated with the provision of blood and its derivatives are reimbursable); (G) private hospital rooms, except when the member is being treated for an infectious disease that requires a private room, or in other circumstances in which a private room would be medically necessary; and (H) 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 for the diagnosis of male or female infertility. 415.409: Sterilization Services: Introduction (A) Eligible Members. MassHealth members in categories of assistance 0, 1, 2, 3, 5, 6, 7, and 8 are eligible for sterilization services as described in 130 CMR 415.409 through 415.411. For information on reimbursable services for recipients of the Emergency Aid to the Elderly, Disabled and Children Program (category of assistance 4), see 130 CMR 450.106: Emergency Aid to the Elderly, Disabled and Children Program. Commonwealth of Massachusetts MassHealth Provider Manual Series Acute Inpatient Hospital Manual Subchapter Number and Title 4. Program Regulations (130 CMR 415.000) Page 4-4b Transmittal Letter AIH-49 Date 01/01/14 (B) Reimbursable Services. The MassHealth agency will pay for an inpatient stay that includes sterilization services performed by a licensed physician in an acute inpatient hospital for a 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 415.410, and such consent is documented in the manner described in 130 CMR 415.411. (2) The member is at least 18 years old at the time consent is obtained. (3) The member is not mentally incompetent or institutionalized. (C) Assurance of Member Rights. No provider will use any form of coercion in the provision of sterilization services. Neither the MassHealth agency nor any provider, nor any agent or employee of a provider, will mislead any member into believing that a decision to have or not to have a sterilization will adversely affect the member's entitlement to benefits or services for which the member would otherwise be eligible. The MassHealth agency has strict requirements for confidentiality of member records for sterilization services as well as for all other medical services reimbursable under MassHealth. (D) Retroactive Eligibility. The MassHealth agency will not pay for a sterilization performed during the period of a member's retroactive eligibility unless all conditions for payment listed in 130 CMR 415.409(B) are met. 415.410: Sterilization Services: Informed Consent 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 415.410(A) and (B). (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 otherwise might 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;