Commonwealth of Massachusetts
Executive Office of Health and Human Services
Office of Medicaid
600 Washington Street
Boston, MA 02111
www.mass.gov/masshealth

MASSHEALTH
TRANSMITTAL LETTER ALL-126
July 2004
TO:      All Providers Participating in MassHealth
FROM:      Beth Waldman, Medicaid Director
RE:      All Provider Manuals (MassHealth Essential Coverage for Certain Aliens with Special Status)
The attached regulations update information about the MassHealth Essential coverage type at 130 CMR 450.105(I). Effective June 1, 2004, MassHealth Essential coverage is also available to certain adult aliens with special status. Eligibility requirements are different for those under age 65 and those aged 65 or older; however, all persons must meet the “alien with special status” immigration requirements.
•	Aliens with special status, aged 19 through 64, must be disabled and meet the long-term-unemployment requirement. Persons who are eligible for MassHealth Essential coverage and do not have other health insurance receive only MassHealth Limited coverage until they are enrolled with a Primary Care Clinician (PCC) in the PCC Plan. Those with other health insurance receive only wrap coverage under MassHealth Limited (prior to the start date of MassHealth Essential) or under MassHealth Essential.
•	For aliens with special status, aged 65 or older, MassHealth Essential is a new coverage type. Those who are eligible for MassHealth Essential coverage receive their benefits on a fee-for-service basis, instead of enrolling with a PCC.
For detailed information about eligibility requirements for MassHealth Essential coverage for aliens with special status, see the MassHealth eligibility regulations at 130 CMR 505.007 and 519.013. These regulations are posted on the MassHealth Web site at www.mass.gov/masshealth. Click on the “Government” tab. Click on “Laws, Regulations, and Policies.” Click on “MassHealth Regulations and Other Publications.”
The Massachusetts legislature has authorized these benefits through September 30, 2004. These regulations were filed as an emergency, with a retroactive effective date of June 1, 2004.
NEW MATERIAL
(The pages listed here contain new or revised language.)
All Provider Manuals
Pages 1-13 and 1-14
OBSOLETE MATERIAL
(The pages listed here are no longer in effect.)
All Provider Manuals
Pages 1-13 and 1-14 — transmitted by Transmittal Letter ALL-118

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
ALL PROVIDER MANUALS	SUBCHAPTER NUMBER AND TITLE
1 INTRODUCTION (130 CMR 450.000)	PAGE
1-13	

	TRANSMITTAL LETTER
ALL-126	DATE
06/01/04	
(aa) prosthetic services;
(bb) rehabilitation services;
(cc) renal dialysis services;
(dd) speech and hearing services;
(ee) therapy services: physical, occupational, and speech/language;
(ff)   vision care; and
(gg) X-ray/radiology services.
(4)	Managed Care Participation.
(a)	MassHealth Family Assistance members who meet the eligibility requirements of 130 CMR 505.005(E) must enroll with a Primary Care Clinician or a MassHealth-contracted managed care organization (MCO) (see 130 CMR 450.117).
(b)	MassHealth Family Assistance members who meet the eligibility requirements of 130 CMR 505.005(F) must enroll with a Primary Care Clinician (see 130 CMR 450.118.)
(5)	Managed Care Organizations. For MassHealth Family Assistance members who are
enrolled in a MassHealth MCO, the following rules apply.
(a)	MassHealth does not pay a provider other than the MCO for any services that are covered by MassHealth’s contract with the MCO, except for family planning services that were not provided or arranged for by the MCO. It is the responsibility of the provider to verify the scope of services covered by MassHealth’s contract with the MCO.
(b)	MassHealth pays providers other than the MCO for those services listed in 130 CMR 450.105(H)(3) that are not covered by MassHealth’s contract with the MCO. Such payment is subject to all conditions and restrictions of MassHealth, including all applicable prerequisites for payment.
(6)	Behavioral Health Services.
(a)	MassHealth Family Assistance members enrolled in the PCC Plan receive behavioral health services only through MassHealth’s behavioral health contractor. (See 130 CMR 450.124 et seq.)
(b)	MassHealth Family Assistance members enrolled in an MCO receive behavioral health services only through the MCO. (See 130 CMR 450.117 et seq.)
(c)	MassHealth Family Assistance members who are not receiving premium assistance, and have not enrolled in an MCO or been enrolled with MassHealth’s behavioral health contractor may receive behavioral health services from any participating MassHealth provider of such services.
(I) MassHealth Essential. MassHealth Essential members receive services through either the purchase of medical benefits or premium assistance.
(1) Covered Services. The following services are covered for MassHealth Essential members
(See 130 CMR 505.007 and 519.013).
(a)	abortion services;
(b)	acute inpatient hospital services;
(c)	ambulatory surgery services;
(d)	behavioral health (mental health and substance abuse) services;
(e)	community health center services;
(f)	dental services;
(g)	durable medical equipment and supplies; (h) family planning services;
(a)	
Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
ALL PROVIDER MANUALS	SUBCHAPTER NUMBER AND TITLE
1 INTRODUCTION (130 CMR 450.000)	PAGE
1-14	

	TRANSMITTAL LETTER
ALL-126	DATE
06/01/04	
(i)   emergency ambulance services;
(j)   laboratory services;
(k) nurse practitioner services;
(l)   outpatient hospital services;
(m) oxygen and respiratory therapy equipment;
(n) pharmacy services;
(o) physician services;
(p) podiatrist services;
(q) prosthetic services;
(r)  rehabilitation services (except in inpatient hospital settings);
(s) renal dialysis services;
(t)   speech and hearing services;
(u) therapy services: physical, occupational, and speech/language; and
(v) X-ray/radiology services.
(2)	Managed Care Member Participation. MassHealth Essential members for whom eligibility is determined under 130 CMR 505.007 must enroll with a Primary Care Clinician as described in 130 CMR 450.117(B)(1). These members are eligible to receive services listed in 130 CMR 450.105(I)(1) only after enrolling with a Primary Care Clinician in accordance with 130 CMR 508.002(I)(2), except as described in 130 CMR 505.007(E).
(3)	Behavioral Health Services. MassHealth Essential members enrolled in the PCC Plan receive behavioral health services only through MassHealth’s behavioral health contractor. (See 130 CMR 450.124 et seq.)
(4)	Premium Assistance. For adults who meet the eligibility requirements for MassHealth Essential but have health insurance, MassHealth pays part or all of the member’s health insurance premium. The amount of the payment for premium assistance is based on MassHealth’s determination of cost effectiveness. MassHealth does not pay for any other benefits for these members, except as described in 130 CMR 505.007(E). Premium assistance members are excluded from participation in managed care in accordance with 130 CMR 508.004(B).
450.106: Emergency Aid to the Elderly, Disabled and Children Program
(A) Covered Services. The following services are covered for EAEDC recipients:
(1)	physician services specified in 130 CMR 433.000;
(2)	community health center services specified in 130 CMR 405.000;
(3)	legend drugs (those drugs that require a prescription under federal or state law) specified in 130 CMR 406.000;
(4)	insulins (the only nonlegend 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;
(7)	substance abuse treatment services as specified in 130 CMR 418.000 if provided in public detoxification and outpatient substance abuse 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.