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-151 August 2007 TO: All Providers Participating in MassHealth FROM: Tom Dehner, Medicaid Director RE: All Provider Manuals (Revised Administrative and Billing Regulations for MassHealth Essential Vision Care Services) This transmittal letter concerns only services for MassHealth Essential members and does not apply to any other MassHealth coverage type. These regulations are effective September 15, 2007, but they codify a policy that went into effect on November 1, 2006. Through Vision Care Bulletin 13 (October 2006), MassHealth implemented a policy effective for dates of service on or after November 1, 2006, expanding the types of providers from whom MassHealth Essential members could receive covered vision-care services. For MassHealth Essential members, covered vision-care services include eye exams, supplementary testing, and related treatment, but does not include the provision of ophthalmic materials. Such vision-care services provided by physicians and ophthalmologists participating in MassHealth have been covered for MassHealth Essential members since the inception of this eligibility category. Effective for dates of service on or after November 1, 2006, covered vision-care services for MassHealth Essential members also may be provided by an optometrist participating in MassHealth. Please note that there will be no change to the range of vision benefits for which MassHealth Essential members are eligible. This change affects only the types of providers who may bill MassHealth for covered vision-care services for MassHealth Essential members. MassHealth Essential members are not eligible for the provision or dispensing of ophthalmic materials such as eyeglasses, contact lenses, or other visual aids. If you have any questions about the information in this transmittal letter please contact MassHealth Customer Service at 1-800-841-2900, e-mail 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.) All Provider Manuals Page 1-13 and 1-14 OBSOLETE MATERIAL (The pages listed here are no longer in effect.) All Provider Manuals Page 1-13 and 1-14 – transmitted by Transmittal Letter ALL-126 Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 1. Introduction (130 CMR 450.000) Page 1-13 All Provider Manuals Transmittal Letter ALL-151 Date 09/15/07 (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) The MassHealth agency 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) The MassHealth agency 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; (i) emergency ambulance services; (j) laboratory services; Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 1. Introduction (130 CMR 450.000) Page 1-14 All Provider Manuals Transmittal Letter ALL-151 Date 09/15/07 (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; (v) vision care services provided by a licensed doctor of optometry, including eye exams and supplementary testing services, but not including the provision or dispensing of ophthalmic materials such as eyeglasses, contact lenses, or other visual aids; and (w) 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, the MassHealth agency pays part, or all, of the member’s health insurance premium. The amount of the payment for premium assistance is based on the MassHealth agency’s determination of cost effectiveness. The MassHealth agency 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.