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-170 September 2009 TO: All Providers Participating in MassHealth FROM: Tom Dehner, Medicaid Director RE: All Provider Manuals (Managed Care Requirements) MassHealth is revising the regulations about managed care requirements and the MassHealth behavioral-health contractor to implement the Children’s Behavioral Health Initiative (CBHI). These regulations are effective October 1, 2009. 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 All Provider Manuals Pages 1-7, 1-8, 1-11, and 1-12 OBSOLETE MATERIAL (The pages listed here are no longer in effect.) All Provider Manuals Pages 1-7, 1-8, 1-11, and 1-12 — transmitted by Transmittal Letter ALL-163 Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 1 Introduction (130 CMR 450.000) Page 1-7 All Provider Manuals Transmittal Letter ALL-170 Date 10/01/09 (gg) prosthetic services; (hh) rehabilitation services; (ii) renal dialysis services; (jj) speech and hearing services; (kk) therapy services: physical, occupational, and speech/language; (ll) transportation services; (mm) vision care; and (nn) X-ray/radiology services. (2) Managed Care Member Participation. MassHealth Standard members must enroll with a MassHealth managed care provider unless excluded from participation in managed care (see 130 CMR 450.117 et seq. and 130 CMR 508.000) or during a period of presumptive eligibility. (See 130 CMR 505.002(C)(4).) Women described at 130 CMR 505.002(H), who receive MassHealth Standard as a result of a diagnosis of breast or cervical cancer, may only enroll in the PCC Plan. (3) Managed Care Organizations. For MassHealth Standard 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 the MassHealth agency’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 the MassHealth agency’s contract with the MCO. (b) The MassHealth agency pays providers other than the MCO for those services listed in 130 CMR 450.105(A)(1) that are not covered by the MassHealth agency’s contract with the MCO. Such payment is subject to all conditions and restrictions of MassHealth, including all applicable prerequisites for payment. (4) Behavioral-Health Services. (a) MassHealth Standard members enrolled in the PCC Plan receive behavioral- health services only through the MassHealth behavioral-health contractor. (See 130 CMR 450.124 et seq.) (b) MassHealth Standard members enrolled in an MCO receive behavioral-health services only through the MCO. (See 130 CMR 450.117 et seq.) (c) MassHealth Standard members who are excluded from participating in managed care under 130 CMR 508.004 or who have not enrolled in an MCO or with the MassHealth behavioral-health contractor may receive behavioral-health services from any participating MassHealth provider of such services. (d) MassHealth Standard members who participate in a senior care organization receive all behavioral-health services only through the senior care organization. (e) MassHealth Standard members who are under the age of 21 and who are excluded from participating in the PCC Plan or a MassHealth-contracted MCO under 130 CMR 508.004(A) must enroll with the MassHealth behavioral-health contractor. (f) MassHealth Standard members who are under the age of 21 and who are excluded from participating in the PCC Plan or a MassHealth-contracted MCO under 130 CMR 508.004(I) through (L) may choose to enroll with the MassHealth behavioral- health contractor. (5) Purchase of Health Insurance. The MassHealth agency may purchase third- party health insurance for MassHealth Standard members, with the exception of members described at 130 CMR 505.002(H), if the MassHealth agency determines such premium payment is cost effective. Under such circumstances, the MassHealth agency pays a provider only for those services listed in 130 CMR 450.105(A)(1) that are not available through the member’s third-party health insurer. Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 1 Introduction (130 CMR 450.000) Page 1-8 All Provider Manuals Transmittal Letter ALL-170 Date 10/01/09 (6) Senior Care Organizations. MassHealth Standard members aged 65 and over may voluntarily enroll in a senior care organization in accordance with the requirements under 130 CMR 508.008. The MassHealth agency does not pay a provider other than a senior care organization for any services that are provided to the MassHealth member while the member is enrolled in a senior care organization. (B) MassHealth Basic. MassHealth Basic members receive services through either the purchase of medical benefits or premium assistance. (1) Covered Services. The following services are covered for MassHealth Basic members (see 130 CMR 505.006): (a) abortion services; (b) acute inpatient hospital services; (c) ambulance services (emergency only); (d) ambulatory surgery services; (e) audiologist services; (f) behavioral-health (mental health and substance abuse) services; (g) Chapter 766: home assessments and participation in team meetings; (h) chiropractor services; (i) community health center services; (j) dental services; (k) durable medical equipment and supplies; (l) family planning services; (m) hearing aid services; (n) home health services; (o) laboratory services; (p) nurse midwife services; (q) nurse practitioner services; (r) orthotic services; (s) outpatient hospital services; (t) oxygen and respiratory therapy equipment; (u) pharmacy services; (v) physician services; (w) podiatrist services; (x) prosthetic services; (y) rehabilitation services (except in inpatient hospital settings); (z) renal dialysis services; (aa) speech and hearing services; (bb) therapy services: physical, occupational, and speech/language; (cc) vision care; and (dd) X-ray/radiology services. (2) Managed Care Member Participation. MassHealth Basic members for whom eligibility is determined under 130 CMR 505.006 must participate in managed care as described in 130 CMR 450.117. These members are eligible to receive services listed in 130 CMR 450.105(B)(1) only after enrolling with a MassHealth managed care provider in accordance with 130 CMR 508.002(I). Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 1 Introduction (130 CMR 450.000) Page 1-11 All Provider Manuals Transmittal Letter ALL-170 Date 10/01/09 (2) Managed Care Member Participation. (a) MassHealth CommonHealth members have the option of participating in managed care through MassHealth unless excluded pursuant to 130 CMR 508.004. For CommonHealth members who choose to participate in managed care, the provisions of 130 CMR 450.105(A)(3) and (4) apply. (b) MassHealth CommonHealth members who are under the age of 21 and who are excluded from participation in the PCC Plan or a MassHealth-contracted MCO under 130 CMR 508.004(A) must enroll with the MassHealth behavioral-health contractor. (c) MassHealth CommonHealth members who are under the age of 21 and who are excluded from participation in the PCC Plan or a MassHealth-contracted MCO under 130 CMR 508.004(I) through (L) may choose to enroll with the MassHealth behavioral-health contractor. (3) Purchase of Health Insurance. The MassHealth agency may purchase third- party health insurance for any MassHealth CommonHealth member if the MassHealth agency determines such premium payment is cost-effective. Under such circumstances, the MassHealth agency will pay a provider only for those services listed in 130 CMR 450.105(E)(1) that are not available through the member’s third-party health insurer. (F) MassHealth Prenatal. (1) Covered Services. For MassHealth Prenatal members (see 130 CMR 505.003), the MassHealth agency will pay only for ambulatory prenatal care provided by a MassHealth provider. (2) Managed Care Member Participation. MassHealth Prenatal members are excluded from participation in managed care pursuant to 130 CMR 508.004. (G) MassHealth Limited. (1) Covered Services. For MassHealth Limited members (see 130 CMR 505.008 and 519.009), the MassHealth agency will pay only for the treatment of a medical condition (including labor and delivery) that manifests itself by acute symptoms of sufficient severity that the absence of immediate medical attention reasonably could be expected to result in: (a) placing the member’s health in serious jeopardy; (b) serious impairment to bodily functions; or (c) serious dysfunction of any bodily organ or part. (2) Organ Transplants. Pursuant to 42 U.S.C. 1396b(v)(2), the MassHealth agency will not pay for an organ-transplant procedure, or for care and services related to that procedure, for MassHealth Limited members, regardless of whether such procedure would otherwise meet the requirements of 130 CMR 450.105(G)(1). (3) Managed Care Member Participation. MassHealth Limited members are excluded from participation in managed care pursuant to 130 CMR 508.004. (H) MassHealth Family Assistance. (1) Premium Assistance. The MassHealth agency provides benefits for MassHealth Family Assistance members who meet the eligibility requirements of 130 CMR 505.005(B), (C), or (D). (a) For MassHealth Family Assistance members who meet the eligibility requirements of 130 CMR 505.005(B)(4) and (C), the only benefit the MassHealth agency provides is partial payment of the member's employer-sponsored health insurance, except as provided in 130 CMR 450.105(H)(2). No MassHealth card is issued to these members. (b) For MassHealth Family Assistance members who meet the eligibility requirements of 130 CMR 505.005(D), the MassHealth agency issues a MassHealth card and provides: Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 1 Introduction (130 CMR 450.000) Page 1-12 All Provider Manuals Transmittal Letter ALL-170 Date 10/01/09 (i) full payment of the member's private health-insurance premium; and (ii) coverage of any services listed in 130 CMR 450.105(H)(3) not covered by the member's private health insurance. Coverage includes payment of copayments, coinsurance, and deductibles required by the member's private health insurance. (2) Payment of Copayments, Coinsurance, and Deductibles for Certain Children Who Receive Premium Assistance. (a) For children who meet the requirements of 130 CMR 505.005(B)(6), the MassHealth agency pays providers directly, or reimburses the member, for (i) copayments, coinsurance, and deductibles relating to well-baby and well- child care; and (ii) copayments, coinsurance, and deductibles for services covered under the member’s employer-sponsored health insurance once the member’s family has incurred and paid copayments, coinsurance, and deductibles for eligible members that equal or exceed five percent of the family group’s annual gross income. (b) Providers should check the Recipient Eligibility Verification System (REVS) to determine whether the MassHealth agency will pay a provider directly for a copayment, coinsurance, or deductible for a specific MassHealth Family Assistance member. (3) Covered Services for Members Who Are Not Receiving Premium Assistance. For MassHealth Family Assistance members who meet the eligibility requirements of 130 CMR 505.005(B)(3), (E), (F), or (G), the following services are covered: (a) abortion services; (b) acute inpatient hospital services; (c) ambulance services (emergency only); (d) ambulatory surgery services; (e) audiologist services; (f) behavioral-health (mental health and substance abuse) services; (g) Chapter 766: home assessments and participation in team meetings; (h) chiropractor services; (i) chronic disease and rehabilitation inpatient hospital services; (j) community health center services; (k) dental services; (l) durable medical equipment and supplies; (m) early intervention services; (n) family planning services; (o) hearing aid services; (p) home health services; (q) hospice services; (r) laboratory services; (s) nurse midwife services; (t) nurse practitioner services; (u) orthotic services; (v) outpatient hospital services; (w) oxygen and respiratory therapy equipment; (x) pharmacy services; (y) physician services; (z) podiatrist services;