Commonwealth of Massachusetts Executive Office of Health and Human Services Office of Medicaid 600 Washington Street Boston, MA 02111 www.mass.gov/masshealth MassHealth Eligibility Letter 188 September 1, 2009 TO: MassHealth Staff FROM: Tom Dehner, Medicaid Director RE: Revisions to the Regulations about 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. MANUAL UPKEEP Insert Remove Trans. By 508.000 508.000 E.L. 135 508.001 (1 of 2) 508.001 E.L. 135 508.001 (2 of 2) -- -- 508.002 (1 of 4) 508.002 (1 of 4) E.L. 135 508.004 508.004 E.L. 120 130 CMR: DIVISION OF MEDICAL ASSISTANCE Trans. by E.L. 188 Rev. 10/01/09 MASSHEALTH MANAGED CARE REQUIREMENTS Chapter 508 Page 508.000 TABLE OF CONTENTS Section 508.001: MassHealth Managed Care Requirement 508.002: Choosing a MassHealth Managed Care Provider 508.003: Behavioral Health Contractor 508.004: Members Excluded from Participation in the Primary Care Clinician Plan or a MassHealth Managed Care Organization 508.005: MassHealth Managed Care Providers 508.006: Right to a Fair Hearing (130 CMR 508.007 Reserved) 508.008: Voluntary Enrollment in Senior Care Organizations 508.009: Timely Notice of Appealable Actions 508.010: Time Limits for Resolving Internal Appeals 508.011: Timely Notice of Internal Appeal Decisions (130 CMR 508.012 through 508.015 Reserved) 508.016: Copayments Required by MassHealth 130 CMR: DIVISION OF MEDICAL ASSISTANCE Trans. by E.L. 188 Rev. 10/01/09 MASSHEALTH MANAGED CARE REQUIREMENTS Chapter 508 Page 508.001 (1 of 2) 508.001: MassHealth Managed Care Requirement (A) Member Participation. (1) MassHealth Standard members described in 130 CMR 505.002(B) through (F), certain MassHealth Family Assistance members described in 130 CMR 505.005(E), and MassHealth Basic members described in 130 CMR 505.006(B), except those MassHealth members who are receiving services from the Department of Children and Families or the Department of Youth Services, must enroll in one of the following managed care options unless excluded from participation in 130 CMR 508.004: (a) the Primary Care Clinician (PCC) Plan; or (b) a MassHealth-contracted managed care organization (MCO). (2) MassHealth Family Assistance members described in 130 CMR 505.005(F) and MassHealth Standard members described at 130 CMR 505.002(H) must enroll in the PCC Plan, unless excluded from participation in 130 CMR 508.004. (3) MassHealth Essential members who have coverage through the purchase of medical benefits described in 130 CMR 505.007(B) and (E) must enroll in the PCC Plan. (4) MassHealth Standard and 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. (5) MassHealth Standard and 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. (6) MassHealth members who are receiving services from the Department of Children and Families or the Department of Youth Services may choose to enroll in the PCC Plan or a MassHealth-contracted MCO. Such members who do not choose to enroll in the PCC Plan or a MassHealth-contracted MCO must enroll with the MassHealth behavioral-health contractor. 130 CMR: DIVISION OF MEDICAL ASSISTANCE Trans. by E.L. 188 Rev. 10/01/09 MASSHEALTH MANAGED CARE REQUIREMENTS Chapter 508 Page 508.001 (2 of 2) (B) Obtaining Services. (1) Primary Care. When the member selects or is assigned to either a PCC or MCO, that MassHealth managed care provider will deliver the member’s primary care, decide if the member needs medical care from other providers, and make referrals for such necessary medical services. (2) Other Medical Services (Excluding Behavioral-Health Services). (a) Service Delivery to Members Enrolled in the PCC Plan. All medical services to members enrolled in the PCC Plan, except those services listed in 130 CMR 450.118(J), require a referral or authorization from the PCC. MassHealth members enrolled in the PCC Plan may receive those services listed in 130 CMR 450.118(J), for which they are otherwise eligible, without a referral from their PCC. (b) Service Delivery to Members Enrolled in an MCO. All medical services to members enrolled in an MCO, except those services not covered under the MassHealth contract with the MCO and family planning services, are subject to the referral requirements of the MCO. MassHealth members enrolled in an MCO may receive family planning services from any MassHealth family planning provider and do not need an authorization or referral in order to receive such services. Members enrolled with an MCO should contact their MCO for information about covered services and referral requirements. (3) Behavioral-Health Services. (a) Members Enrolled in the PCC Plan. All members who enroll in the PCC Plan receive behavioral-health (mental health and substance abuse) services through the MassHealth behavioral-health contractor. See 130 CMR 508.003. (b) Members Enrolled in an MCO. (i) Members who enroll in a MassHealth-contracted MCO that is under contract to provide behavioral health services receive behavioral health services through that MCO. (ii) All behavioral health services to members enrolled in an MCO, except those services not covered under the MassHealth contract with the MCO, are subject to the authorization requirements of the MCO. Members enrolled with an MCO should contact their MCO for information about covered services and authorization requirements. (c) Members with Presumptive or Time-Limited Eligibility, or Fee-for-Service. Members with presumptive or time-limited eligibility, or fee-for-service receive behavioral health services through any qualified participating MassHealth provider. 130 CMR: DIVISION OF MEDICAL ASSISTANCE Trans. by E.L. 188 Rev. 10/01/09 MASSHEALTH MANAGED CARE REQUIREMENTS Chapter 508 Page 508.002 (1 of 4) 508.002: Choosing a MassHealth Managed Care Provider All MassHealth members, except those excluded under 130 CMR 508.004, must enroll with a MassHealth managed care provider. For MassHealth Basic members, described at 130 CMR 505.006(B), and MassHealth Essential members, described at 130 CMR 505.007(B) and (E), services are available only as of the member’s enrollment effective date, as established by the MassHealth agency in accordance with 130 CMR 508.002(I), with a MassHealth managed care provider. MassHealth Essential members described in 130 CMR 505.007(E) are also provided services under MassHealth Limited pursuant to 130 CMR 505.007(E) and 505.008. (A) Selection of a Managed Care Provider. (1) Procedure. The MassHealth agency notifies the member of the availability of MassHealth managed care providers in the member’s service area, and of the member’s obligation to select such a provider within the time period specified by the MassHealth agency. The member may select any provider from the MassHealth agency’s list of MassHealth managed care providers in his or her service area, if the provider is able to accept new patients. (2) Member’s Service Area. The member’s service area is determined by the MassHealth agency based on zip codes. Service area listings may be obtained from the MassHealth agency. (B) Assignment to a Managed Care Provider. If a member does not choose a managed care provider within the time period specified by the MassHealth agency in a notice to the member, the MassHealth agency assigns the member to a MassHealth managed care provider. (C) Criteria for Assigning Members. (1) The MassHealth agency assigns a member eligible to enroll with a managed care provider only if the provider is: (a) in the member's service area as described in 130 CMR 508.002(A)(2); (b) physically accessible to the member, if the member is disabled; 130 CMR: DIVISION OF MEDICAL ASSISTANCE Trans. by E.L. 188 Rev. 10/01/09 MASSHEALTH MANAGED CARE REQUIREMENTS Chapter 508 Page 508.004 508.004: Members Excluded from Participation in the Primary Care Clinician Plan or a MassHealth Managed Care Organization The following members are excluded from required participation in the MassHealth Primary Care Clinician (PCC) Plan or a MassHealth-contracted managed care organization (MCO): (A) a MassHealth Standard or CommonHealth member who has other health insurance, including Medicare; (B) a MassHealth Family Assistance, Basic, or Essential member who has or has access to other health insurance; (C) a member who is aged 65 or older; (D) a MassHealth Standard member institutionalized in a (1) nursing facility; (2) chronic disease or rehabilitation hospital; (3) state school for the mentally retarded; or (4) state psychiatric hospital; (E) a member who is eligible solely for (1) MassHealth Limited; or (2) MassHealth Prenatal; (F) a MassHealth Standard or CommonHealth member who is receiving hospice care through MassHealth, or who is terminally ill as documented by a medical prognosis of a life expectancy of six months or less; (G) a member who is receiving medical services through the Emergency Aid to the Elderly, Disabled and Children Program pursuant to 130 CMR 450.106; (H) a MassHealth Standard, Family Assistance, or CommonHealth member who has presumptive or time-limited eligibility is excluded from enrolling in the PCC Plan or an MCO for primary care; (I) members who are enrolled in the Kaileigh Mulligan Program described at 130 CMR 519.007(A); (J) members who are enrolled in a Home- and Community-Based Waiver; (K) members who are refugees described at 130 CMR 522.002; and (L) members who are receiving Title IV-E adoption assistance described at 130 CMR 522.003.