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January 10, 2014

MassHealth Changes regulations to comply with Affordable Care Act


MassHealth has made numerous changes to its program regulations to comply with requirements under the Affordable Care Act. Some of the highlights include the following:

MassHealth will pay for the diagnosis of male or female infertility.

MassHealth does not pay for the treatment of infertility, including laboratory tests, drugs, and procedures associated with treatment. However, the regulations now expressly provide that despite the lack of coverage for treatment of infertility, MassHealth will in fact pay for the diagnosis. This revision was implemented in the following program regulation manuals: Acute Inpatient Hospital (AIH), Acute Outpatient Hospital (AOH), Community Health Centers (CHC), Free Standing Ambulatory Surgery Center (FAS), Family Planning (FPA), Independent Diagnostic Testing Facility (IDTF), Independent Clinical Laboratory (LAB), and Physicians (PHY).

MassHealth members are eligible to receive acupuncture for treatment of pain.

MassHealth previously covered acupuncture for substance abuse detox and acupuncture as a substitution for surgical anesthetic, but did not cover acupuncture for the general treatment of pain. The AOH, CHC and PHY program regulation manuals now add provisions for such coverage. Each of these manuals contain a definition for acupuncture and terms for provider qualifications and claims submission.

MassHealth provides a total of 20 sessions of acupuncture for treatment of pain per member per year without prior authorization. If the member’s condition, treatment, or diagnosis changes, the member may receive more sessions of medically necessary acupuncture treatment with prior authorization. Qualified providers are physicians and other providers licensed by the board of Registration in Medicine (“BoRM”) under 243 CMR 5.00. For claims to be paid, services must be limited to the scope of practice authorized by state law or regulation, the acupuncturist must have a current license with BoRM, and (for non-physician providers) services must be provided pursuant to a supervisory agreement with a physician.

Changes in MassHealth coverage types; introduction of MassHealth CarePlus

The All Provider program manual introduces the new coverage type MassHealth CarePlus which provides coverage for the Medicaid expansion population in MA – individuals age 21 to 64 whose income is at or below 133% of the FPL and who do not qualify for MassHealth Standard. The new regulations list the covered services under this new plan, and describe its managed care requirements and premium assistance rules. There are 6 MCOs which were selected in 2013 to manage these members. MassHealth will not pay a provider other than one of these 6 MCOs for any services that are covered by the MassHealth agency’s contract with the MCO, except for non-network family planning services.

As mentioned above, the MassHealth Basic, MassHealth Essential, and MassHealth Prenatal coverage types are now discontinued under the new regulations. References to these coverage types were removed wherever they appeared in the MassHealth program regulations. Moreover, 19 and 20 year olds are now exempt from premiums and copayments. This change was made possible by the state’s 1115 demonstration waiver.

Hospital-determined presumptive eligibility

MassHealth will provide coverage for certain individuals for a limited period of time if, on the basis of attested information, a qualified hospital determines that the individual is presumptively eligible for MassHealth benefits. Coverage begins on the date the qualified hospital makes a determination regarding eligibility and continues until the end of the month following the determination, if the individual hasn’t formally applied for benefits; or until an eligibility determination is made upon submission of a completed application for benefits, provided the application is submitted prior to the end of the month following the determination by the hospital.

A qualified hospital is one that participates as a MassHealth provider, notifies the agency of its election to make presumptive eligibility determinations, agrees to follow MassHealth policies and procedures when doing so, has certified application counselors on-site to assist with the MassHealth application process, and has not otherwise been disqualified from making these determinations.

To view the Transmittal Letters in their entirety, click on the links below:

AIH-49: Change In Coverage For Diagnosis Of Infertility – Acute Inpatient Hospitals

ALL-205: Changes To Masshealth Coverage Types; Hospital-Determined Presumptive Eligibility; Copayment Exclusions And Caps; Exempting 19- And 20-Year-Olds From Premium And Copayment Requirements – All Providers

AOH-31: Changes In Coverage For Acupuncture And The Diagnosis Of Infertility –Acute Outpatient Hospitals

CHC-99: Changes In Coverage For Acupuncture And The Diagnosis Of Infertility –Community Health Centers

FAS-27: Changes In Coverage For The Diagnosis Of Infertility – Freestanding Ambulatory Surgery Centers

FPA-50: Changes In Coverage For The Diagnosis Of Infertility – Family Planning Agencies

HHA-49: Home Health Services Covered For Masshealth Careplus Members –Home Health Agencies

IDTF-13: Changes In Coverage For The Diagnosis Of Infertility – Independent Diagnostic Testing Facilities

LAB-42: Changes In Coverage For The Diagnosis Of Infertility – Independent Clinical Laboratories

PHM-60: Coverage for Family Planning Services – Pharmacies

PHY-140: Coverage For Acupuncture And The Diagnosis Of Infertility – Physicians

POD-70: Coverage For Family Planning Services – Podiatrists

About the Author

Andrew Levine

Andrew Levine is the senior partner overseeing the firm’s Health Law Regulatory practice. He provides regulatory guidance, business and corporate legal services, as well as strategic advice to healthcare clients. You can find him on LinkedIn.


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