Summit Health Law Partners

Contact

Boston
Providence

Boston

One Beacon Street
Suite 1320
Boston, MA 02108

T 617.598.6700
F 617.720.5092

Providence

One Richmond Sq.
Suite 165W
Providence, RI 02906
T 401.454.0400
F 401.454.0404

January 10, 2014

MassHealth Changes regulations to comply with Affordable Care Act

By Andrew Levine

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.

© 2021  |  website: visual dialogue

Related Articles

News

Health Law

Litigation

Corporate

Research Misconduct

Related Articles

Notice

This website presents general information about Summit Health Law Partners and is not intended as legal advice nor should you consider it as such. You should not act upon this information without seeking professional counsel.

Please note that contacting Summit Health Law Partners by email, telephone or facsimile will not establish an attorney-client relationship, obligate us to act as your attorney or impose an obligation on either the law firm or the receiving lawyer to keep the transmitted information confidential. Completion of Summit Health Law Partners' new client intake protocol, including without limitation the firm’s conflicts checking process and an engagement letter, is necessary to establish an attorney-client relationship. Absent a current attorney-client relationship with Summit Health Law Partners, any information or documents communicated or transmitted by you to Summit Health Law Partners will not be treated as confidential, secret or protected in any way. If you are not a current client of Summit Health Law Partners, please do not send any confidential information to us through this website or otherwise concerning any potential or actual legal matter you have. Before providing any confidential information to us, you must obtain permission to do so from one of the firm’s lawyers. By clicking "Accept," you acknowledge that we have no obligation to maintain the confidentiality of any information you submit to us unless we already represent you or unless we have agreed to receive limited confidential material/information from you as a prospective client.

If you would like to discuss becoming a client, please contact one of our attorneys to arrange for a meeting or telephone conference. If you wish to disclose confidential information to a lawyer in the firm before an attorney-client relationship is established, the protections that the law firm will provide to such information from a prospective client should be discussed with the firm attorney before such information is submitted. Thank you for your interest in Summit Health Law Partners.

© 2021   Privacy Policy  |  Attorney Advertising/Legal Notice  |  website: visual dialogue