130 CMR 450.105
Coverage Types
A member is eligible for services and benefits according to the member’s coverage type.
Each coverage type is described in 130 CMR 450.105(A) through (H). Payment for the covered
services listed in 130 CMR 450.105 is subject to all conditions and restrictions of MassHealth,
including all applicable prerequisites for payment. See individual program regulations and
managed care contracts and performance specifications for information on covered services and
specific service limitations, including age restrictions applicable to certain services.
(A) MassHealth Standard.
(1) Covered Services. The following services are covered for MassHealth Standard
members (see 130 CMR 505.002: MassHealth Standard and 130 CMR 519.002: MassHealth
Standard):
(a) abortion services;
(b) acupuncture services;
(c) adult day health services;
(d) adult foster care / group adult foster care services;
(e) ambulance services;
(f) ambulatory surgery services;
(g) audiologist services;
(h) behavioral health services;
(i) certified nurse midwife services;
(j) certified nurse practitioner services;
(k) certified registered nurse anesthetist services;
(l) Chapter 766: home assessments and participation in team meetings;
(m) chiropractor services;
(n) clinical nurse specialist services;
(o) community health center services;
(p) day habilitation services;
(q) dental services;
(r) doula services;
(s) durable medical equipment and supplies;
(t) Early and Periodic Screening, Diagnosis and Treatment (EPSDT) services in
accordance with 130 CMR 450.140;
(u) early intervention services;
(v) family planning services;
(w) freestanding birth center services;
(x) hearing aid services;
(y) home health services;
(z) homeless medical respite services;
(aa) hospice services;
(bb) independent nurse (private duty nursing) and continuous skilled nursing agency
services;
(cc) inpatient hospital services;
(dd) laboratory services;
(ee) nursing facility services;
(ff) orthotic services;
(gg) outpatient hospital services;
1. Introduction
(130 CMR 450.000)
(hh) oxygen and respiratory therapy equipment;
(ii) personal care services;
(jj) pharmacy services;
(kk) physician services;
(ll) physician assistant services;
(mm) podiatrist services;
(nn) prosthetic services;
(oo) psychiatric clinical nurse specialist services;
(pp) rehabilitation services;
(qq) renal dialysis services;
(rr) speech and hearing services;
(ss) therapy services: physical, occupational, and speech/language;
(tt) transportation services;
(uu) urgent care clinic services;
(vv) vision care; and
(ww) X-ray/radiology services.
(2) Managed Care Member Participation. MassHealth Standard members may be enrolled in
managed care in accordance with 130 CMR 508.001: MassHealth Member Participation in
Managed Care. (See also 130 CMR 450.117.)
(3) MCOs, Accountable Care Partnership Plans, One Care Plans, and SCO Plans. For
MassHealth Standard members who are enrolled in an MCO, Accountable Care Partnership
Plan, One Care Plan, or SCO Plan, 130 CMR 450.105(A)(3)(a) and (b) apply.
(a) The MassHealth agency does not pay a provider other than the MCO, Accountable
Care Partnership Plan, One Care Plan, or SCO Plan for any services that are covered by
the MassHealth agency’s contract with the MCO, Accountable Care Partnership Plan,
One Care Plan, or SCO Plan except for family planning services that were not provided
or arranged for by the MCO, Accountable Care Partnership Plan, One Care Plan, or SCO
Plan. It is the provider’s responsibility to determine whether a MassHealth member is
enrolled in an MCO, Accountable Care Partnership Plan, One Care Plan, or SCO Plan
and to verify the scope of services covered by the MassHealth agency’s contract with the
MCO, Accountable Care Partnership Plan, One Care Plan, or SCO Plan. Payment for
such services is subject to the terms of the managed care contracts, including but not
limited to provisions governing service authorization, performance specifications,
provider networks, and billing requirements.
(b) The MassHealth agency pays providers for those services listed in 130 CMR
450.105(A)(1) that are not covered by the MassHealth agency’s contract with the MCO,
Accountable Care Partnership Plan, One Care Plan, or SCO Plan in accordance with
applicable MassHealth regulations. 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 or a Primary Care ACO
receive behavioral health services only through the MassHealth behavioral health
contractor, in accordance with the MassHealth agency’s contract with the behavioral
health contractor. (See 130 CMR 450.124.)
1. Introduction
(130 CMR 450.000)
(b) MassHealth Standard members enrolled in an MCO, Accountable Care Partnership
Plan, One Care Plan, or SCO Plan receive behavioral health services only through the
MCO, Accountable Care Partnership Plan, One Care Plan, or SCO Plan, in accordance
with the MassHealth agency’s contract with the MCO, Accountable Care Partnership
Plan, One Care Plan, or SCO Plan. (See 130 CMR 450.117.)
(c) MassHealth Standard members who are not enrolled in an MCO, Accountable Care
Partnership Plan, One Care Plan, or SCO Plan or with the behavioral health contractor
may receive behavioral health services from any participating MassHealth provider of
such services in accordance with applicable MassHealth regulations.
(d) MassHealth Standard members who are enrolled with the behavioral health
contractor pursuant to 130 CMR 508.001(E) receive behavioral health services only
through the MassHealth behavioral health contractor, in accordance with the MassHealth
agency’s contract with the behavioral health contractor. (See 130 CMR 450.124.)
(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(F): Individuals with Breast or Cervical Cancer, 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.
(B) MassHealth CarePlus.
(1) Covered Services. The following services are covered for MassHealth CarePlus members
(see 130 CMR 505.008: MassHealth CarePlus):
(a) abortion services;
(b) acupuncture services;
(c) ambulance services;
(d) ambulatory surgery services;
(e) audiologist services;
(f) behavioral health services;
(g) certified nurse midwife services;
(h) certified nurse practitioner services;
(i) certified registered nurse anesthetist services;
(j) chiropractor services;
(k) clinical nurse specialist services;
(l) community health center services;
(m) dental services;
(n) doula services;
(o) durable medical equipment and supplies;
(p) family planning services;
(q) freestanding birth center services;
(r) hearing aid services;
(s) home health services;
(t) homeless medical respite services;
(u) hospice services;
(v) inpatient hospital services;
(w) laboratory services;
(x) nursing facility services;
(y) orthotic services;
1. Introduction
(130 CMR 450.000)
(z) outpatient hospital services;
(aa) oxygen and respiratory therapy equipment;
(bb) pharmacy services;
(cc) physician services;
(dd) physician assistant services;
(ee) podiatrist services;
(ff) prosthetic services;
(gg) psychiatric clinical nurse specialist 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) urgent care clinic services;
(nn) vision care; and
(o) X-ray/radiology services.
(2) Managed Care Member Participation. MassHealth CarePlus members may be enrolled in
managed care in accordance with 130 CMR 508.001: MassHealth Member Participation in
Managed Care. (See also 130 CMR 450.117.)
(3) MCOs and Accountable Care Partnership Plans. For MassHealth CarePlus members who
are enrolled in an MCO or Accountable Care Partnership Plan, the following rules apply.
(a) The MassHealth agency does not pay a provider other than the MCO or Accountable
Care Partnership Plan for any services that are covered by the MassHealth agency’s
contract with the MCO or Accountable Care Partnership Plan, except for family planning
services that were not provided or arranged for by the MCO or Accountable Care
Partnership Plan. It is the provider’s responsibility to determine whether a MassHealth
member is enrolled in an MCO or Accountable Care Partnership Plan and to verify the
scope of services covered by the MassHealth agency’s contract with the MCO or
Accountable Care Partnership Plan. Payment for such services is subject to the terms of
the managed care contracts, including but not limited to provisions governing service
authorization, performance specifications, provider networks, and billing requirements.
(b) The MassHealth agency pays providers other than the MCO or Accountable Care
Partnership Plan for those services listed in 130 CMR 450.105(B)(1) that are not covered
by the MassHealth agency’s contract with the MCO or Accountable Care Partnership
Plan in accordance with applicable MassHealth regulations. Such payment is subject to
all conditions and restrictions of MassHealth, including all applicable prerequisites for
payment.
(4) Behavioral Health Services.
(a) MassHealth CarePlus members enrolled in the PCC Plan or Primary Care ACO
receive behavioral health services only through the MassHealth behavioral health
contractor, in accordance with the MassHealth agency’s contract with the behavioral
health contractor. (See 130 CMR 450.124.)
(b) MassHealth CarePlus members enrolled in an MCO or Accountable Care Partnership
Plan receive behavioral health services only through the MCO or Accountable Care
Partnership Plan, in accordance with the MassHealth agency’s contract with the MCO or
Accountable Care Partnership Plan. (See 130 CMR 450.117.)
1. Introduction
(130 CMR 450.000)
(c) MassHealth CarePlus members who are not enrolled in an MCO, Accountable Care
Partnership Plan, or with the behavioral health contractor may receive behavioral health
services from any participating MassHealth provider of such services in accordance with
applicable MassHealth regulations.
(5) Purchase of Health Insurance. The MassHealth agency may purchase third-party health
insurance for MassHealth CarePlus members, with the exception of members described at
130 CMR 505.002(F): Individuals with Breast or Cervical Cancer, 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(B)(1)
that are not available through the member’s third-party health insurer.
(C) MassHealth Buy-In.
(1) For a MassHealth Buy-In member who is 65 years of age or older or is institutionalized
(see 130 CMR 519.011: MassHealth Buy-In), the MassHealth agency pays all of the member's
Medicare Part B premium. The MassHealth agency does not pay for any other benefit for these
members.
(2) MassHealth Buy-In members are responsible for payment of copayments, coinsurance, and
deductibles. MassHealth Buy-In members are also responsible for payment for any services that
are not covered by the member's insurance.
(3) The MassHealth agency does not pay providers directly for any services provided to any
MassHealth Buy-In member, and therefore does not issue a MassHealth card to MassHealth
Buy-In members.
(4) MassHealth Buy-In members are excluded from participation with any MassHealth
managed care provider pursuant to 130 CMR 508.002(A): MassHealth Managed Care
Provider.
(D) MassHealth Senior Buy-In.
(1) Covered Services. For MassHealth Senior Buy-In members (see 130 CMR 519.010:
MassHealth Senior Buy-In), the MassHealth agency pays the member's Medicare Part B
premiums, and where applicable, Medicare Part A premiums. The MassHealth agency also
pays for coinsurance and deductibles under Medicare Parts A and B.
(2) Managed Care Member Participation. MassHealth Senior Buy-In members are excluded
from participation with a MassHealth managed care provider pursuant to 130 CMR
508.002(A): MassHealth Managed Care Provider.
(E) MassHealth CommonHealth.
(1) Covered Services. The following services are covered for MassHealth CommonHealth
members (see 130 CMR 505.004: MassHealth CommonHealth and 130 CMR 519.012:
MassHealth CommonHealth):
(a) abortion services;
(b) acupuncture services;
(c) adult day health services;
(d) adult foster care / group adult foster care services;
(e) ambulance services;
(f) ambulatory surgery services;
(g) audiologist services;
(h) behavioral health services;
(i) certified nurse midwife services;
1. Introduction
(130 CMR 450.000)
(j) certified nurse practitioner services;
(k) certified registered nurse anesthetist services;
(l) Chapter 766: home assessments and participation in team meetings;
(m) chiropractor services;
(n) clinical nurse specialist services;
(o) community health center services;
(p) day habilitation services;
(q) dental services;
(r) doula services;
(s) durable medical equipment and supplies;
(t) Early and Periodic Screening, Diagnosis and Treatment (EPSDT) services in
accordance with 130 CMR 450.140;
(u) early intervention services;
(v) freestanding birth center services;
(w) family planning services;
(x) hearing aid services;
(y) home health services;
(z) homeless medical respite services;
(aa) hospice services;
(bb) independent nurse (private duty nursing) and continuous skilled nursing agency
services;
(cc) inpatient hospital services;
(dd) laboratory services;
(ee) nursing facility services;
(ff) orthotic services;
(gg) outpatient hospital services;
(hh) oxygen and respiratory therapy equipment;
(ii) personal care services;
(jj) pharmacy services;
(kk) physician services;
(ll) physician assistant services;
(mm) podiatrist services;
(nn) prosthetic services;
(oo) psychiatric clinical nurse specialist services;
(pp) rehabilitation services;
(qq) renal dialysis services;
(rr) speech and hearing services;
(ss) therapy services: physical, occupational, and speech/language;
(tt) transportation services;
(uu) urgent care clinic services;
(vv) vision care; and
(ww) X-ray/radiology services.
(2) Managed Care Member Participation. MassHealth CommonHealth members may be
enrolled in managed care in accordance with 130 CMR 508.001: MassHealth Member
Participation in Managed Care. (See also 130 CMR 450.117.)
1. Introduction
(130 CMR 450.000)
(3) MCOs, Accountable Care Partnership Plans, and One Care Plans. For MassHealth
CommonHealth members who are enrolled in an MCO, Accountable Care Partnership Plan,
or One Care Plan, 130 CMR 450.105(E)(3)(a) and (b) apply.
(a) The MassHealth agency does not pay a provider other than the MCO, Accountable
Care Partnership Plan, or One Care Plan for any services that are covered by the
MassHealth agency’s contract with the MCO, Accountable Care Partnership Plan, or One
Care Plan, except for family planning services that were not provided or arranged for by
the MCO, Accountable Care Partnership Plan, or One Care Plan. It is the provider’s
responsibility to determine whether a MassHealth member is enrolled in an MCO,
Accountable Care Partnership Plan, or One Care Plan and to verify the scope of services
covered by the MassHealth agency’s contract with the MCO, Accountable Care
Partnership Plan, or One Care Plan. Payment for such services is subject to the terms of
the managed care contracts, including but not limited to provisions governing service
authorization, performance specifications, provider networks, and billing requirements.
(b) The MassHealth agency pays providers other than the MCO, Accountable Care
Partnership Plan, or One Care Plan for those services listed in 130 CMR 450.105(E)(1)
that are not covered by the MassHealth agency’s contract with the MCO, Accountable
Care Partnership Plan, or One Care Plan in accordance with applicable MassHealth
regulations. Such payment is subject to all conditions and restrictions of MassHealth,
including all applicable prerequisites for payment.
(4) Behavioral Health Services.
(a) MassHealth CommonHealth members enrolled in the PCC Plan or a Primary Care
ACO receive behavioral health services only through the MassHealth behavioral health
contractor, in accordance with the MassHealth agency’s contract with the behavioral
health contractor. (See 130 CMR 450.124.)
(b) MassHealth CommonHealth members enrolled in an MCO, Accountable Care
Partnership Plan, or One Care Plan receive behavioral health services only through the
MCO, Accountable Care Partnership Plan, or One Care Plan, in accordance with the
MassHealth agency’s contract with the MCO, Accountable Care Partnership Plan, or One
Care Plan. (See 130 CMR 450.117.)
(c) MassHealth CommonHealth members who are not enrolled in an MCO, Accountable
Care Partnership Plan, or One Care Plan or with the behavioral health contractor may
receive behavioral health services from any participating MassHealth provider of such
services in accordance with applicable MassHealth regulations.
(d) MassHealth CommonHealth members who are enrolled with the behavioral health
contractor pursuant to 130 CMR 508.001(E) receive behavioral health services only
through the MassHealth behavioral health contractor, in accordance with the MassHealth
agency’s contract with the behavioral health contractor. (See 130 CMR 450.124.)
(5) 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
pays 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.
1. Introduction
(130 CMR 450.000)
(F) MassHealth Limited.
(1) Covered Services. For MassHealth Limited members (see 130 CMR 505.006:
MassHealth Limited and 130 CMR 519.009: MassHealth Limited), the MassHealth agency
pays 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 does 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(F)(1).
(3) Managed Care Member Participation. MassHealth Limited members are excluded from
participation in managed care pursuant to 130 CMR 508.002: MassHealth Members Excluded
from Participation in Managed Care.
(G) 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) 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).
(b) For MassHealth Family Assistance members who meet the eligibility requirements of
130 CMR 505.005(B): Eligibility Requirements for Children with Modified Adjusted
Gross Income of the MassHealth MAGI Household Greater than 150 and Less than or
Equal to 300% of the Federal Poverty Level, the MassHealth agency provides dental
services as described in 130 CMR 420.000: Dental Services.
(c) For MassHealth Family Assistance members who meet the eligibility requirements of
130 CMR 505.005(D): Eligibility Requirements for Adults and Young Adults Aged 19
and 20 Who Are Nonqualified PRUCOLs with Modified Adjusted Gross Income of the
MassHealth MAGI Household at or below 300% of the Federal Poverty Level, the
MassHealth agency issues a MassHealth card and provides
1. full payment of the member's private health insurance premium; and
2. coverage of any services listed in 130 CMR 450.105(H) 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): Eligibility
Requirements for Children with Modified Adjusted Gross Income of the MassHealth
MAGI Household Greater than 150 and Less than or Equal to 300% of the Federal
Poverty Level, the MassHealth agency pays providers directly, or reimburses the member,
for
1. copayments, coinsurance, and deductibles relating to well-baby and well-child
care; and
1. Introduction
(130 CMR 450.000)
2. 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 5% of the family group’s annual gross income.
(b) Providers should check the Eligibility Verification System (EVS) 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), (E), (F), or (G), the following services are covered:
(a) abortion services;
(b) acupuncture services;
(c) ambulance services (emergency only);
(d) ambulatory surgery services;
(e) audiologist services;
(f) behavioral health services;
(g) certified nurse midwife services;
(h) certified nurse practitioner services;
(i) certified registered nurse anesthetist services;
(j) Chapter 766: home assessments and participation in team meetings;
(k) chiropractor services;
(l) chronic disease and rehabilitation hospital services;
(m) clinical nurse specialist services;
(n) community health center services;
(o) dental services;
(p) doula services;
(q) durable medical equipment and supplies;
(r) preventive pediatric health care screening and diagnosis (PPHSD), in accordance with
130 CMR 450.150;
(s) early intervention services;
(t) freestanding birth center services;
(u) family planning services;
(v) hearing aid services;
(w) home health services;
(x) homeless medical respite services;
(y) hospice services;
(z) inpatient hospital services;
(aa) laboratory services;
(bb) nursing facility services;
(cc) orthotic services;
(dd) outpatient hospital services;
(ee) oxygen and respiratory therapy equipment;
(ff) pharmacy services;
(gg) physician services;
(hh) physician assistant services;
(ii) podiatrist services;
(jj) prosthetic services;
1. Introduction
(130 CMR 450.000)
(kk) psychiatric clinical nurse specialist services;
(ll) rehabilitation services;
(mm) renal dialysis services;
(nn) speech and hearing services;
(oo) therapy services: physical, occupational, and speech/language;
(pp) urgent care clinic services;
(qq) vision care; and
(rr) X-ray/radiology services.
(4) Managed Care Participation. MassHealth Family Assistance members may be enrolled
in managed care in accordance with 130 CMR 508.001: MassHealth Member Participation in
Managed Care. (See also 130 CMR 450.117.)
(5) MCOs and Accountable Care Partnership Plans. For MassHealth Family Assistance
members who are enrolled in an MCO or Accountable Care Partnership Plan, 130 CMR
450.105(G)(5)(a) and (b) apply.
(a) The MassHealth agency does not pay a provider other than the MCO or Accountable
Care Partnership Plan for any services that are covered by the MassHealth agency’s
contract with the MCO or Accountable Care Partnership Plan, except for family planning
services that were not provided or arranged for by the MCO or Accountable Care
Partnership Plan. It is the provider’s responsibility to determine whether a MassHealth
member is enrolled in an MCO or Accountable Care Partnership Plan and to verify the
scope of services covered by the MassHealth agency’s contract with the MCO or
Accountable Care Partnership Plan. Payment for such services is subject to the terms of
the managed care contracts including, but not limited to, provisions governing service
authorization, performance specifications, provider networks, and billing requirements.
(b) The MassHealth agency pays providers other than the MCO or Accountable Care
Partnership Plan for those services listed in 130 CMR 450.105(H) that are not covered by
the MassHealth agency’s contract with the MCO or Accountable Care Partnership Plan in
accordance with applicable MassHealth regulations. 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 or a Primary Care
ACO receive behavioral health services only through the MassHealth behavioral health
contractor, in accordance with the MassHealth agency’s contract with the behavioral
health contractor. (See 130 CMR 450.124.)
(b) MassHealth Family Assistance members enrolled in an MCO or Accountable Care
Partnership Plan receive behavioral health services only through the MCO or
Accountable Care Partnership Plan, in accordance with the MassHealth agency’s contract
with the MCO or Accountable Care Partnership Plan. (See 130 CMR 450.117.)
(c) MassHealth Family Assistance members who are not receiving premium assistance,
and are not enrolled in an MCO, Accountable Care Partnership Plan, or with the
MassHealth behavioral health contractor may receive behavioral health services from any
participating MassHealth provider of such services in accordance with applicable
MassHealth regulations.
1. Introduction
(130 CMR 450.000)
(H) Children’s Medical Security Plan. Children determined to be eligible for the Children’s
Medical Security Plan (CMSP) receive benefits described in 130 CMR 522.004(G): Benefits
Provided.
(130 CMR 450.106 Reserved)
1. Introduction
(130 CMR 450.000)