Section 450.105 - Coverage TypesA member is eligible for services and benefits according to the member's coverage type. Each coverage type is described below. 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 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 (see130 CMR 505.002: MassHealth Standard and 130 CMR 519.002: MassHealth Standard).(b) acupuncture services;(c) adult day health services;(d) adult foster care 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;(r) durable medical equipment and supplies;(s) early intervention services;(t) family planning services;(u) hearing aid services;(v) home health services;(x) independent nurse (private duty nursing) services;(y) inpatient hospital services;(aa) nursing facility services;(cc) outpatient hospital services;(dd) oxygen and respiratory therapy equipment;(ee) personal care services;(hh) physician assistant services;(ii) podiatrist services;(jj) prosthetic services;(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) transportation services;(qq) urgent care clinic services;(ss) X-ray/radiology services.(2)Managed Care Member Participation. MassHealth Standard members must enroll with a MassHealth managed care provider unless excluded from enrollment with a MassHealth managed care provider. (See130 CMR 450.117, and 130 CMR 508.000: MassHealth: Managed Care Requirements.) MassHealth members who are enrolled in the Kaileigh Mulligan Program, described in 130 CMR 519.007(A): The Kaileigh Mulligan Program, or who are enrolled in a home- and community-based services waiver 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 are enrolled with the MassHealth behavioral health contractor. Such members may choose to receive all services on a fee-for-service basis.(3)MCOs, Accountable Care Partnership Plans, SCOs, and ICOs. For MassHealth Standard members who are enrolled in an MCO, Accountable Care Partnership Plan, SCO, or ICO, 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, SCO, or ICO for any services that are covered by the MassHealth agency's contract with the MCO, Accountable Care Partnership Plan, SCO, or ICO except for family planning services that were not provided or arranged for by the MCO, Accountable Care Partnership Plan, SCO, or ICO. It is the responsibility of the provider to verify the scope of services covered by the MassHealth agency's contract with the MCO, Accountable Care Partnership Plan, SCO, or ICO.(b) The MassHealth agency pays providers other than the MCO, Accountable Care Partnership Plan, SCO, or ICO 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, SCO, or ICO. 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. (See130 CMR 450.124.)(b) MassHealth Standard members enrolled in an MCO, Accountable Care Partnership Plan, SCO, or ICO receive behavioral health services only through the MCO, Accountable Care Partnership Plan, SCO, or ICO. (See130 CMR 450.117.)(c) MassHealth Standard members who are not enrolled in an MCO, Accountable Care Partnership Plan, SCO, ICO, or with the behavioral health contractor may receive behavioral health services from any participating MassHealth provider of such services.(d) MassHealth Standard members who are younger than 21 years old and who are excluded from participating with a MassHealth managed care provider under 130 CMR 508.002(A)(1) or (2) must enroll with the MassHealth behavioral health contractor.(e) MassHealth members who are enrolled in the Kaileigh Mulligan Program, described in 130 CMR 519.007(A): The Kaileigh Mulligan Program, may choose to enroll with a MassHealth managed care provider. Such members who do not choose to enroll with a MassHealth managed care provider are enrolled with the MassHealth behavioral health contractor. Such members may choose to receive all services on a fee-for-service basis.(f) MassHealth members who are receiving services from the Department of Children and Families (DCF) or the Department of Youth Services (DYS) may choose to enroll with a MassHealth managed care provider. Such members who do not choose to enroll with a MassHealth managed care provider must enroll with the MassHealth behavioral health contractor.(g) MassHealth members who receive Title IV-E adoption assistance, described in 130 CMR 522.003: Adoption Assistance and Foster Care Maintenance, may choose to enroll with a MassHealth managed care provider. Such members who do not choose to enroll with a MassHealth managed care provider are enrolled with the MassHealth behavioral health contractor. Such members may choose to receive all services on a fee-for-service basis.(h) MassHealth members who participate in one of the Money Follows the Person home- and community-based services waivers who are not enrolled with a MassHealth managed care provider or not otherwise enrolled with the behavioral health contractor must enroll with the 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(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.(6)Senior Care Organizations. MassHealth Standard members 65 years of age or older may voluntarily enroll in a senior care organization (SCO) in accordance with the requirements under 130 CMR 508.008: Senior Care Organizations. The MassHealth agency does not pay a provider other than a SCO for any services that are provided to the MassHealth member while the member is enrolled in a SCO.(7)Integrated Care Organizations. MassHealth Standard members 21 through 64 years of age who are enrolled in Medicare Parts A and B, are eligible for Medicare Part D, and have no other health insurance that meets the basic benefit level defined in 130 CMR 501.001: Definition of Terms may voluntarily enroll in integrated care organization (ICO) in accordance with the requirements at 130 CMR 508.007: Integrated Care Organizations. While enrolled in an ICO, MassHealth members who turn 65 years of age and are eligible for MassHealth CommonHealth may remain in One Care after 65 years of age. The MassHealth agency does not pay a provider other than the ICO for any services that are provided by an ICO while the member is enrolled in the ICO, except for family planning services that were not provided or arranged for by the ICO. It is the responsibility of the provider of services to determine if a MassHealth member is enrolled in an ICO. Upon request, the ICO must inform providers and enrolled members of ICO covered benefits. ICOs are responsible for providing enrolled members with the full continuum of Medicare and MassHealth covered services.(B)MassHealth CarePlus.(1)Covered Services. The following services are covered for MassHealth CarePlus members (see130 CMR 505.008: MassHealth CarePlus).(b) acupuncture 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;(n) durable medical equipment and supplies;(o) family planning services;(p) hearing aid services;(q) home health services;(s) inpatient hospital services;(u) nursing facility services;(w) outpatient hospital services;(x) oxygen and respiratory therapy equipment;(aa) physician assistant services;(bb) podiatrist services;(cc) prosthetic services;(dd) psychiatric clinical nurse specialist services;(ee) rehabilitation services;(ff) renal dialysis services;(gg) speech and hearing services;(hh) therapy services: physical, occupational, and speech/language;(ii) transportation services;(jj) urgent care clinic services;(ll) X-ray/radiology services.(2)Managed Care Member Participation. MassHealth CarePlus members must enroll with a MassHealth managed care provider 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 responsibility of the provider to verify the scope of services covered by the MassHealth agency's contract with the MCO or Accountable Care Partnership Plan.(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. 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. (See130 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. (See130 CMR 450.117.)(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.(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 (see130 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: MassHealth Members Excluded from Participation in Managed Care.(D)MassHealth Senior Buy-In.(1)Covered Services. For MassHealth Senior Buy-In members (see130 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: MassHealth Members Excluded from Participation in Managed Care.(E)MassHealth CommonHealth.(1)Covered Services. The following services are covered for MassHealth CommonHealth members (see130 CMR 505.004: MassHealth CommonHealth and 130 CMR 519.012: MassHealth CommonHealth).(b) acupuncture services;(c) adult day health services;(d) adult foster care 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;(r) durable medical equipment and supplies;(s) early intervention services;(t) family planning services;(u) hearing aid services;(v) home health services;(x) independent nurse (private duty nursing) services;(y) inpatient hospital services;(aa) nursing facility services;(cc) outpatient hospital services;(dd) oxygen and respiratory therapy equipment;(ee) personal care services;(hh) physician assistant services;(ii) podiatrist services;(jj) prosthetic services;(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) transportation services;(qq) urgent care clinic services;(ss) X-ray/radiology services.(2)Managed Care Member Participation. MassHealth CommonHealth members must enroll with a MassHealth managed care provider or ICO, unless excluded from participation in a MassHealth managed care provider. (See130 CMR 450.117, and 130 CMR 508.000: Managed Care Requirements.)(3)MCOs, Accountable Care Partnership Plans, and ICOs. For MassHealth CommonHealth members who are enrolled in an MCO, Accountable Care Partnership Plan, or ICO, 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 ICO for any services that are covered by the MassHealth agency's contract with the MCO, Accountable Care Partnership Plan, or ICO, except for family planning services that were not provided or arranged for by the MCO, Accountable Care Partnership Plan, or ICO. It is the responsibility of the provider to verify the scope of services covered by the MassHealth agency's contract with the MCO, Accountable Care Partnership Plan, or ICO.(b) The MassHealth agency pays providers other than the MCO, Accountable Care Partnership Plan, or ICO 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 ICO. 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. (See130 CMR 450.124.)(b) MassHealth CommonHealth members enrolled in an MCO, Accountable Care Partnership Plan, or ICO receive behavioral health services only through the MCO, Accountable Care Partnership Plan, or ICO. (See130 CMR 450.117.)(c) MassHealth CommonHealth members who are not enrolled in an MCO, Accountable Care Partnership Plan, or ICO, or with the behavioral health contractor may receive behavioral health services from any participating MassHealth provider of such services.(d) MassHealth CommonHealth members who are younger than 21 years of age and who are excluded from participation in a MassHealth managed care provider or ICO under 130 CMR 508.002(A)(1) or (2) must enroll with the MassHealth behavioral health contractor.(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.(6)Integrated Care Organizations. MassHealth CommonHealth members 21 through 64 years of age who are enrolled in Medicare Parts A and B, are eligible for Medicare Part D, and have no other health insurance that meets the basic benefit level defined in 130 CMR 501.001: Definition of Terms, may voluntarily enroll in an integrated care organization (ICO) in accordance with the requirements at 130 CMR 508.007: Integrated Care Organizations; while enrolled in an ICO, MassHealth members who turn 65 years of age and are eligible for MassHealth CommonHealth may remain in One Care after 65 years of age. The MassHealth agency does not pay a provider other than the ICO for any services that are provided by an ICO while the member is enrolled in the ICO, except for family planning services that were not provided or arranged for by the ICO. It is the responsibility of the provider of services to determine if a MassHealth member is enrolled in an ICO. Upon request, the ICO must inform providers and enrolled members of ICO covered benefits. ICOs are responsible for providing enrolled members with the full continuum of Medicare and MassHealth covered services.(F)MassHealth Limited.(1)Covered Services. For MassHealth Limited members (see130 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; and2. 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; and2. 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: (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) clinical nurse specialist services;(m) community health center services;(o) durable medical equipment and supplies;(p) early intervention services;(q) family planning services;(r) hearing aid services;(s) home health services;(u) inpatient hospital services;(w) nurse midwife services;(x) nurse practitioner services;(z) outpatient hospital services;(aa) oxygen and respiratory therapy equipment;(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) urgent care clinic services;(nn) X-ray/radiology services.(4)Managed Care Participation.(a) MassHealth Family Assistance members who meet the eligibility requirements of 130 CMR 505.005(e): Eligibility Requirement for HIV-positive Individuals Who Are Citizens or Qualified Noncitizens with Modified Adjusted Gross Income of the Masshealth MAGI Household Greater than 133 and Less than or Equal to 200% of the Federal Poverty Level, must enroll with a MassHealth managed care provider. (See 130 CMR 450.117.)(b) MassHealth Family Assistance members who meet the eligibility requirements of 130 CMR 505.005(F): Eligibility Requirement for Disabled Adults Who Are Qualified Noncitizens Barred, Nonqualified Individuals Lawfully Present, and Nonqualified Prucols with Modified Adjusted Gross Income of the Masshealth Disabled Adult Household at or below 100% of the Federal Poverty Level, must enroll with the PCC Plan. (See130 CMR 450.118.)(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 responsibility of the provider to verify the scope of services covered by the MassHealth agency's contract with the MCO or Accountable Care Partnership Plan.(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. 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. (See130 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. (See130 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.(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.Amended by Mass Register Issue 1298, eff. 10/23/2015.Amended by Mass Register Issue 1322, eff. 10/1/2016.Amended by Mass Register Issue 1341, eff. 6/16/2017.Amended by Mass Register Issue S1345, eff. 8/11/2017.Amended by Mass Register Issue 1354, eff. 12/18/2017.Amended by Mass Register Issue 1374, eff. 9/21/2018.Amended by Mass Register Issue 1461, eff. 1/21/2022.