130 CMR, § 450.117

Current through Register 1533, October 25, 2024

Section 450.117 - Managed Care

(A) MassHealth members participate in managed care pursuant to 130 CMR 508.001: MassHealth Member Participation in Managed Care. MassHealth members may be excluded from participating in managed care pursuant to 130 CMR 508.002: MassHealth Members Excluded from Participation in Managed Care.

(B) MassHealth managed care provides for the management of medical care, including primary care, behavioral health services, and other medical services. MassHealth members who participate in managed care obtain services as follows:

(1) Members who enroll with an MCO obtain services in accordance with 130 CMR 508.004(B): Obtaining Services when Enrolled in an MCO.

(2) Members who enroll with the PCC Plan obtain services in accordance with 130 CMR 508.005(B): Obtaining Services when Enrolled with the PCC Plan.

(3) Members who enroll with an Accountable Care Partnership Plan obtain services in accordance with 130 CMR 508.006(A)(2): Obtaining Services when Enrolled in an Accountable Care Partnership Plan.

(4) Members who enroll with a Primary Care ACO obtain services in accordance with 130 CMR 508.006(B)(2): Obtaining Services when Enrolled in a Primary Care ACO.

(5) Members who enroll with an ICO obtain services in accordance with 130 CMR 508.007(C): Obtaining Services when Enrolled in an ICO. Members who enroll in the Duals Demonstration Program may continue to receive services from their current providers who accept current Medicare or Medicaid fee-for-service provider rates during a continuity-of-care period. A continuity-of-care period is a period beginning on the date of enrollment into the Duals Demonstration Program and extends to either of the following:

(a) up to 90 days, unless the comprehensive assessment and the individualized-care plan are completed sooner and the enrollee agrees to the shorter time period; or

(b) until the comprehensive assessment and the individualized-care plan are complete.

(6) Members who enroll with a SCO obtain services in accordance with 130 CMR 508.008(C): Obtaining Services when Enrolled in a SCO.

(7) Members who are Native Americans (within the meaning of "Indians" as defined at 42 U.S.C. 1396u-2) or Alaska Natives and who participate in managed care may choose to receive covered services from an Indian health-care provider. All participating MCOs, Accountable Care Partnership Plans, SCOs and ICOs must provide payment for such covered services in accordance with the provisions of 42 U.S.C. 1396u-2(h) and comply with all other provisions of 42 U.S.C. 1396u-2(h). For the purposes of 130 CMR 450.117(B)(7), the term Indian health-care provider means a health care program, including contracted health services, operated by the Indian Health Service or by an Indian tribe, Tribal Organization, or Urban Indian Organization as those terms are defined in § 4 of the Indian Health Care Improvement Act (25 U.S.C. 1603) .

(C) Members who participate in managed care are identified on EVS. (See 130 CMR 450.107.) For members who participate in managed care, this system will give the name and telephone number of the MassHealth managed care provider, the behavioral health contractor, the SCO, or the ICO, as applicable. The MassHealth agency pays for services provided to MassHealth members who participate in managed care as described in 130 CMR 450.105 and 450.118.

(D) The MassHealth agency may impose sanctions on MassHealth managed care providers, the behavioral health contractor, SCOs, and ICOs pursuant to the terms of the MassHealth agency's contracts with those entities. If EOHHS is required to provide a pre-termination hearing pursuant to 42 CFR Part 438 , EOHHS shall provide the contractor with such hearing in accordance with 42 CFR 438.710 and 130 CMR 450.241 through 247.