130 CMR, § 508.005

Current through Register 1536, December 6, 2024

Section 508.005 - MassHealth Primary Care Clinician Plan (PCC Plan)

(A)Enrollment in the PCC Plan.

(1)Selection Procedure. When a member becomes eligible for managed care, the MassHealth agency notifies the member of the member's obligation to select a MassHealth managed care provider within the time period specified by the MassHealth agency. To enroll in the PCC Plan, the member must select the PCC Plan and an available primary care clinician (PCC). The MassHealth agency makes available to the member a list of the PCCs in the member's service area. The member's service area is determined by the MassHealth agency based on zip codes or geographic area. Service area listings may be obtained from the MassHealth agency. The list of PCCs that the MassHealth agency will make available to members may include those approved as a PCC by MassHealth in accordance with 130 CMR 450.118: Primary Care Clinician (PCC) Plan and who practices within the member's service area.

(2) MassHealth members assigned to the PCC Plan, may transfer from the PCC Plan, may be disenrolled from a PCC's panel, and may be re-enrolled in the PCC Plan as described in 130 CMR 508.003(B) through 130 CMR 508.003(E).

(B)Obtaining Services when Enrolled with the PCC Plan.

(1)Primary Care. When the member selects or is assigned to the PCC Plan, the member's selected or assigned PCC will deliver the member's primary care, determine if the member needs medical or other specialty care from other providers, and make referrals for such necessary medical services.

(2)Other Medical Services. All medical services, except those services listed in 130 CMR 450.118(J): Referral for Services, require a referral or authorization from the member's PCC. MassHealth members enrolled in the PCC Plan may receive those services listed in 130 CMR 450.118(J), for which they are otherwise eligible, without a referral from their PCC.

(3)Behavioral Health Services. All members enrolled with the PCC Plan receive behavioral health (mental health and substance use disorder) services, except those services not covered under the MassHealth contract with the behavioral health contractor, through the MassHealth behavioral health contractor. Such behavioral health services, except for emergency services, may be obtained only from a provider that has entered into an agreement with the MassHealth behavioral health contractor. The MassHealth behavioral health contractor is responsible for authorizing or denying behavioral health services based on the member's medical need for those services.

(4)Emergency Services. Members enrolled with the PCC Plan may obtain emergency services, including emergency behavioral health services, from any qualified participating MassHealth provider as well as any provider that has entered into an agreement with the MassHealth behavioral health contractor.

(5)Native Americans and Alaska Natives. Individuals who are Native Americans (within the meaning of "Indians" as defined at 42 U.S.C. 1396u-2) or Alaska Natives may choose to receive covered services from an Indian health-care provider. Such Indian health-care providers may participate in MassHealth subject to applicable provisions of 130 CMR 450.000: Administrative and Billing Regulations.

(C)Copayments. MassHealth requires MassHealth members enrolled in the PCC Plan to make the copayments described in 130 CMR 506.014 through 506.018 and 520.036 through 520.040. If the usual and customary fee for the service is less than the copayment amount, the member must pay the amount of the service. Members enrolled in the MassHealth behavioral health contractor must make copayments in accordance with the MassHealth behavioral health contractor's MassHealth copayment policy. Those MassHealth behavioral health contractor copayment policies must

(1) be approved by MassHealth;

(2) exclude the persons and services listed in 130 CMR 506.014: Copayments Required by MassHealth and 520.037: Copayment and Cost Sharing Requirement Exclusions;

(3) not exceed the MassHealth copayment amounts set forth in 130 CMR 506.015: Copayment and Cost Sharing Requirement Exclusions and 520.038: Services Subject to Copayments; and

(4) include the copayment maximums set forth in 130 CMR 506.018: Maximum Cost Sharing and 520.040: Maximum Cost Sharing. (See also 130 CMR 450.130: Copayments Required by the MassHealth Agency.)